Patient Health Information Consent Form
|
|
|
- Beverley Barber
- 5 years ago
- Views:
Transcription
1
2
3 Patient Health Information Consent Form We want you to know your Patient Health Information (PHI) is going to be used in this office as well as your rights concerning those records. Before we will begin any health care operations, we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information, we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. 1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to Health Insurance Company (or companies) provided by us by the patient for the purpose of payment. 2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. 3. A patient s written consent need only be obtained one time for all subsequent care given to the patient in this office. 4. The patient may provide a written request to revoke consent at any given time during care. This would not effect the use of those records for the care given prior to the written request to revoke consent, but would apply to any care given after the request has been presented. 5. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them. 6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures. 7. If the patient refuses to sign this consent for the purpose of treatment, payment, and health care operations, the chiropractic physician has the right to refuse to give care. I have read and understand my Patient Health Information will be used and I agree to these policies and procedures. Name of Patient Date
4 CHIROPRACTIC SPECIALISTS OF PITTSBURGH Dr. James DiDiano, D.C. INFORMED CONSENT Chiropractic, as well as other types of healthcare, is associated with potential risk in the delivery of treatment. Therefore, it is necessary to inform the patient of such risks prior to initiating care. While Chiropractic treatment is remarkably safe, you need to be informed about the potential risks related to your care to allow you to fully be informed in contesting to treatment. SPECIFIC RISK POSSIBILIES ASSOCIATED WITH CHIROPRACTIC CARE ARE: Stroke: Stroke is the most serious complication of Chiropractic treatment. It is rare. According to the journal of CCA, vol. 37 no2, June 1993, recent studies estimate the risk of this type of stroke is 1 in every 3 million upper cervical adjustments. Vertebral arteries, which supply the brain with blood, are located within the bones of the upper spine. Therefore, cervical treatment poses a small risk for the stroke, which is temporary or permanent brain dysfunction. On extremely rare conditions, death occurs. Soreness: Chiropractic adjustments are sometimes accompanied with post treatment soreness. This is normal, but please advise your doctor of Chiropractic of the soreness. Soft Tissue Injury: Occasionally, Chiropractic treatment may aggravate a disc injury, or cause minor joint, ligament, tendon, or other soft tissue injury. Rib Injury: Manual adjustments to the thoracic spine, in rare cases, may cause a rib injury or fracture. Precautions such as pre-adjustment X-rays are taken in cases considered at risk. Treatment is performed carefully to minimize such risks. Physical Therapy Burns: Heat generated by physical therapy modalities can cause minor burns to the skin. These are rare, but should be reported, as well as other side affects you may be experiencing. Chiropractic is a system of healthcare delivery and therefore, as with any healthcare delivery system, we cannot promise a cure for any symtoms, condition or disease. An attempt to provide the best Chiropractic care is our goal, and if the results are not successful, we will refer you to another healthcare provider. If you have any questions, please ask your doctor. Having carefully read the above, I hearby give my informed consent to have Chiropractic treatment administered. Patients Printed Name Todays Date Patients Signature Parent/Guardian if Minor
