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Patient Registration Form

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Disclaimer

Disclaimer

If you think you have a medical emergency, call your doctor or 911 immediately or go to the emergency room.

Do not rely on electronic communications or communications through this application for immediate or urgent medical needs.

The purpose of this self-health screening is only an informational tool and does not give medical advice, diagnosis, or treatment, this can be done only by a license healthcare professional.

Once all the questions have been completed your information will be sent to a licensed health professional to set-up an appointment with a physician via tele-health. This would require a laptop/computer with a camera or a phone with a camera. Please understand that until the physician assesses your health concerns, these are ONLY questionnaires and are not giving you any medical advice, diagnosis, or treatment.

ALL demographics and medical data is required in order for the health care professional to contact you for the tele-health appointment and assessment. Please have a government identification and insurance card present for verification purposes.


PRIVACY POLICIES

Protecting your private information is our priority and we are committed to maintain the highest privacy standards. This Privacy Policies Statement applies to www.CapStoneclinical.com and CapStone Clinical Laboratories LLC ("CapStone") and governs data collection and usage. For the purposes of this Privacy Policy, unless otherwise noted, all references to CapStone Clinical, Inc include www.CapStoneclinical.com and CapStone. The CapStone website is a healthcare and clinical laboratory portal site. By using the CapStone website, you consent to the data practices described in this statement.

PATIENT HEALTH INFORMATION (PHI)

The privacy and security of Patients’ individually identifiable health information provided to CapStone in connection with Services may be protected by federal law Health Insurance Portability and Accountability Act of 1996. (HIPAA), the HITECH Act, and their regulations) and state privacy laws, because CapStone provides Services to health care providers. This health information Protected Health Information (PHI). PHI is information that includes, but is not limited to, identifying data such as name, social security number, address, contact information, as well as information about personal health issues and insurance submitted through our Services. CapStone collects PHI and other PHI that you voluntarily submit. Privacy is of the utmost importance, so we are committed to protecting and keeping confidential all PHI that identifies an individual whether or not it relates to an individual’s past, present, or future physical or mental health condition. PHI may be used and disclosed by CapStone as necessary to provide Services, for our own management and operations, to meet our legal obligations, and for any other purpose for which Patients have given consent. We may share PHI with third parties and government agencies for these purposes in compliance with applicable law.

We use your PHI for treatment, payment, or healthcare operations purposes and for other purposes permitted or required by law. We need your written authorization to use or disclose your health information for any purpose not covered by one of the categories below. Subject to compliance with limited exceptions, we will not use or disclose psychotherapy notes, use or disclose your PHI for marketing purposes or sell your PHI, unless you have signed an authorization. You may revoke any authorization you sign at any time. If you revoke your authorization, we will no longer use or disclose your health information for the reasons stated in your authorization except to the extent we have already taken action based on your authorization.


Information We Collect Directly From You

Users may browse the informational areas of the Site without registering with. However, registration is required to use the Services. Once a Healthcare Provider has registered with us and subscribed to our Services, the Healthcare Provider can then invite Patients to use the Services. After receiving an invite, the Patient would then need to register for an account to use the Services. We may share your contact information with health care professionals involved in collection of any biospecimens, professional facilities or clinics, clinical laboratories that process collected biospecimens and relevant public health authorities, such as the California Department of Public Health (CDPH) and the United States Centers for Disease Control and Prevention (CDC), public health agencies and FDA, for purposes related to performing tests, administering and improving the testing program and for public health purposes.


Healthcare Provider Registration

Certain features and Services are available to patients because their Healthcare Providers use our Services. To register, Healthcare Providers must provide certain information about themselves and their practices including: the Healthcare Provider’s name, date of birth, gender, address, email, mobile and work phone; the Healthcare Provider’s practice name, address, phone number and fax number; and a user id and password. We may also collect certain optional information, including: middle name or initial, bank account or other payment information and other contact details, picture and communication preferences.


Patient Registration

Patients must provide certain information, including: name, date of birth, gender, address, email, mobile and work phone, as well as a user id and password. We may also collect certain optional information, including: middle name or initial, home phone and other contact info, pharmacy name and contact details, other demographic information, health insurance information, credit card number and billing details, picture and communications preferences. In addition, the Patient can communicate other health-related information to the Healthcare Provider during a video consultation


Payment & Authorization of Benefits

CapStone Clinic Services will use and disclose your PHI for purposes of billing and payment. For example, we may disclose your PHI to health plans or other payers to determine whether you are enrolled with the payer or eligible for health benefits or to obtain payment for our services. If you are insured under another person’s health insurance policy (for example, parent, spouse, domestic partner or a former spouse), we may also send invoices to the subscriber whose policy covers your health services website or third party website not affiliated with CapStone. CapStone is not affiliated with any healthcare provider and is a third party independent clinical laboratory providing health care providers with laboratory results.


