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Register with Kaplan Clinic

Welcome to the Kaplan Clinic registration page. Thank you for selecting us to provide you with comprehensive and compassionate medical care. We look forward to partnering with you to improve your health and wellbeing.

To register as a new patient, please enter your information in the fields below. Please do not use this form if you are already a patient (you have seen any of our practitioners in the past). To set up patient portal access or amend your information, please contact us.

If you are already a registered patient with online access, you can log in here

Basic Contact Information

First Name * Middle Name (or initial) Last Name * Date of Birth * Social Security Number Nickname/Preferred Name Gender *

Your Address

Address 1 * Address 2 City * State/Province * Zip Code *

Contact Information

Mobile Phone Number Home Phone Number Work Phone Number Preferred Contact Number Email Address (Primary) * Secondary Email Address Home Fax Number

Emergency Contact

First Name * Middle Name Last Name * Relationship to Patient Email Address Phone Number *

Medical Information

Please enter your basic medical information below. You may also add or edit this information after you've signed up.

Height (in INCHES) Weight (in POUNDS) Personal Medical History (please also include surgeries and hospitalizations) Relevant Family Medical History (indicate which family member if applicable)

Set Username and Password for Patient Portal

Please create a username and password that you will use to log into the patient portal in the future.

Your username must be at least 4 characters long

Username *

Your password must be at least 8 characters long and include at least one number or special character.

Password * Confirm Password *

The patient portal gives you access to your medical records and lets you securely communicate with our office. When you sign up, you will receive an email with instructions for logging in.

"I consent to having medical information sent to my email address (we cannot guarantee the security of messages delivered by email)." "I have read and accept the terms of the privacy policy below:" *

The touchstone of excellent medical care is the confidentiality of communications between you and your healthcare providers. This is a value of utmost importance at the Kaplan Clinic.

As you may know, federal legislation entitled the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires healthcare professionals and other healthcare related entities, such as insurance companies and pharmacies, to notify clients about their rights to privacy concerning their personal healthcare records. In compliance with HIPAA, the Kaplan Clinic has prepared a statement outlining our rights to privacy under the new legislation. Our "Notice of Privacy Practices" is attached for your review.

At Kaplan Clinic, we have always and will continue to uphold policies and practices that protect the confidentiality of your private health information. Thank you for selecting us as your physicians and healthcare providers.

Sincerely,

Gary Kaplan, D.O., Medical Director, and Staff

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

During your first appointment at the Kaplan Clinic, a medical record was created that contains critical information such as your name, address, age, insurance coverage and medical condition. As you are aware, this record is updated each time you visit or contact the Kaplan Clinic. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), this information is referred to as your Individual Identifiable Health Information (IIHI) or Protected Health Information (PHI).

The terms of this Notice of Privacy Practices (Notice) apply to all records containing your PHI that are created or retained by the Kaplan Clinic. We reserve the right to revise or amend this Notice of Privacy Practices (such as, if the Privacy Officer changes or there is a change in the law). Any revision or amendment to this Notice will be effective for all of your records that our practice has created or maintained in the past and for any of your records that we may create in the future. The Kaplan Clinic will post a copy of the current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.

OUR OBLIGATIONS

We are required by law to:

Maintain the privacy of Protected Health Information (PHI)
Give you this notice of our legal duties and privacy practices regarding your health information about you
Follow the terms of our notice that is currently in effect

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION

We may use and disclose your Protected Health Information (PHI) under the following circumstances:

Treatment: The Kaplan Clinic may use your PHI to treat you. For example, we might use your PHI to contact a pharmacy when we order a prescription for you. We may disclose your PHI to others who assist in your care such as a consulting physician.
Payment: The Kaplan Clinic may use and disclose your PHI to bill and collect payment for the services and items you receive from us. For example, we may contact your health insurance company to preauthorize treatment or to obtain payment. We may use your PHI to bill you directly for services rendered, and in the event of non-payment, we may forward selective information (such as your name, address, phone number, and amount due) to other entities to assist us with billing and collections.
Healthcare Operations: The Kaplan Clinic may use and disclose your PHI to operate our business. For example, we may use your IIHI to evaluate the quality of care you receive from us.
In Response to a Public Health Risk: The Kaplan Clinic may disclose your PHI to public health agencies that are authorized by law to collect it. For example, personal health information may be disclosed for the purpose of maintaining vital records (such as a birth or death); reporting child abuse or neglect; preventing or controlling disease, injury, or disability; notifying a person regarding a potential exposure to a communicable disease; notifying a person regarding a potential risk for spreading or contracting a disease or condition; reporting reactions to drugs or problems with products or devices; notifying individuals if a product or device they may be using has been recalled; and notifying appropriate government agencies and authorities regarding potential abuse or neglect of an adult (including domestic violence). Please note that we will report potential domestic violence or the neglect of an adult only when the patient agrees or when we are legally mandated to disclose the information.
Health Oversight Activities: The Kaplan Clinic may disclose your PHI to a health oversight agency for activities required or authorized by law (such as activities necessary to monitor government programs, for example: a Medicare audit).
Lawsuits and Similar Proceedings: The Kaplan Clinic may disclose your PHI in response to a Court or Administrative Order. For example, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a subpoena, or other lawful process initiated by a party involved in the dispute, but only when the request is accompanied by a signed release from you.
Workers' Compensation: The Kaplan Clinic may disclose your PHI for workers' compensation and similar programs.
Law Enforcement: The Kaplan Clinic may release PHI if asked to do so by a law enforcement official.
Military: The Kaplan Clinic may disclose your PHI if you are a member of the United States military forces and, the request is made by the proper authorities.
National Security: The Kaplan Clinic may disclose your PHI to federal officials to cooperate with intelligence and national security activities authorized by law.
Data Breach Notification Purposes: The Kaplan Clinic may use or disclose your PHI to provide legally required notices of unauthorized access to or disclosure of your health information.

USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT AND OPT

Individuals involved in Your care or Payment for Your Care: Unless you object, the Kaplan Clinic may disclose to a member of your family, a relative, a close friend, or any other person you identify, your PHI that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that if is in your best interest based on our professional judgment.
Disaster relief: The Kaplan Clinic may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.

YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES

The following uses and disclosures of your PHI will be made only with your written authorization:

Uses and disclosures of PHI for marketing purposes.
Disclosures that constitute sale of your PHI; and
Uses and disclosures of psychotherapy notes about you.

Other uses and disclosures of PHI not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose PHI under the authorization. But disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.

YOUR RIGHTS

You have the following rights regarding your PHI maintained by the Kaplan Clinic:

Confidential Communications: You have the right to request that the Kaplan Clinic communicate with you about your health and health-related issues in a particular way to protect your privacy. To do so, you must send your request in writing to: Office Manager/ Privacy Officer at the Kaplan Clinic. Your letter must specify the method of confidential communication/contact you want the Kaplan Clinic to employ. We will accommodate reasonable requests.
Requesting Restrictions: You have a right to request a restriction in the Kaplan Clinic's use or disclosure of your PHI; however, the Kaplan Clinic is not required to accommodate your request. (For example, there may be circumstances where the Kaplan Clinic is legally required to disclose medical records, such as when responding to a Court Order or during a public health emergency). To request that the Kaplan Clinic restrict its use of your PHI, you must write to: Office Manager/ Privacy Officer at the Kaplan Clinic. Your request must include both the information you want restricted and a list of the persons/entities to whom the restrictions should apply.
Inspection and Copies: You have the right to inspect and obtain a copy of your PHI (excluding psychotherapy notes). To do so, you must submit a request in writing to Office Manager/ Privacy Officer at the Kaplan Clinic. The Kaplan Clinic has up to 30 days to make your PHI available to you and may charge a fee to cover the costs associated with your request, such as supplies, copying, postage, and labor. The Kaplan Clinic may not charge a fee if you need the information for a claim benefits under the Social Security Act or any other state or federal needs-based benefit program. The Kaplan Clinic may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.
Right to an Electronic Copy of Electronic Medical Records: If your PHI is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your PHI in the form or format you request, if it is readily producible in such form or format. If the PHI is not readily producible in the form or format you request your record will be provided in either our standard electronic format or, if you do not want this form or format, a readable hard copy form. The Kaplan Clinic may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.
Right to Get Notice of a Breach: You have the right to be notified upon a breach of any of your unsecured PHI.