5 CHIROPRACTIC SPECIALISTS OF PITTSBURGH Dr. James DiDiano, D.C. PATIENT NOTIFICATION OF FINANCIAL RESPONSIBILITY I understand that I may be financially responsible for any charges incurred at this office including copayments, deductibles, and charges denied or not covered by my insurance company. I realize that my care may be subject to pre-authorization by my insurance company, and I accept all responsibility for any treatments that are determined to be not medically necessary. I understand that my coverage does not cover routine maintenance, preventative or wellness visits. My initial office visit and examination is covered under my contract and will not be billed to me if continued treatment is determined to be medically necessary. Chiropractic Specialists of Pittsburgh will submit all required documentation to the insurance company, or their designee, so that a review relative to determination of medical necessity can be made for subsequent treatment. I understand that both Chiropractic Specialists of Pittsburgh and myself will receive direct notification from the insurance company, or their designee, and will be advised as to whether additional treatment has been approved or denied and the number of visits that have been approved for specified time period. Charges for services determined to be not medically necessary by the insurance company will be my responsibility. Insurance policy limiation is per individual insurance policy plan, as are co-payments, co-insurance, deductibles, pre-authorization, and/or referrals. I have read and understand my obligations for payment care in the absence of insurance coverage. Print Patients Name Signature (Patient, Parent, Guardian) Date
Patient Registration & Health History
Patient Registration & Health History Today s Date: / / How did you hear about us? Legal Name: How do you prefer to be addressed? Address: City: State: Zip: Date of Birth / / Age: Gender: M / F Marital
SHEDDON PHYSIOTHERAPY AND SPORTS CLINIC
Patient Name: Date of Birth: / / Last First Day Month Year Address: City: Home Tel: Other Tel: Postal Code: *E-mail: Family Physician: Do you have a Doctors referral? How did you hear about us? If so,
Personal and Family Health History
Personal and Family Health History Name Date of Service Address Phone: (H) City State Zip (W) E-mail Marital Status S M D W Date of Birth (Age ) Occupation Employer Spouse s Name Spouse s Occupation In
SHEDDON PHYSIOTHERAPY AND SPORTS CLINIC
INTAKE FORM Patient First Name Patient Last Name Date of Birth: / / DD month YYYY Address: City: Prov: Postal Code: Mobile Tel: Home Tel: Accepts to receive SMS Text message appointment reminders *E-mail:
WELCOME TO WINDROSE CHIROPRACTIC
WELCOME TO WINDROSE CHIROPRACTIC Please complete the following information. We appreciate your cooperation! Chiropractic Case History/Patient Information (Please print) Date: Patient # Doctor Name: Social
INFORMED CONSENT TO CHIROPRACTIC CARE
INFORMED CONSENT TO CHIROPRACTIC CARE I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy, on me (or
Welcome to Phillips Family Chiropractic
Welcome to Phillips Family Chiropractic Name: Age: DOB: / / SS# / / Address: City: State: Zip Code: Phone: ( ) - Employer: Occupation: Circle One: Single / Married Number of Children: Email: Spouse: Employer:
1150 Prairie Parkway Suite 102 Dr. Heidi Western, D.C. West Fargo, ND (701)
AKER CHIROPRACTIC Dr. JaNyne Aker, D.C. 1150 Prairie Parkway Suite 102 Dr. Heidi Western, D.C. West Fargo, ND 58078 (701) 356-4900 PATIENT INFORMATION: TODAY S DATE: / / Name First MI Last Address City
BACK-HEALTH CHIROPRACTIC INITIAL PATIENT REGISTRATION (2016) Dr. Goudarz Vassigh, DC THIS SECTION REFERS TO PATIENT ONLY
INITIAL PATIENT REGISTRATION (2016) Dr. Goudarz Vassigh, DC PATIENT THIS SECTION REFERS TO PATIENT ONLY Patient: LAST FIRST MIDDLE Address: City, State, Zip: Cell Phone ( ) of birth Male Female Social
Prairie Life Chiropractic 1224 S. Main Ave. Sioux Center, IA 51250
Patient Information Name Birth Date Guardian s Name (If applicable) Address City State Zip Home Phone ( ) Cell ( ) Email Sex: Age SS# Race: Ethnicity: Occupation Employer Employer City Employer Phone(
PATIENT APPLICATION FORM
PATIENT APPLICATION FORM WELCOME TO OUR CLINIC! We specialize in assisting our patients to achieve their highest level of health through our spinal and postural corrective programs. Our approach is very
WELCOME TO OUR OFFICE
WELCOME TO OUR OFFICE We realize that this is your first visit to our office, and our past experience has shown us that new patients have many unanswered questions on their minds. Our staff will attempt
FINANCIAL POLICY & AGREEMENT
BACK TO HEALTH CHIROPRACTIC WELLNESS CENTER, P.C. 10990 Chicago Drive Zeeland, MI 49464 (616) 546-3500 FINANCIAL POLICY & AGREEMENT SOURCE OF PAYMENT The Financial Policy of Back to Health Chiropractic
you like listed as your primary
Patient Information Southlake Chiropractic welcomes you to our office. We strive to provide the best possible chiropractic care. Dr. Devos will conduct a thorough history and physical exam to decide how
Northwest Functional Neurology Dr. Glen Zielinski DC, DACNB, FACFN 4035 SW Mercantile Dr., Suite 112 Lake Oswego OR