Information We Collect Automatically

The CapStone website may use "cookies" to help you personalize your online experience. A cookie is a text file that is placed on your hard disk by a web page server. Cookies cannot be used to run programs or deliver viruses to your computer. Cookies are uniquely assigned to you and can only be read by a web server in the domain that issued the cookie to you. One of the primary purposes of cookies is to provide a convenience feature to save you time. The purpose of a cookie is to tell the Web server that you have returned to a specific page. For example, if you personalize CapStone pages, or register with CapStone site or services, a cookie helps CapStone to recall your specific information on subsequent visits. This simplifies the process of recording your personal information, such as billing addresses, shipping addresses, and so on. When you return to the same CapStone website, the information you previously provided can be retrieved, so you can easily use the CapStone features that you customized. You have the ability to accept or decline cookies. Most Web browsers automatically accept cookies, but you can usually modify your browser setting to decline cookies if you prefer. If you choose to decline cookies, you may not be able to fully experience the interactive features of the CapStone services or websites you visit. We may automatically collect the following information about your use of our Site or Services through cookies, web beacons, and other technologies: your domain name; your browser type and operating system; web pages you view; links you click; your IP address; a time and date stamp and the length of time you visit our Site and or use our Services; the referring URL, or the webpage that led you to our Site; and your browser type. We may combine this information with other information that we have collected about you, including, where applicable, your user name, name, and other personal information Sharing Information with Third Parties CapStone does not sell, rent or lease its customer lists to third parties. CapStone may share data with trusted partners to help perform statistical analysis, send you email or postal mail, provide customer support, or arrange for deliveries. All such third parties are prohibited from using your personal information except to provide these services to CapStone, and they are required to maintain the confidentiality of your information.

CapStone may disclose your personal information, without notice, if required to do so by law or in the good faith belief that such action is necessary to: (a) conform to the edicts of the law or comply with legal process served on CapStone or the site;

(b) protect and defend the rights or property of CapStone; and/or (c) act under exigent circumstances to protect the personal safety of users of CapStone, or the public.


Tracking User Behavior

CapStone may keep track of the websites and pages our users visit within CapStone, in order to determine what CapStone services are the most popular. This data is used to deliver customized content and advertising within CapStone to customers whose behavior indicates that they are interested in a particular subject area.


Automatically Collected Information

Information about your computer hardware and software may be automatically collected by CapStone. This information can include: your IP address, browser type, domain names, access times and referring website addresses. This information is used for the operation of the service, to maintain quality of the service, and to provide general statistics regarding use of the CapStone website. If you submit any personal information that is not your own, you represent that you have the authority to do so and to permit us to use that information in accordance with this Privacy Policy. If you contact us with a question, comment, or complaint, we may collect your name and contact information (such as your email address or mailing address) in order for us to respond to your request. We may also keep a record of the correspondence in order to assist you in the future.


Security of your Personal Information

CapStone secures your personal information from unauthorized access, use, or disclosure. CapStone uses the following methods for this purpose: SSL Protocol. When personal information (such as a credit card number) is transmitted to other websites, it is protected through the use of encryption, such as the Secure Sockets Layer (SSL) protocol.

We strive to take appropriate security measures to protect against unauthorized access to or alteration of your personal information. Unfortunately, no data transmission over the Internet or any wireless network can be guaranteed to be 100% secure. As a result, while we strive to protect your personal information, you acknowledge that: (a) there are security and privacy limitations inherent to the Internet which are beyond our control; and (b) security, integrity, and privacy of any and all information and data exchanged between you and us through this Site cannot be guaranteed.


Children Under Thirteen

CapStone does not knowingly collect personally identifiable information from children under the age of thirteen. If you are under the age of thirteen, you must ask your parent or guardian for permission to use this website.


E-mail Communications

From time to time, CapStone may contact you via email for the purpose of providing announcements, promotional offers, alerts, confirmations, surveys, and/or other general communication. In order to improve our Services, we may receive a notification when you open an email from CapStone or click on a link therein.

If you would like to stop receiving marketing or promotional communications via email from CapStone, you may opt out of such communications by info@CapStoneclinical.com.


