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PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM


E-Newsletter: If you would like to be informed about Special Offers, Discounts, New Procedures/Products or other information, please indicate that we may contact you via email.
 
 
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES: I have been given the opportunity to read a copy of Notice of Privacy Practices. I also understand that I have the right to request a copy of the Notice of Privacy Practices for my records.
The information I have provided on this form is true to the best of my knowledge.

 

HIPAA COMPLAINT FORM

PATIENT AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
 
 
 
 
 
 
 
 
 
 
I understand that the information outlined in this release will be disclosed according to the instructions of this release within five (5) business days of our office having received this release authorization. I understand that I am free to revoke this release authorization at any time by notifying the practice in writing. I also understand that the information disclosed under this release is subject to re-disclosure and no longer protected by the Privacy Regulations (45 C.F.R. 164).

 
 
FOR OFFICE USE ONLY

This authorization was revoked on . Revocation letter/document must be attached.

Document flow: Patient's Medical Record.

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