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Charleston Internal Medicine

Important Forms

Notice of Privacy Practices

Charleston Internal Medicine Group, Inc. (CIM) respects the sensitivity of the information you provide to us as your chosen healthcare provider. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was enacted to give you rights over your health information, as well as setting rules and limits on who can look at and receive your protected health information. The regulations protect medical records and other individually identifiable health information, whether it is on paper, in a computer or communicated orally. CIM is required by law to take reasonable steps to ensure the privacy of your personally identifiable health information.

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Discuss Medical Care Sheet

This form tells Charleston Internal Medicine who you give us permission to discuss your medical care with. If someone calls and requests health information about you and they are not listed on your form, we will not be able to assist them. You can update your list at anytime.

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Authorization to Contact by Telephone

This form gives Charleston Internal Medicine instructions on how and where we can contact you via telephone. You can update your form at anytime.

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Authorization to Fax Patient Test Results/Financial Information

This form tells Charleston Internal Medicine what fax number(s) you authorize us to send your test results and/or financial information to. These types of information contain personal health information and will only be faxed at your direction and only to the number(s) you have on file with our office. This form can be updated at anytime.


Financial Policy


Charleston Internal Medicine Group is committed to providing quality care at a fair monetary rate to patients. Prompt payment of your account is a part of your overall relationship with CIM and necessary for the office to continue itís tradition of offering quality care to the community. By keeping your account current, both parties can benefit from the relationship. Here is CIMís Financial Policy which outlines the expectation of each patient with regards to their financial account:

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Living Will

A Living Will (sometimes called a healthcare directive or directive to physicians) is a document which expresses a personís desires and preferences about certain medical treatments or interventions, such as artificial life support, in case he or she becomes unable to communicate these instructions during terminal illness or permanent unconsciousness. It gives your doctors and loved ones an idea of the care you prefer if you canít speak for yourself.

Once you have completed and properly executed your Living Will, you should make sure all your healthcare providers have a copy in their medical records for you. It is also advised that copies be given to those individuals you trust to participate in your health care, such as a family member or close friend.

You should review your Living Will on a regular basis and make any necessary changes to ensure your most current desires are expressed.

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Durable Power of Attorney

A Durable Power of Attorney is a document which gives an attorney-in-fact, or decision maker, the legal power to make health care decisions for a person who cannot make those decisions for him or herself. If there is any question about what type of care a patient would desire, the Durable Power of Attorney directs the doctor(s) and/or family members to the person that has been selected by the patient to answer those questions. A Durable Power of Attorney differs from a Living Will in that it may direct the attorney-in-fact to carry out the living willís instructions or it may allow the attorney-in-fact to use his or her own judgment.

Once you have completed and properly executed your Durable Power of Attorney, you should make sure all your healthcare providers have a copy in their medical records for you. Your attorney-in-fact should also be given a copy. It is also advised that copies be given to those individuals you trust to have knowledge of your healthcare, such as a family member or close friend.

You should review your Durable Power of Attorney on a regular basis and make any necessary changes to ensure your most current desires are expressed.

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Choosing an Attorney-In-Fact

An Attorney-In-Fact is that individual chosen to carry out a patientís medical decisions should they be unable to do so. This person should be a trusted individual who is comfortable discussion healthcare issues. Because this person may need to argue the patientís case with doctors or family members, or even go to court, so an assertive and diplomatic individual may be preferred. The Attorney-In-Fact should be well aware of the personís health choices, and how they feel about a variety of health choices such as artificial life support, dialysis, etc, and have all the relevant documents to support their desires.

The person you select as an Attorney-In-Fact should be reviewed on a regular basis to ensure that you are still comfortable with your selected individual, making a change should you feel it necessary.

Advance directives are legal documents that allow you to spell out your decisions about end-of-life care ahead of time. They give you a way to tell your wishes to family, friends, and health care professionals and to avoid confusion later on. Follow the link below for more information about this important document.

http://www.wvendoflife.org/


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