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病人信息 & 形式

At 乌兰巴托诊所, we want you to have the best possible experience. 加快 your visit, kindly print 和 complete the appropriate forms below 和 bring them with you to 你约会的时间. In addition, feel free to review our Patient’s Bill of Rights below.

取消/缺席政策

UB诊所简介(英文)
UB诊所概述(西班牙语)

病人形式

Complete the appropriate forms below 和 bring a copy with you to 你约会的时间.

UB诊所入院表格(英文)
UB诊所入学表格(西班牙语)
To be completed by all new UB Clinic patients except for Fones 口腔卫生诊所 patients.

医疗释放表格
Please complete to authorize to obtain/release medical 信息.

同意治疗未成年人
Please complete to authorize healthcare 服务 for a minor child.

UB针灸患者同意书 Form
Please complete if you are visiting the UB 针灸诊所.

口腔卫生诊所健康 历史形式
Please complete if you are visiting the Fones 口腔卫生诊所.


作为病人,你有一定的权利. 有些权利受到联邦法律的保障 such as the right to obtain a copy of your medical records 和 the right to keep 他们的私人. (See UB Clinic’s 请注意 of Privacy Practices)

We seek to provide quality care that is fair, responsive 和 accountable to the 每个病人和家属的需要. 为了有效地实现这一目标, we must work as a team to ensure that each patient is 治疗 with respect 和 作为护理方面的平等伙伴. You can help us make your healthcare experience safe by being an active 和 informed partner with your healthcare team.

As our patient, we want to make sure you underst和 your rights 和 责任.

您有权:
  • 体贴、保密和尊重的关怀.
  • Obtain from clinicians 和 临床 students relevant, current, 和 underst和able 信息 concerning diagnosis, treatment, 和 prognosis.
  • Know the identity of those involved in your 护理, including those involved 谁 是学生还是实习生?.
  • Make decisions about the plan of care prior to 和 during the course of treatment 和 to refuse a recommended treatment or plan of care. 这 包括 your right to ask questions about treatment 和 treatment alternatives, or 停止治疗.
  • Continuity 和 completion of treatment with the same clinician 和/or 临床 学生团队.
  • 对隐私的所有考虑. 病例讨论、咨询、检查、 和 treatment will be conducted so as to protect each patient’s privacy.
  • Expect that all 通信 和 records pertaining to care will be 治疗 as confidential by the 乌兰巴托诊所, except in cases such as suspected abuse 和 public health hazards when reporting is permitted or required by law.
  • Review the records pertaining to your care 和 to have the 信息 explained or interpreted as necessary, except when restricted by law.
  • Expect that, within its capacity 和 policies, the 乌兰巴托诊所 will make reasonable response to the request of a patient for appropriate care 和 服务.
  • Ask 和 be informed of the existence of business relationships among the UB Clinics, educational institutions, other health care providers that may 影响病人的治疗和护理.
  • Consent to or decline to participate in proposed research studies or human experimentation affecting care 和 treatment or requiring direct patient involvement, 和 to have those studies fully explained prior to consent.
  • Be informed of health care policies 和 practices that relate to patient 护理, 待遇和责任.
  • Treatment in an environment that observes St和ard Precautions for the 预防传染病的传播.
  • To be informed of the UB Clinic’s charges for 服务 和 available payment 治疗开始前的方法.
患者有责任:
  • Providing to your clinicians 和 临床 students an accurate 和 complete health background 和 信息 about present illnesses 和 complaints.
  • Reporting changes in the conditions 和 complaints being 治疗 in this 设施.
  • Being responsible for consequences when you refuse 和 choose not to follow the 临床医生的指导和建议.
  • Being on time for appointments 和 communicating with the 乌兰巴托诊所 immediately if an appointment needs to be cancelled or changed.
  • Following 乌兰巴托诊所 rules 和 policies regarding 护理, treatment, payment 和 通信.
  • If you feel any of your rights have been violated while a patient at the 乌兰巴托诊所, 请与UB诊所管理员联系.

    In response to growing concerns about keeping health 信息 private, the United States Congress adopted the 健康保险 Portability 和 1996年的责任法案(HIPAA). 这个隐私规则创造了国家标准 to protect individuals’ personal health 信息.

    In keeping with HIPAA 和 the 乌兰巴托诊所 Patients Rights & 责任 we will consistently strive to respect personal privacy 和 confidentiality of 信息 和 records regarding patient care. 受保护的运行状况信息 will only be used 和 disclosed in accordance with Clinic policies 和 State 和 Federal laws to maintain privacy of individually identifiable health 信息.

    Each patient should expect to receive a 请注意 of Privacy Practices at the time 你的第一次预约. 这 document describes how your personal medical 信息 may be used 和 disclosed 和 how to access this 信息.

    健康保险 《十大网赌平台》 隐私规则要求 that we develop 和 distribute a notice that provides a clear, user friendly explanation of your rights regarding your personal health 信息 和 我们的隐私保护措施.

    请注意 私隐实务(pdf)

    If you have any questions or concerns about our 请注意 of Privacy Practices, please contact the 乌兰巴托诊所 Privacy Officer at (203) 576-2355.


    2024年春季:1月2日- 5月3日

      周一 周二 周三 周四 星期五 周六
    针灸* 8 a.m.-12 p.m. /
    1-5 p.m.
    10 a.m.-2 p.m. /
    3-6 p.m.
    8:30 a.m.-12:30 p.m. /
    1:30‑5:30 p.m.
    9 a.m.-12:30 p.m. /
    1:30‑5:30 p.m.
    关闭 9 a.m.-1 p.m. 指定日期* *
    脊椎按摩疗法 9 a.m.-6 p.m. 12-6 p.m. 1-6 p.m. 12-6 p.m. 9 a.m.-3 p.m. 关闭
    口腔卫生* * 8 a.m.-12 p.m. /
    1‑5 p.m.
    8 a.m.-12 p.m. /
    1‑5 p.m.
    8 a.m.-12 p.m. /
    1‑5 p.m.
    8 a.m.-12 p.m. /
    1‑5 p.m.
    8 a.m.-12 p.m. /
    1‑5 p.m.
    关闭

    * Acupuncture 周六 Schedule: 1/12, 1/27, 2/10, 2/24, 3/16, 4/13, 4/27
    ** Fones诊所开放时间为1/9-4/12