Dr. Zitnay's Forms  (You will need Adobe Acrobat Reader)

FORMS FOR YOUR FIRST APPOINTMENT

PLEASE CLICK HERE TO DOWNLOAD FORMS. There are five sections.

1. Past Medical History Form: this form is to learn about your past medical history the medicines you take, what you are allergic to, your social and family history. Please complete this form and bring it to your first appointment.
2. Consent form: This Privacy Notice informs you of your right for confidentiality and sharing your medical information with other health care professionals by HIPAA standards. It also allows us to release information to your insurance company for our claims process and informs you of the Virginia code on exposure to infections from blood.
3. Patient Information: this form is to know your full name, address, and insurance information. Please complete this form and bring it to your first appointment. If you already are a patient and have changes in your address or insurance, please fill this out and bring it to your next appointment.
4. Missed Appointment Policy: Policy on missing appointments.
5. Sharing Information with Family or Friends: Whom we may or may not dicuss your care with.

OTHER FORMS FOR YOUR HEALTHCARE

Blood Glucose (Sugar) Log: this form is for you to record your blood sugars. Please note the time you checked your sugar and what the blood sugar level was on your glucometer. You have 2 choices in forms: 1) An EXCEL 2002 Program that automatically averages your sugars and you can Email to Dr. Zitnay; OR 2)A normal file you print out and fill out by hand. Blood Glucose Log: If you choose the second, PLEASE average your sugars for each month and write that down. This would be most appreciated.

HbA1C (Hemoglobin A1C): a table of what your values mean (Blood glucose)

Release of Information: If you want Dr. Zitnay to receive medical records from another facility, this form needs to be completed by you and sent to the medical facility you are requesting records from.

Dr. Hong's Forms (You will need Adobe Acrobat Reader)

FORMS FOR YOUR FIRST APPOINTMENT

PLEASE CLICK HERE TO DOWNLOAD FORMS. There are five sections.

1. Medical Information: this form is to learn about your past medical history the medicines you take, what you are allergic to, your social and family history. Please complete this form and bring it to your first appointment.
2. Consent form: This Privacy Notice informs you of your right for confidentiality and sharing your medical information with other health care professionals by HIPAA standards. It also allows us to release information to your insurance company for our claims process and informs you of the Virginia code on exposure to infections from blood.
3. Patient Information: this form is to know your full name, address, and insurance information. Please complete this form and bring it to your first appointment. If you already are a patient and have changes in your address or insurance, please fill this out and bring it to your next appointment.
4. Missed Appointment Policy: Policy on missing appointments.
5. Sharing Information with Family or Friends: Whom we may or may not dicuss your care with.

OTHER FORMS FOR YOUR HEALTHCARE

Medical Release of Information & Consent: Release of Information - If you want Dr. Hong to receive medical records from another facility, this form needs to be completed by you and sent to the medical facility you are requesting records from.

Advanced Directives: We encourage you fill out an advanced directive form if you have not before and give it to your doctor. This form states what you would want done in case of a life threatening emergency, who we can talk to about your care if you cannot express your thoughts, and what your overall goals are for your healthcare. For example, if you would prefer to have a DNR status ("Do Not Resuscitate") but would like to have overall care if your quality of life can be preserved, you can express this in writing as well as discuss it with your caretaker/family member who will be responsble for you should you not be able to consent during an illness. This form should be put in your chart as well as a copy at Martha Jefferson Hospital.