External Data Storage Sites

We may store your data on servers provided by third party hosting vendors with whom we have contracted.


Disclosures in Accordance with Law

CapStone discloses PHI about you as required or permitted by law, including complying with legal process (for example, we may disclose your information as necessary to comply with an authorized department of health, civil, criminal, or regulatory investigation). We fully cooperate with law enforcement agencies in identifying those who use our services for illegal activities and may, in our sole discretion, disclose personal information or other information to satisfy any law, regulation, subpoena, or government request. We reserve the right to release personal information or other information about users who we believe are engaged in illegal activities or are otherwise in violation of our Terms of Use, even without a subpoena, warrant, or court order, if we believe, in our sole discretion, that such disclosure is necessary or appropriate to operate our web site or to protect our rights or property, or that of our affiliates, or our officers, directors, employees, agents, third-party content providers, suppliers, sponsors, or licensors. We also reserve the right to report to law enforcement agencies any activities we reasonably believe in our sole discretion to be unlawful. If we are legally compelled to disclose information about you to a third party, we will attempt to notify you by sending an email to the email address in our records unless doing so would violate the law or unless you have not provided your email address to us.


Contact Information

CapStone welcomes your questions or comments regarding this Statement of Privacy. If you believe that CapStone has not adhered to this Statement, please contact CapStone at: Registration@CapStoneclinical.com. Telephone number: 951-465-3500


Changes to this Statement

CapStone reserves the right to change this Privacy Policy from time to time. We will notify you about significant changes in the way we treat personal information by sending a notice to the primary email address specified in your account, by placing a prominent notice on our site, and/or by updating any privacy information on this page. Your continued use of the Site and/or Services available through this Site after such modifications will constitute your: (a) acknowledgment of the modified Privacy Policy; and (b) agreement to abide and be bound by that Policy.

Effective as of April 01, 2020


ASSIGNMENT OF BENEFITS AND DESIGNATION OF AUTHORIZED REPRESENTATIVE

PATIENT CONSENT: I AGREE THE SPECIMEN IDENTIFIED ON THIS FORM IS MY OWN AND IT IS NOT ALTERED. I AM VOLUNTARILY SUBMITTING THIS SPECIMEN FOR THE PURPOSE TO ENHANCE PATIENT CARE, PROVIDING OBJECTIVE DOCUMENTATION OF MY TREATMENT PLAN FOR MY PHYSICIAN. I HEREBY AUTHORIZE MY PHYSICIAN TO RELEASE PERSONAL HEALTH INFORMATION TO BIO CLINICAL INC OR A CLIA-CERTIFIED LABORATORY OR THEIR DESIGNEE FOR ANY PURPOSES, CONSISTENT WITH HIPAA INCLUDING BILLING, AUDITS, AND OTHER PURPOSES.

I UNDERSTAND AND AGREE THAT:

THIS AUTHORIZATION IS VOLUNTARY. MY HEALTH INFORMATION MAY CONTAIN INFORMATION CREATED BY OTHER PERSONS OR ENTITIES INCLUDING HEALTH CARE PROVIDERS AND MAY CONTAIN MEDICAL, PHARMACY, DENTAL, VISION, MENTAL HEALTH, SUBSTANCE ABUSE, HIV/AIDS, PSYCHOTHERAPY, REPRODUCTIVE, COMMUNICABLE DISEASE AND HEALTH CARE PROGRAM INFORMATION: I MAY NOT BE DENIED TREATMENT, PAYMENT FOR HEALTH CARE SERVICES, OR ENROLLMENT OR ELIGIBILITY FOR HEALTH CARE BENEFITS IF I DO NOT SIGN THIS FORM MY HEALTH INFORMATION MAY BE SUBJECT TO RE-DISCLOSURE BY THE RECIPIENT, AND OF THE RECIPIENT IS NOT A HEALTH PLAN OR HEALTH CARE PROVIDER, THE INFORMATION MAY NO LONGER BE PROTECTED BY THE FEDERAL PRIVACY REGULATION.THIS AUTHORIZATION WILL EXPIRE ONE YEAR FROM THE DATE I SIGN THE AUTHORIZATION. I MAY REVOKE THIS AUTHORIZATION AT ANY TIME BY NOTIFYING MY INSURANCE POLICY IN WRITING; HOWEVER, THE REVOCATION WILL NOT HAVE AN EFFECT ON ANY ACTIONS TAKEN PRIOR TO THE DATE OF MY REVOCATION IS RECEIVED AND PROCESSED.