rthwest Functional Neurology Dr. Glen Zielinski DC, DACNB, FACFN 4035 SW Mercantile Dr., Suite 112 Lake Oswego OR 97035 503-850-4526 DEMOGRAPHCS Last Name: First Name: MI: Date of Birth / / Gender: SS#:
Greenberg Chiropractic LLC REGISTRATION FORM (Please Print)
Today s Date: LLC REGISTRATION FORM (Please Print) PATIENT INFORMATION Patient s last name: First: Middle: Mr. Miss Marital status: Mrs. Ms. Single Mar Div Sep Wid Is this your legal name? If not, what
PS CHIROPRACTIC PATIENT CASE HISTORY
PS CHIROPRACTIC PATIENT CASE HISTORY Personal Information Last Name First Name Middle Initial Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Date of Birth: age Social Security
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM NAME: Age: DATE OF BIRTH: SSN: Sex: MARITAL STATUS: PRIMARY CARE PHYS: DRIVER S LICENSE # STATE IF CHILD, GUARDIAN S NAME: ADDRESS: City State Zip Code PHONE: Home Phone Cell Phone
PATIENT INFORMATION. Street address: Social Security no.: Home phone no.: ( ) City: State: ZIP Code:
Today s date: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Married / Divorced / Separated / Widow Is this your legal name? If not, what
ADKINS CHIROPRACTIC LIFE CENTER 157 KEVELING DRIVE SALINE, MICHIGAN Notice of Patient Privacy Policy
ADKINS CHIROPRACTIC LIFE CENTER 157 KEVELING DRIVE SALINE, MICHIGAN 48176 734 429 2410 Notice of Patient Privacy Policy This notice describes how medical information about you may be used and disclosed,
(Please Print Clearly) Primary Care Physician and clinic: PATIENT INFORMATION. If not, what is your legal name? (Former name): Birth date:
Today s date: (Please Print Clearly) Primary Care Physician and clinic: PATIENT INFORMATION Last name: First: MI: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your
Practice Member Health Questionnaire
89 Route 101A Amherst, NH 03031 Practice Member Health Questionnaire Name What do you prefer to be called? Home Phone Cell Phone Work Phone Address City, State, Zip of Birth Would you like text message
Patient Health Information Consent Form
Patient Health Information Consent Form We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any
PATIENT INFORMATION. Name Soc. Sec. # - - Last Name First Name Initial Address. City State Zip code. E mail address Sex M F Age Birth date
PATIENT INFORMATION Name Soc. Sec. # - - Last Name First Name Initial Address City State Zip code E mail address Sex M F Age Birth date Home phone Mobile phone Work phone In case of emergency who should
CHIROPRACTIC PATIENT REGISTRATION AND HISTORY
CHIROPRACTIC PATIENT REGISTRATION AND HISTORY Today s Date: / / Date Symptoms began: / / Is your condition due to an accident? Yes No Type: Auto Work Home Other Name : Address: Last First Middle Street
Consent for Purposes of Treatment, Payment and Healthcare Operations
Consent for Purposes of Treatment, Payment and Healthcare Operations I consent to the use or disclosure of my protected health information by Neuropsych Associates for the purpose of diagnosing or providing
Patient Name (print): Responsible Party (if a minor): Relationship to patient: address *Emergency contact? Tel #:
PATIENT INFORMATION: Patient Name (print): Responsible Party (if a minor): Relationship to patient: E-mail address *Emergency contact? Tel #: Patient Birth : / / Sex: F / M Age: Social Security #: - -
Appointment Confirmation Policy
Appointment Confirmation Policy Our Office strives to be respectful of each patient s time. When patients do not show up for their scheduled appointments or are late to notify our office of a cancelation,
Christos Vasakiris, D.C.,D.A.C.A.N. 350 West Montauk Highway Lindenhurst, N.Y, 11757
Christos Vasakiris, D.C.,D.A.C.A.N. 350 West Montauk Highway Lindenhurst, N.Y, 11757 PLEASE PRINT Patient Name SS# Address City State Zip Code Birth Date / / Age Circle one: Marital Status: S/M/D/W/P How
Robert E. Parker, Ph.D., P.C st Ave S. #101 Normandy Park, WA (206)
Robert E. Parker, Ph.D., P.C. 19987 1 st Ave S. #101 Normandy Park, WA 98148 (206) 824-7275 HIPAA - WASHINGTON NOTICE FORM Notice of Psychologists Policies and Practices to Protect the Privacy of Your
The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in
The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in Patient Information Thank you for choosing our practice for your chiropractic needs. Please
Welcome to MARTIN CHIROPRACTIC
Welcome to MARTIN CHIROPRACTIC 225 E. Buena Vista Street, Barstow, CA 92311 (760)-256-2171 www.drscottmartin.com Name: Date of Birth Age Last First Middle Initial Address: Social Security # City State
MICHIGAN HEALTHCARE PROFESSIONALS, P.C.
