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Dr. Swami's Wellness LLC

Phone: (803) 617-7553

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Now Open !!!!!

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6326 Saint Andrews Road
Columbia, SC 29212

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Dr. Swami's Wellness LLC

Travel Questionnaire
Notice of Privacy Practices
Your Information. Your Rights. Our Responsibilities.

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.


Your Rights

You have the right to:

  • Get a copy of your paper or electronic medical record

  • Correct your paper or electronic medical record

  • Request confidential communication

  • Ask us to limit the information we share

  • Get a list of those with whom we’ve shared your information

  • Get a copy of this privacy notice

  • Choose someone to act for you

  • File a complaint with the provider if you believe your privacy rights have been violated


Your Choices

You have some choices in the way that we use and share information as we:

  • Share with your family and friends about your condition


Our Uses and Disclosures

We may use and share your information as we:

  • Treat you for your health related conditions.

    We can use your health information and share it with other professionals who are treating you.

  • Run our organization

    We can use and share your health information to run our practice, improve your care, and contact you when necessary.

  • Bill for your services

    We can use and share your health information to bill and get payment from health plans or other entities.

  • Help with public health and safety issues.

  • Work with a medical examiner or funeral director

    We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

  • Comply with the law.

    We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

  • Respond to lawsuits and legal actions.

    We can share health information about you in response to a court or administrative order, or in response to a subpoena.

To the extent that we have your substance use disorder patient records, subject to 42 CFR part 2, we will not share that information for investigations or legal proceedings against you without (1) your written consent or (2) a court order and a subpoena.


Our Responsibilities
  • We are required by law to maintain the privacy and security of your protected health information.

  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

  • We must follow the duties and privacy practices described in this notice and give you a copy of it.Changes to the Terms of this Notice

    We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.


    Changes to the Terms of this Notice

    We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.


    Effective Date: June 1, 2026

Birthday
Month
Day
Year
Gender
Male
Female
Multi-line address
Travel Details
Date of Departure
Month
Day
Year
Purpose of Trip
Duration of Stay longer than 2 weeks?
No
Yes
Are you going to spend time in a rural area?
No
Yes
Are you going to spend time above 5000 feet?
No
Yes
Medical and Vaccination Status
Are you pregnant or breastfeeding an infant?
No
Yes
Are you allergic to eggs or chicken products?
No
Yes
Have you had Guillan-Barre Syndrome?
No
Yes
Have you had all of your childhood vaccinations?
No
Yes
Have you had any hypersensitivity or reaction to vaccination?
No
Yes
Have you had any significant medical problems in the past?
No
Yes
Are you currently being treated for any medical conditions?
No
Yes
Are you currently on any medications?
No
Yes
Do you have any allergies?
No
Yes
Have you had a tetanus/diptheria/pertussis(Tdap) vaccination in the last 10 years?
No
Yes
Have you had your Measles,Mums,Rubella(MMR) vaccination?
No
Yes
Have you had a Polio vaccination as an adult?
No
Yes
Have you had a Hepatitis A Vaccination?
No
Yes
Have you had a typhoid vaccination in the past 2 years?
No
Yes
Have you ever had a Yellow Fever vaccination?
No
Yes

Thank you for your submission.  We will contact you within 48 hours.  If you haven't heard from us, please call us at +1 803-617-7553.


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