ASSIGNMENT OF BENEFITS: I HEREBY AUTHORIZED AND WANT THE PAYMENT TO GO TO OPTIMUM BIO LAB, INC TO RECEIVE PAYMENT FOR THIS BILL FROM MY INSURANCE COMPANY (THIS IS AN “ASSIGNMENT” AND "POWER OF ATTORNEY"). I WANT MY HEALTH INSURER TO PAY THE PROVIDER FOR ANY HEALTH CARE SERVICES I OR MY DEPENDENT RECEIVED THAT ARE COVERED UNDER MY HEALTH INSURANCE. WITH MY ASSIGNMENT, THE PROVIDER CANNOT SEEK PAYMENT FROM ME, EXCEPT FOR ANY CO-PAYMENT, COINSURANCE OR DEDUCTIBLE THAT WOULD BE OWED IF I OR MY DEPENDENT USED A PARTICIPATING PROVIDER. IF MY INSURER PAID ME FOR THE SERVICES, I AGREE TO SEND THE PAYMENT TO THE PROVIDER WITHIN 15 DAYS WITH A TRACKING NUMBER.

APPEAL AUTHORIZATION: I HEREBY AUTHORIZE CAPSTONE CLINICAL, INC AND THEIR DESIGNEE TO ACT AS MY FINANCIAL REPRESENTATIVE IN REQUESTING: A COMPLAINT, AN APPEAL, AND DOCUMENTS FROM MY INSURANCE PROVIDER REGARDING THE SERVICES PROVIDED. THIS AUTHORIZATION WILL EXPIRE IN ONE YEAR FROM THE DATE OF MY REVOCATION IS RECEIVED AND PROCESSED. I UNDERSTAND THAT IF ANY INSURER DOESN'T PAY AND DENIES THE CLAIM AS AN UNCOVERED SERVICE, I AM RESPONSIBLE FOR PAYMENT IN FULL. IF MY INSURER PAYS ME DIRECTLY, I AGREE TO ENDORSE THE CHECK AND FORWARD IT TO THE LABORATORY WITHIN 30 DAYS. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AMOUNTS NOT TO BE PAID BY INSURER FOR REASONS INCLUDING, BUT NOT LIMITED TO, NON- COVERAGE, NON-PARTICIPATING PROVIDER/PHYSICIAN AND NON-AUTHORIZED SERVICES.

I, DO HEREBY ALLOWED, CAPSTONE CLINICAL, INC OR A CLIA-CERTIFIED LABORATORY, TO ACT AS MY FINANCIAL REPRESENTATIVE IN REQUESTING, A COMPLIANT, AN APPEAL AND DOCUMENTS FROM MY INSURANCE PROVIDER REGARDING THE SERVICES PROVIDED. I, AUTHORIZATION FOR ASSIGNMENT OF BENEFITS I, THE UNDERSIGNED, AUTHORIZE MY INSURANCE TO MAKE PAYMENT FOR BENEFITS DUE HERE INTO:

PROVIDER: CAPSTONE CLINICAL INC

NPI: 1346696648

TAX: 84-3447582

CLIA: 05D2109888


Medical Data


Please answer to the best of your knowledge



Please answer to the best of your knowledge


Have you been diagnosed with Diabetes?


Have you been hospitalized in the past 3 months?


In the past 3 days, do you experience Cough?


In the past 3 days, do you experience Sore Throat?


In the past 3 days, do you experience Subjective Fever?


In the past 3 days, do you experience Fever (Temp >100.4◦F)?


In the past 3 days, do you experience Shortness of Breath?


In the past 3 days, do you experience Runny Nose?


In the past 3 days, do you experience Muscle Aches?


In the past 3 days, do you experience Chills?


In the past 3 days, do you experience Nausea?


In the past 3 days, do you experience Headaches?


In the past 3 days, do you experience Diarrhea?


In the past 3 days, do you experience Vomiting?


In the last 14 days have you traveled outside the US or on a Cruise?


Have you had surgery in the past 3 months?


Are you Allergic to any Medication?


Are you a Smoker?


Have you been diagnosed with Hypertension?


Have you been diagnosed with Cardiovascular Disease/Abnormalities?


Have you been diagnosed with Chronic pulmonary Disease?


Have you been diagnosed with Asthma?


Have you been diagnosed with Chronic Renal Disease?


Have you been diagnosed with Chronic Liver Disease?


Have you been diagnosed with Anemia?


Have you been diagnosed with Neurologic Disability?


Have you been diagnosed with Cancer/Tumor?


Are you an Organ Transplant Recipient?


