Forms & Patient Privacy

Forms and Patient Privacy

NEW PATIENT PACKET:

(All forms may be downloaded using Adobe Acrobat Reader).

You may download and print out all of the forms in the New Patient Packet below. Fill out the information and bring the completed packet with you to your New Patient Appointment.

Patient Demographic/Insurance Information

Back and Neck History Form

Financial Policies

Consent to Use and Disclose Health Information

Authorization to Communicate or Disclose Health Information

Notice of Privacy Practices

Notice of Privacy Practices Acknowledgement

Patient List of PHI Recipients



OTHER FORMS:

MEDICAL RECORDS - Authorization to Use, Disclose or Request

Patient Referral Form

Patient Authorization Request Form


Please bring all completed and pertinent new patient forms and records with you to your first visit. In order to better serve you, all and/or any related x-rays or imaging studies must be received PRIOR to the appointment.

You may mail records and x-rays to:

Triangle Spine and Back Care Center
3320 Wake Forest Road, Suite 430
Raleigh, NC 27609
ATTN: New Patient Referral

OR fax records to:

919.876.7163
ATTN: New Patient Appointments


PATIENT PRIVACY POLICIES:

As a patient at Triangle Spine and Back Care Center℠, you have a right to the following:

  • •Request and Receive a Copy of Triangle Spine and Back Care Center’s Notice of Privacy Practices.
    TSBCC’s NPP is a legal document stating how our practice protects your privacy. We have posted this itemized Privacy Notice for you to read and we will provide a detailed copy for each patient. You may choose to refuse a copy, but may request on at any time.


  • •Request Access to Your Protected Health Information (PHI).
    You may request access to and/or obtain a copy of your PHI (certain exceptions may apply). If TSBCC denies a request, specific denial procedures will be followed.


  • •Request Amendments of Your PHI.
    You may request amendments to your PHI if you believe information is incorrect or incomplete. If TSBCC denies a request, we will follow specific procedures and explain the action in plain written language.


  • •Request an Accounting of Disclosures.
    You may request an accounting of disclosures. This is a record of where your PHI has been disclosed for purposes other than treatment, payment, or healthcare operations.


  • •Request Restriction and Limitations.
    You may request restrictions or limitation of your PHI and also confidential communications with you at an alternate location. This will be documented in your chart.


  • •No Waiver of Rights.
    This practice cannot require an individual to wave rights as a condition of treatment.


  • •File a Complaint.
    You have the right to file complaint about how PHI has been used or disclosed, or about denial of access to PHI. Complaints may be submitted to HHS and/or to our Privacy Officer.

If you have any questions regarding the above office policies, please don't hesitate to contact our Privacy Officer.


Triangle Spine & Back Care Center is the longest standing orthopedic practice in Raleigh, NC that focuses solely on spine and back care with a fellowship-trained, board-certified orthopedic surgeon at its helm. William F. Lestini, MD, provides operative and non- operative treatments for all spinal conditions.