Amendment: You may ask us to amend your PHI if you believe it is incorrect or incomplete. You can obtain a "Request for Correction/Amendment of Protected Health Information" form at the Kaplan Clinic or by calling or writing to us. The form requires you to provide reasons supporting your request for amendment/correction. The completed form should be sent to the attention of Office Manager/ Privacy Officer, at the Kaplan Clinic. It is the responsibility of the Kaplan Clinic to review, and then, either approve or deny your request to amend your PHI. When a request for amendment is denied, the Kaplan Clinic will provide an explanation in writing.

Accounting for Disclosure: All of our patients have the right to request an accounting of disclosures. An "accounting of disclosures" is a list of certain non-routine disclosures the Kaplan Clinic has made of your PHI for non-treatment, non-payment or non-operations purposes. Use of your PHI as part of the routine patient care in our practice is not required to be documented. In order to obtain an accounting of non-routine disclosures, you must submit your request in writing to Office Manager/ Privacy Officer at the Kaplan Clinic.

Paper Copy of this Notice: You are entitled to receive a paper copy of the Kaplan Clinic's Notice of Privacy Practices. You may ask for a copy of this notice at any time. To obtain a paper copy of this notice, contact HIPAA Coordinator.
9. Out-of-Pocket-Payments: If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your PHI with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and the Kaplan Clinic will honor that request.

COMPLAINTS

Filing a Complaint: If you believe your privacy rights have been violated, you may file a complaint with the Kaplan Clinic or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact Office Manager/ HIPAA Coordinator at the Kaplan Clinic. To file a complaint with the United States Secretary of Health and Human Services, you may write to: Barbara Holland, Regional Manager, Office for Civil Rights, U.S. Department of Health and Human Services, 150 S Independence Mall West, Suite 372, Public Ledger Building, Philadelphia, PA 19106-9111. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

If you have questions about this notice, please contact:

Title: Office Manager/Privacy Officer
Address: 6829 Elm St, Suite 300
Mclean, VA 22101
Telephone No: (703) 532-4892

I voluntarily present myself for treatment at the Kaplan Clinic, and I herby authorize my physicians and such associates, assistants and designees as they may select and the staff, agents and employees to perform, and I herby consent to, such medical care, including diagnostic procedures, medical treatments and examinations, as may be necessary in the opinion of my physicians. I hereby authorize Kaplan Clinic to apply for benefits on my behalf for services rendered. I request payment be made directly to Kaplan Clinic, PC. I certify that the information I have provided is true and accurate. I further authorize the release of any medical information or other information for this or any related claim to any insurance company. I permit a copy of this authorization and assignment to be used in place of the original. This will remain in effect until revoked by me in writing. I understand that I am financially responsible for all charges whether or not paid by insurance. I understand that if my balance remains unpaid for 45 days or more, it will be subject to an 18% annual interest rate, and if it becomes necessary to refer my account to a collection agency, I agree to pay the collection costs. I have reviewed and agree to the insurance information below:

Although we do not participate with any insurance programs, we want you to receive the maximum possible reimbursement for our services. We recommend that you contact your insurance company prior to your first visit to obtain the following information:

Find out if you have 'out-of-network' benefits and what percent of your insurance company's 'allowable charges' will be covered. The initial office visit will be billed using insurance code '99205'. Your insurance company can estimate the reimbursement you can expect to receive. Your insurance company should provide you with claim forms and the mailing address to which claims should be sent.
Find out if any medical services require prior authorization. Many companies require prior authorization for acupuncture, osteopathic manipulation, physical therapy, and radiological studies. Have a clear understanding of your insurance company's procedure for obtaining prior authorization.
Ask if your insurance company requires that office-visit notes be attached to your reimbursement-claim form. If so, we will be happy to provide you with this information.
Your doctor may order laboratory testing or other procedures as part of your evaluation. The cost of any such tests is not included in the fee for your initial appointment. For routine laboratory testing, many patients prefer the convenience of having their blood drawn at The Kaplan Center. Other patients prefer to obtain an order for labs to be drawn at an 'in-network' facility. Please note that specialty laboratory testing may only be available through The Kaplan Medical Center.

We will make every effort to provide you with the most complete and accurate fee slip to submit to your insurance company. After your appointment, but before leaving the Kaplan office, please review your fee slip to ensure that it includes the date of service, your doctor's signature, and a checkmark in the box next to the doctor's name. This will help ensure that your insurance company processes your request for reimbursement expeditiously.

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