MICHIGAN HEALTHCARE PROFESSIONALS, P.C. PATIENT NOTICE OF PRIVACY PRACTICES As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996-(HIPAA),
Chirohealth 825 NE. 7 th St Grants pass OR Patient Information. Occupation: Employer s Address: Alternate contact person: name
825 NE. 7 th St Grants pass OR 97526 Dr. David Ray D.C. FNP Dr. Todd Harris D.C. Eve Ledesma PT Patient Information Name: Date: Address: Birth Date: City, State, Zip: Male / female Home Phone: Cell Phone:
New Patient Intake Paperwork
New Patient Intake Paperwork NAME: Last First Middle DATE OF BIRTH: SEX: M / F ADDRESS: Street City State Zip PHONE: MOBILE: EMAIL ADDRESS: EMPLOYER NAME: PHONE: EMPLOYER ADDRESS: EMERGENCY CONTACT: PHONE:
PRIMARY CARE PHYSICIAN
PATIENT INFORMATION OFFICE USE ONLY HIPAA No-Show form Patient Financial form Referral LRYGB / LVSG / LAGB / DOS: SELF LAST NAME FIRST ADDRESS CITY DATE OF BIRTH PLEASE LIST PREFERRED NUMBER OF CONTACT
Barrett Spinal Care, PC 441 S Muskogee Ave. Tahlequah, OK Notice of Patient Privacy Policy
Barrett Spinal Care, PC 441 S Muskogee Ave. Tahlequah, OK 74464 918-453-0112 Notice of Patient Privacy Policy This notice describes how medical information about you may be used and disclosed, and how
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Name: Primary Phone: Secondary Phone Address:_ City: State: Zip: Social: Age: DOB: Height: Weight: Primary Physician: _ Referral Source: Email Address: HISTORY Chief Complaint:
ACKNOWLEDGMENT OF RECEIPT OF HIPAA PRIVACY NOTICE
WELCOME to our office! Please allow our staff to make a photocopy of your insurance card(s) (if applicable). Please Print Clearly PERSONAL INFORMATION: Patient Name: Preferred Name: Address: City/State/Zip:
NOTICE TO OUR PATIENTS
NOTICE TO OUR PATIENTS Although we participate with most insurance plans, you as the patient and/or insured party are responsible for co-pays, deductibles and any non-covered services, which are outlined,
Health care provider instructions
Workers Compensation Division Health care provider instructions Worker s and Health Care Provider s Report for Workers Compensation Claims The worker should complete the worker section of this form for
RD Physical Therapy & Wellness, LLC
RD Physical Therapy & Wellness, LLC Tel: 443-253-4603 Fax: 410-720-2690 Clinic Location : 3450 Ellicott Center Dr., Suite 105 Ellicott City, MD 21043 Patient information: Registration Form Last name: First
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Name: Primary Phone: Secondary Phone Address: City: State: Zip: Social: Age: DOB: Height: Weight: Primary Physician: Referral Source: Email Address: HISTORY Chief Complaint: Where
HIPAA MANUAL Whole Child Pediatrics
HIPAA MANUAL HIPAA Manual Table of Contents 1.General a. Abbreviated Notice of Privacy Practices Framed for Reception Area b. Notice of Privacy Practices 6 pages to printer c. Training Agenda d. Privacy
CHIROPRACTIC 1 ST NEW PATIENT INFORMATION PATIENT INFORMATION
PATIENT INFORMATION INSURANCE INFORMATION Patient Name: : Address: Birthdate: Responsible for this account: Relationship to Patient: Insurance Co.: Group #: ID #: SS Number: Sex: M F Age: Employer/School:
CHAMBERS MEDICAL GROUP 1802 East Busch Blvd. * Tampa, FL * (813) * (813) fax
CHAMBERS MEDICAL GROUP 1802 East Busch Blvd. * Tampa, FL 33612 * (813) 932-5150 * (813) 931-3542 fax PERSONAL INFORMATION: PLEASE PRINT MISS/MRS/MS/MR: AGE: FIRST MIDDLE MAIDEN LAST DATE OF BIRTH: / /
Patient Health Summary
Patient Health Summary Patient Name: Birthdate: / / Sex: M F Address: City: State: Zip: CIRCLE which telephone # to leave appointment reminders or health related messages: Home: Work: Cell: Do you give
PHYSICAL THERAPY & CHIROPRACTIC CARE
PHYSICAL THERAPY & CHIROPRACTIC CARE Patient Information Name: Social Security #: Date of Birth: Telephone: Home: _ Cell: Email: (Communications are for appointments, office information & newsletters)
CREEKSIDE DENTAL REGISTRATION FORM. Please Print PATIENT INFORMATION. Patient s Last Name: First: Middle:
Today s date CREEKSIDE DENTAL REGISTRATION FORM Please Print PATIENT INFORMATION Patient s Last Name: First: Middle: Home Phone #: Work #: Cell #: Email Address: Street Address: City: State: Zip Code:
Welcome to our office!
2007 Rainbow Drive Gadsden, AL 35901 Ph: 256-543-0009 Fax: 256-549-1221 Patient Information Page 1of 2 Welcome to our office! Dr. Shan Tian, D. C. Patient Information Please complete all questions. Today
Have you had Chiropractic Care Before? When? Where? What is your current complaint (be specific)?
Welcome to Rizzo Chiropractic Holistic Health and Wellness Center Check the following services you are interested in: Chiropractic Physical Rehabilitation Nutritional Analysis (Hair, Blood & Urine) Detox
Perpetual Motion Physical Therapy, Inc. Patient Information
Perpetual Motion Physical Therapy, Inc. Patient Information Date Patient Information Name Last First MI Address Birth Date Age Social Security Sex: Male Female Contact Phone Work Phone Email Employer Occupation
AUTHORIZATION FOR TREATMENT
Thank you for choosing ARIZONA MANUAL THERAPY CENTERS. Please read each section below carefully, sign and date, and return to the front office personnel. If you have any questions or concerns, please ask
Nicholas Southworth, D.C.
Always Active, Always Improving Nicholas Southworth, D.C. PATIENT INFO Patient Name: Male [] Female [] Birthdate: / / Age: SS#: - - DL # Home Address City/State/ZIP Home Phone: ( ) Cell Phone: ( ) Would
Patient Case History
Patient Case History Name: Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Email Address: Preferred Contact: Home Phone Cell Work E-mail Employer & Occupation: Date of Birth:
PEDRO J. MORALES, M.D. & TIM P. CARLSON, M.D., P.A. NOTICE OF PRIVACY PRACTICES UPDATED 01/01/2014
PEDRO J. MORALES, M.D. & TIM P. CARLSON, M.D., P.A. NOTICE OF PRIVACY PRACTICES UPDATED 01/01/2014 PLEASE REVIEW, SIGN AND RETURN TO THE FRONT DESK OR MAIL TO: 2191 9 TH Avenue North, Suite 220 St. Petersburg,
Integrated Spinal Solutions Patient Information
Integrated Spinal Solutions Patient Information Patient Name: City/State/Zip: Today s Date: Home Telephone: Work Telephone: Birth Date: Age: Cellular Telephone: Height: Weight: Employer s Name: Social
ANDERS CHIROPRACTIC & SPORTS PERFORMANCE Application for Treatment Involving Accident of Trauma Marc Anders, D.C.
