The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office.
What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov
We have adopted the following policies:
Minoxidil Hair Loss Treatment Questionnaire
This form is designed to determine your eligibility for Minoxidil treatment for hair loss. Please answer all questions accurately to help our healthcare providers develop the most appropriate treatment plan for you.
Please answer the following questions to determine if Minoxidil is suitable for you:
By signing below, I confirm that the information provided in this form is accurate and complete to the best of my knowledge. I understand that Minoxidil may have certain side effects and that I should follow the treatment plan prescribed by my healthcare provider.