Patient Forms
For visits with Dr. Heather Johnson, D.O.M.
(Fill this out even if you are already a patient of Dr. Joe Johnson or Dr. Morris).
Please download and sign these forms before you come to the office for treatment:
New Patient Health History Form
Patient Acknowledgement of Privacy
Patient Consent to Receive Treatment
When you arrive, we will also have you sign an arbitration agreement, as it is required by Dr. Heather Johnson’s Insurance.
Please call to make an appointment at: 850-834-2118.
HEALTH INFORMATION AND YOUR PRIVACY
FEDERAL HEALTH INSURANCE PORTABILITY and ACCOUNTABILITY ACT (HIPAA)
This is a plain-language, brief explanation of your privacy rights and our general policy regarding medical records. Please feel free to look up the full language of the law. The federal law regarding your medical records is called the FEDERAL HEALTH INSURANCE PORTABILITY and ACCOUNTABILITY ACT (HIPAA). The United States government has an excellent general information site regarding this law: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html
We understand that your Private Health Information (“PHI”) is personal, and we are committed to treating your information with discretion.
- We will respect your health care information and treat it properly. This includes your personal non-medical information.
- We will keep your records private with reasonable measures.
- We will share your information with other providers as appropriate, to keep you safe and allow you the best care possible.
- Your records may be shared for payment and health care operations including third party payers/ insurance companies.
- Your records, (with identification and personal details removed), may be used for statistical outcomes-assessment measurements, other medical quality assurance measurements, or case-study review.
- Your information will not be shared with insurance companies (besides your own insurance company) or attorneys without them presenting a proper request validated by you or required by law.
- We are always required to release your information to the government, law enforcement, in response to subpoenas, or in an emergency.
- You are entitled to a copy of your records if you desire. Fees will be the reasonable amount dictated by current Florida law.
- If you have concerns about your notes, you should address this with your provider.
- If you have a specific privacy request, then you the patient must make that need known in writing.
PLEASE FEEL FREE TO READ THE POLICY PAPER ON PRIVATE HEALTH INFORMATION IN THE NEW PATIENT INFORMATION SECTION OF THIS SITE. The policy paper is more detailed, but is still basically in “plain language.”
PRIVACY REGARDING THIS WEBSITE OR ANY E-MAIL COMMUNICATIONS:
We and the webhost may use statistical counters and typical non-invasive “cookies” on this site.
Any emails to us will be treated as strictly confidential. If you become a patient, all e-mails (even from before your initial visit) may be made part of your medical file.