Virtual Consultation Form

 Virtual Consultation Form

 Virtual Consultation Form

Virtual Consultation Form


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Medical History

Fill up the form below for an accurate record of your medical history. Please don't leave any fields blank. If not applicable, please indicate N/A or none.

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HIPAA ​​​​​​​

Sign Off on HIPAA

Health Insurance Portability and Accountability Act, HIPAA provides national standards to protect the privacy of personal health information. To improve the efficiency and effectiveness of the health care system, the Health Insurance Portability and Accountability Act (HIPAA) of 1996, Public Law 104-191, included "Administrative Simplification" provisions that required HHS to adopt national standards for electronic health care transactions. Congress incorporated into HIPAA provisions that mandated the adoption of Federal privacy protections for individually identifiable health information.

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