Are you currently receiving Dialysis?


Have you ever been diagnosed with Immunocompromised disease (i.e. HIV)?


Do you have any other pre-existing medical condition(s)?


Date of Your Last Physical Check-up:


In the last 14 days did you have close contact with a Laboratory Positive COVID-19 Patient?


Insurance Information

Please provide your Insurance Information

Submission

Telehealth Appointment Setup

I have read, understood, acknowledge and confirm that the information on this form is true and correct. I understand that the purpose of this self-health screening questionnaire is intended to help myself make decisions about seeking the appropriate medical care. By answering the questionnaire, I understand that this is only an informational tool and does not give medical advice, diagnosis, or treatment, this can be done only by a license healthcare professional.

By signing the form, I Authorize the release of medical information Protected Health Information (PHI) to share my screening questionnaire responses with a professional health care provider. I understand that my information will/can be use only to assess, diagnose, test and manage my health and well-being.

Telehealth Consent

By clicking the “I agree” on CapStone Clinical telehealth portal, I understand and agree that I am signing this Consent electronically and

  • (i) I have reviewed, understand, and accept the risks and benefits of telehealth services as described below and wish to receive such services, and
  • (ii) I agree to the remaining terms of this Consent, including the terms of the Private Privacy Notice on CapStone Clinical website.
  • (iii) I certify that I am a person with legal authority to act on behalf of the patient, including the authority to consent to medical services, and I accept financial responsibility for services rendered
  • (iv) CapStone Clinical is not a liable for the telehealth encounter between the Patient and Health care professional.
  • (v) This is a just a consent for a telehealth encounter and the Patient is not obligate to meet with the Health Care Professional or responsible for any fees if they do not show or cancel.
  • (vi) I may have to sign another consent from the Telehealth encounter with the health care professional

Telehealth

Telehealth involves the use of interactive electronic communications (telephone, computer, etc.) to with the patient and healthcare professional to be able to see and speak to each other remotely. This enables health care providers (doctors, nurses, physician assistants, laboratory, and others) at a different location from the patient to share medical information with that patient for the purpose of improving access to patient care. The information may be used for assessment, treatment, diagnosis, therapy, follow-up and/or education, and may include any of the following: Patient medical records, Medical images, Live two-way audio and video, Output data from medical devices and sound and video files.

The electronic systems used will attempt to incorporate security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against corruption.


Expected Benefits:

  • Improved access to medical care by enabling a patient to remain in his/her location while the healthcare provider provides medical information from a remote site
  • Reduce the exposure and spread of COVID-19 and other communicable diseases to patients, medical staff and other individuals at a physician location.
  • Ability to obtain consultation from a distant with a healthcare professional without traveling
  • Conservation of personal protective equipment (PPE) such as gloves and masks to reduce shortages for healthcare providers
  • Allow medical evaluation and management of patients who are unable to travel

Potential Risks:

As with any medical procedure, there are risks associated with the use of telemedicine. I understand and will not hold the health care professionals responsible for the following risks or can cause a delay in treatment or evaluation include, but may not be limited to:

  • Limited or no available of diagnostic laboratory, x-ray, EKG and other testing and some prescriptions, to assist the medical provider in the diagnosis or treatment
  • The inability of a health care professional to conduct a hand on physical examination or me and my condition
  • Delays in evaluation and treatment due to technical difficulties or interruptions, distortion or poor resolution of diagnostic images or specimens resulting from electronic transmission issues, unauthorized access to my information, or loss of information due to technical difficulties.
  • Security protocols could fail, causing a breach of privacy of personal medical information.
  • A lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other medical errors.
  • I understand that the health care professional’s advice, recommendation and or decisions may be based on factors not within their control, including incomplete or inaccurate data provided by me.
  • I understand that the health care professional relies on information provided by me before and during the telehealth encounter and I will provide the most accurate medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability.
  • If the provider believe that I should seek medical attention in face to face service I will seek the nearest medical center, hospital emergency department, urgent care or other health care provider.
  • Of in case of emergency I will dial 911 or go to the nearest emergency room.

Patient's Acceptance of Risks

The laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine will be disclosed to researchers or other entities without my consent.

I have the rights to discuss the risks and benefits all procedures and courses of treatment proposed by my health care provider.

I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.

I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction and may receive copies of this information for a reasonable fee. Telemedicine may involve electronic communication of my personal medical information to other medical practitioners located elsewhere, including out of state.

I understand that no results from the use of telemedicine can be guaranteed or assured.