ANDERS CHIROPRACTIC & SPORTS PERFORMANCE Application for Treatment Involving Accident of Trauma Marc Anders, D.C. Today s Date: Name: DOB: Sex: M F Address: City/State: Zip Code: Home Phone: Alt. Phone
Patient Information. Name Birthdate Age. Single Married Separated Divorced Widowed. Cell Phone ( )
Patient Information Name Birthdate Age Male Female Single Married Separated Divorced Widowed Primary Phone ( ) Secondary Phone ( ) Cell Phone ( ) Email Appoint Reminder Message Type (Please circled preferred)
Patient name: LAST FIRST MIDDLE. Address: Responsible Party SS#: Required If patient a minor and/or full-time student. Employer: Occupation:
PATIENT Information SHEET ACCT # PT Patient name: LAST FIRST MIDDLE Date of Birth: Age: (please circle :) Female Male Address: Responsible Party SS#: Required If patient a minor and/or full-time student
GETTING TO KNOW YOU. 1. How important is it for you to keep your teeth healthy for a lifetime?
Robert W. Renger, D.D.S., L.L.C. 510 W. 32 nd St. Joplin, MO 64804 417-781-6700 GETTING TO KNOW YOU 1. How important is it for you to keep your teeth healthy for a lifetime? 2. If you could change one
Joint Chiropractic Case History/Patient Information
1 Joint Chiropractic Case History/Patient Information Name: Date: Social Security # Birth Date: Race: Marital Status: M S W D Address: City: State: Zip: E-mail address: Cell: Home: Work Occupation: Employer:
HIPAA NOTICE OF PRIVACY PRACTICES PLEASE REVIEW IT CAREFULLY
HIPAA NOTICE OF PRIVACY PRACTICES Arlington Orthopedics And Hand Surgery Specialists, Ltd. Effective Date: April 14, 2003 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
NOTICE OF PRIVACY PRACTICES ORTHOPEDIC ASSOCIATES OF LANCASTER, LTD.
NOTICE OF PRIVACY PRACTICES ORTHOPEDIC ASSOCIATES OF LANCASTER, LTD. Willow Valley Medical Center North Pointe Business Park Spooky Nook Sports Complex 212 Willow Valley Lakes Drive 170 North Pointe Boulevard
Name: Social Security: Address: City: State: Zip: Birthdate: Age: address: Cell Telephone: ( ) Fax: ( )
Dear Patient: Please complete this questionnaire. You answers will help us determine if chiropractic care can help you. If we do not sincerely believe your condition will respond satisfactorily, we will
New patient intake information
Carrollton Douglasville Villa Rica - Mirror Lake New patient intake information Last Name: First Name: MI: Address: City: State: Zip Code: Home Phone #: Work Phone #: Cell Phone #: Email Address: SS#:
Saint Louis University Notice of Privacy Practices Effective Date: April 14, 2003 Amended: September 22, 2013
Saint Louis University Notice of Privacy Practices Effective Date: April 14, 2003 Amended: September 22, 2013 This notice describes how medical information about you may be used and disclosed and how you
Family History: Cancer Diabetes High Blood Pressure Heart Problems/Stroke Rheumatoid Arthritis
INITIAL HEALTH STATUS Sex M/F Patient Name: Birthdate: Age: Address: City: State: Zip: Phone ( ) Email: Occupation: Employer: Work Phone( ) Address: City: State: Zip: Subscriber Name: Health Plan: Subscriber
MACRI DENTAL LLC 4380 S. Syracuse St. Suite 502 Denver, CO Patient Registration Form
