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:
GLP-1 Medication Qualification Questionnaire
To determine your eligibility for GLP-1 medications, such as Semaglutide or Tirzepatide, please complete the following questionnaire. Your responses will help us assess whether these medications are a suitable option for you. Please answer all questions truthfully and to the best of your knowledge.
Additional Information
Please provide any additional information that you believe is relevant to your health and treatment plan:
Signature
By signing below, I confirm that the information provided in this questionnaire is accurate and complete to the best of my knowledge.