Demographic Information
Include suffix, if any
Employment
Name of your current employer
Contact Information
Street Number and Name or P.O. Box
Include area code
Include area code
Include area code
Required to access Patient Portal
You may give permission for our practice to leave messages regarding appointments or medical information
You may give permission for our practice to contact you regarding appointments or medical issues via e-mail
Preferred Pharmacy and Pharmacy Address
Person Designated to Discuss Your Medical Conditions
Family member or friend with whom our practice may discuss your medical conditions, and who may access your medical record
Spouse, parent, child, sibling, partner, friend, etc.
Include area code
Financial Agreement
Hilton Head General & Laparoscopic Surgery, P.A (HHGLS). also does business as Surgical Specialists. Patient's health care insurance, if any, is a contract between the patient and the insurance company, except in certain cases where Drs. Hussong and Rzeczycki have signed a contract with the patient's PPO or other third party. Payment is expected at the time of service. Cash, check or major credit cards are accepted as the form of payment. Third party payments of assignment are generally accepted for services. All deductibles, co-payments, and co-insurances are due at the time of service.
Necessary to File with your Insurance<br/>XXX-XX-XXXX
XXX-XX-XXXX
Privacy Policy
Hilton Head General & Laparoscopic Surgery, P.A.<br/>dba Surgical Specialists<br/>NOTICE OF PRIVACY PRACTICES<br/>Effective Date: 4/1/2003; Revised 9/16/2012<br/><br/>THIS NOTICE DESCRIBES HOW HEALTH CARE INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.<br/>At Surgical Specialists, we are committed to protecting your personal health information. Each time you are seen by one of our physicians in our office, a record is made containing your symptoms, history, physical examination, test results, treatment, plan for future care, and billing-related information. This notice applies to all information in your medical record generated, received or transmitted by our medical practice. While your medical record is the physical property of Surgical Specialists, the information contained therein belongs to you.<br/>OUR RESPONSIBILITIES AND YOUR RIGHTS<br/>We are required by Federal and/or South Carolina state law to maintain the privacy of your protected health information; to provide you with this notice of our privacy practices and a paper copy upon request; to abide by the terms of our current notice; to accommodate reasonable written requests by you to amend health information you believe to be incorrect or incomplete; to accommodate reasonable written requests by you to restrict or limit health information communicated to other individuals or entities involved in your medical care; to accommodate reasonable written requests by you restricting how our practice communicates with you; to provide upon your written request an accounting of certain disclosures of your health information made for purposes other than treatment, payment or health care operations where an authorization was not required; to submit a written revocation of a previous authorization to release your protected health information; to permit you to inspect and copy your protected health information, with the exception of psychotherapy notes.<br/>HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION WITHOUT YOUR WRITTEN AUTHORIZATION:<br/>For Treatment<br/>For Payment<br/>For Health Care Operations<br/>For Appointment Reminders<br/>For Treatment Alternatives and Services<br/>For Business Associate Functions<br/>For Abuse, Neglect or Domestic Violence Reporting<br/>For Public Health Reporting<br/>For Law Enforcement/Legal Proceedings, as required by law or in response to a valid subpoena<br/>For Correctional Institutions, for inmates<br/>For Military Command Authorities<br/>For Food and Drug Administration<br/>For Organ and Tissue Donation Organizations<br/>For Funeral Directors, Coroners and Medical Examiners<br/>For Workers Compensation Agents<br/>For Health Oversight Agencies<br/>For National Security and Intelligence Agencies<br/>For Protective Services for the President and Others<br/>COMPLAINT PROCESS<br/>If you believe that your privacy rights have been violated by us, you may file a complaint without fear of retaliation by contacting the Regional Manager of the Office for Civil Rights:<br/>Regional Manager<br/>Office for Civil Rights<br/>U.S. Department of Health and Human Services<br/>Sam Nunn Atlanta Federal Center, Suite 16T70<br/>61 Forsyth Street, S.W.<br/>Atlanta, GA 30303-8909<br/>Telephone (404)562-7453<br/>FAX (404)562-7881<br/>
Enter any reasonable restrictions regarding use and disclosure of your medical record