Personal Information Patient Registration Form Responsible Party First Name Initial Last Name Patient First Name Initial Last Name Address City State Zip Home Phone Work Cell Birthday Social Security Email
1641 Tamiami Trail Port Charlotte, Fl Phone: Fax: Health Insurance Portability and Accountability Act of 1996
1641 Tamiami Trail Port Charlotte, Fl. 33948 Phone: 941-629-6262 Fax: 941-629-1782 Health Insurance Portability and Accountability Act of 1996 HIPAA OMNIBUS NOTICE OF PRIVACY PRACTICES Effective April
Regulatory Compliance
Regulatory Compliance Sample Notice of Privacy Practices A covered entity has until September 23, 2013 to update its notice of privacy practices with the 2013 HIPAA amendments. An article on the CDA Practice
Patient Intake Form Patient Information
Patient Intake Form Patient Information Full Name: First MI Last Date: Address: City: State: Zip: Age: Birth Date: Female: Male: Email Address: Home Phone: Work Phone: Cell/Other: I prefer to receive calls
Kruse Park Chiropractic Clinic
Kruse Park Chiropractic Clinic 3990 Collins Way, Suite 201 Lake Oswego, OR 97035 Phone: 503-635-1236 Fax: 503-697-4741 Web: www.kruseparkchiro.com Today s Date: Name NEW PATIENT REGISTRATION How did you
NOTICE ABOUT REFRACTION
NOTICE ABOUT REFRACTION We have you scheduled for a complete eye exam or surgical consultation today. All surgical consultations require a refraction in order to determine which vision correction procedure
COMMERCIAL INSURANCE Patient & Payor Information Form All Patients or Patients Legal Representative, please complete all Sections
COMMERCIAL INSURANCE Patient & Payor Information Form All Patients or Patients Legal Representative, please complete all Sections (1) Patient: (Full Legal Name or as on Insurance Card) Name: Last First
NEW LIFE COMMUNITY MIDWIFERY NOTICE OF PRIVACY PRACTICES Effective 1/1/2006
NEW LIFE COMMUNITY MIDWIFERY NOTICE OF PRIVACY PRACTICES Effective 1/1/2006 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
First Name: Middle Name: Last Name: Preferred Name: Address: City: State: Zip: Mother s First & Last Name: Mother s Home Phone: Mother s Work Phone:
Patient Information First Name: Middle Name: Last Name: Date of Birth: Gender: M F Preferred Name: Address: City: State: Zip: Contact Information Mother s First & Last Name: Mother s Address (If different
Carter Family Dentistry
Carter Family Dentistry General Dentistry Patient Information Patient Name: Date: Last First MI Occupation: Employer: Title/Pos. 1 Male 1 Female 1 Single 1 Married 1 Child 1 Other Spouse s Name Social
Luedtke-Storm-Mackey Chiropractic Clinic S.C. Notice of Privacy Practices. Effective September 23, 2013
Luedtke-Storm-Mackey Chiropractic Clinic S.C. Notice of Privacy Practices Effective September 23, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN
Please list all current medications and supplements that you are taking:
PATIENT HEALTH AND MEDICAL HISTORY Today s Date: Chief Complaint for Today s Visit: Was this injury gradual or sudden onset? Date of sudden onset: Please explain: Do you have a history of present symptoms?
PRO SPORTS THERAPY, INC. (P.S.T.)
PRO SPORTS THERAPY, INC. (P.S.T.) Dear Patient, Thank you for choosing Pro Sports Therapy. Enclosed is the paperwork we need you to complete and bring to your upcoming physical therapy evaluation appointment.
