​Read each of the following very carefully before you sign (click below) this form. This will be placed in your chart and become a part of your medical record. By clicking below, you agree to release all associates of SOUTH PLAINS BARIATRIC and South PLAINS ASSOCIATION, P.A. from any liability on your part and of your heirs should medical problems arise at any time before or after the date your registration is received. If you have any questions, ask and a staff member will be happy to explain.

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This notice is designed to help you understand how we protect your personal information. 



​Your private records are safe with South Plains Bariatric Clinic and Dispensary.

The company has a longstanding policy that maintains the confidentiality of

the personal date necessary to administer bariatric treatment.



Confidentiality and Security



South Plains Bariatric and Dispensary has set out strict policies and procedures to protect the confidentiality of personal information.

We also maintain physical and procedural safeguards to protect personal data from unauthorized

access and unanticipated threats or hazards.



Information That May Be Collected



Information is provided by you on medical history, consent, and prescription

authorization forms. This information may come by telephone, online, or in writing.



Information Disclosure



South Plains Bariatric Clinic and Dispensary regards all personal information as confidential. We will not disclose your personal information without your authorization. A form will be required for release of medical records and pharmacy records.

Even if your relationship with us ends, the company is pledged to maintain its privacy policy and practices so that your privacy will be protected.



ATTN ALL PATIENTS:

This office and staff are not equipped to file any types of insurance. 

WE DO NOT ACCEPT OR FILE ANY MEDICARE, MEDICAID, OR INSURANCE OF ANY KIND

Most treatments here are considered ancillary or alternative treatments and are not covered by your standard medical insurance. If you want to check with your family physician before beginning treatment here perhaps, they can assist you.



I understand that if I have Medicare Medicaid that I cannot file my own forms and that by doing so I will get the physicians and staff in trouble with government authorities.

I understand that I may have copies of my charges for my taxes if so requested.



I understand that I may file my own insurance provided that it is NOT MEDICARE OR MEDICAID if I so desire.

This notice is provided on behalf of South Plains Bariatric Clinic and Dispensary