Patient Registration
Patient Registration Date: / / Patient s First Name: Last Name: MI: Street Address: City,State,Zip: Primary Phone #: Home / Work / Mobile (circle one) Secondary Phone #: Home / Work / Mobile (circle one)
NOTICE ABOUT REFRACTION
NOTICE ABOUT REFRACTION We have you scheduled for a Complete Eye Exam or surgical consultation today. If you are here for your Eye examination and you are experiencing blurry vision or any visual changes,
Patient Release of Information and Assignment of Benefits
Patient Release of Information and Assignment of Benefits Patient Name: Emergency Contact: Name Phone Number I agree to assign payment, be made directly to The Institute for Hand and Upper Extremity Rehabilitation,
New Client Information Sheet
New Client Information Sheet PSY Family Services Please complete ALL questions 301 W. Rosedale, Fort Worth, TX 76104 1. Client Demographics Patient Name: Last: First: Middle: Sex: ( )M ( )F DOB: Age: School
PATIENT INFORMATION. PARENT OR RESPONSIBLE PARTY (if different from patient)
PATIENT INFORMATION Last Name DOB Home Address Home Phone Driver s License # Employer Name Work Address First Name Age Sex Marital Status Cell Phone SSN Email Work Phone Person to contact in case of an
2018 Legal Notice HIPAA Notice of Privacy Practice
2018 Legal Notice HIPAA Notice of Privacy Practice Notice of Privacy Practices TO: Participants in The Prudential Welfare Benefits Plan, The Prudential Retiree Welfare Benefits Plan, The Prudential Flexible
PSYCHOLOGICAL SERVICES AGREEMENT
PSYCHOLOGICAL SERVICES AGREEMENT Jane Allemang, PhD, Clinical Psychologist CLIENT INFORMATION: TODAY S DATE: Name: Date of birth: Age: Sex: Relationship status: (circle) SINGLE MARRIED COHABITING WIDOWED
Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA Phone Fax:
Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA 98005 Phone 425-301-9869 Fax: 866-546-1618 Welcome to my practice. I look forward to meeting with
Our portals are encrypted and password-protected, too, so health data remains secure.
Patient Portal Education Sheet We know you re busy. That s why Palmetto Health-USC Medical Group s physician practices are offering a way for you to manage your health care online. We offer convenient
PATIENT INFORMATION : Please present insurance cards to receptionist. INSURANCE: Please fill out only if you re NOT the subscriber
PATIENT INFORMATION : Please present insurance cards to receptionist First Name: Last Name: Date of Birth: - - Sex: Male Female Address: City: Cell Phone #: ( ) - M.I.: APT: State: Zip Code: Home #: (
Notice of Privacy Policies
Notice of Privacy Policies THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THIS NOTICE BECAME EFFECTIVE
NOTICE OF PRIVACY PRACTICES
CENTER FOR SPORTS MEDICINE AND ORTHOPAEDICS HIPAA PRIVACY POLICIES AND PROCEDURES NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU
Medical Information Sheet
Medical Information Sheet Name: Date: Age: Sex: M F Height: Weight: Dominant hand: R L Occupation: Presently working: Y N Reason for being seen today: Date of Onset: Involved side: R L Both Describe any
CHIROPRACTIC HEALTH QUESTIONNAIRE
CHIROPRACTIC HEALTH QUESTIONNAIRE Name: SS#: Today s Date: / / Address: City: State: Zip: What you prefer to be called: Age: Birthdate: / / Handedness: Height: Weight: Number of Children: Male Female Marital
New Patient Referral and Insurance Verification Form
New Patient Referral and Insurance Verification Form Today s Date: Prior Patient: Y N How did you hear about our practice? Physician: Dr., Internet:, Family/Friend:, Advertising:, Insurance:, Other:. Patient
PATIENT CASE HISTORY
Family Chiropractic Center of Santa Fe 2019 Galisteo St. Suite M6 Santa Fe, NM 87505 505-984-0006 www.spchiro.net PATIENT CASE HISTORY Name: Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell
Grayson and Associates, P. C.
Grayson and Associates, P. C. PATIENT INFORMATION Patient Name Date of Birth Social Security Number - - Male Female Mailing Address City State Zip Email Is it ok for Grayson and Associates, P.C. to communicate
Ra m sd ell P ed iatrics, I nc.
Please Print Patient Information: Last Name First MI Address City State Zip - Home Phone Alt. Phone SSN Sex DOB / / Policyholder Information: Policyholder s Name Policyholder s Address Policyholder s DOB
HIPAA Notice of Privacy Practices
TM HIPAA Notice of Privacy Practices HIPAA is a federal law that requires protections for your protected health information (PHI). UNITE HERE HEALTH (The Fund) is required to provide you with a detailed