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    Patient Information: X - Patient Signature or Legal Representative Date

    Uploaded by

    John Frink
    This document contains a patient's personal information including name, contact details, physician details, current medications, and reason for visit. It notes that missed appointments with less than 24 hours notice will incur a $20 fee. It requests consent to use the patient's health information for treatment, payment, and operations. The patient acknowledges receiving the privacy policy and can request restrictions on how their information is used or disclosed.

    Copyright:

    © All Rights Reserved
    Download as ODT, PDF, TXT or read online from Scribd

    Patient Information: X - Patient Signature or Legal Representative Date

    Uploaded by

    John Frink
    65 views1 page
    This document contains a patient's personal information including name, contact details, physician details, current medications, and reason for visit. It notes that missed appointments with less than 24 hours notice will incur a $20 fee. It requests consent to use the patient's health information for treatment, payment, and operations. The patient acknowledges receiving the privacy policy and can request restrictions on how their information is used or disclosed.

    Original Description:

    an earlier version of a new patient acupuncture intake form with consent and arbitration

    Original Title

    Clinic Form 02162011

    Copyright

    © © All Rights Reserved

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    ODT, PDF, TXT or read online from Scribd

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    This document contains a patient's personal information including name, contact details, physician details, current medications, and reason for visit. It notes that missed appointments with less than 24 hours notice will incur a $20 fee. It requests consent to use the patient's health information for treatment, payment, and operations. The patient acknowledges receiving the privacy policy and can request restrictions on how their information is used or disclosed.

    Copyright:

    © All Rights Reserved
    Download as ODT, PDF, TXT or read online from Scribd
    Download as odt, pdf, or txt
    65 views1 page

    Patient Information: X - Patient Signature or Legal Representative Date

    Uploaded by

    John Frink
    This document contains a patient's personal information including name, contact details, physician details, current medications, and reason for visit. It notes that missed appointments with less than 24 hours notice will incur a $20 fee. It requests consent to use the patient's health information for treatment, payment, and operations. The patient acknowledges receiving the privacy policy and can request restrictions on how their information is used or disclosed.

    Copyright:

    © All Rights Reserved
    Download as ODT, PDF, TXT or read online from Scribd
    Download as odt, pdf, or txt
    of 1

    Patient Information

    ___________________________________________________________________________________________________
    Name Date
    ___________________________________________________________________________________________________
    Email Date of Birth Sex: M F
    ___________________________________________________________________________________________________
    Address/City/Zip
    ___________________________________________________________________________________________________
    Main Phone Alternate Phone
    ___________________________________________________________________________________________________
    Physician's Name Physician's Phone #
    ___________________________________________________________________________________________________
    Current Prescription Medications
    ___________________________________________________________________________________________________
    Current Over the Counter Medications
    ___________________________________________________________________________________________________
    Current Herbs/Nutritional Supplements
    ___________________________________________________________________________________________________
    Reason for visit today
    ___________________________________________________________________________________________________
    Other concerns
    ___________________________________________________________________________________________________
    How did you hear about us?
    ***To be fair to all our patients, missed appointments and cancellations with less
    than 24 hours notice incur a $20 fee which is not billable to insurance.

    CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR


    TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS
    I understand that as part of my healthcare, this organization originates and maintains health records describing my health
    history, symptoms, examination and test results, diagnoses, treatment and any plans for future care of treatment. I
    understand that this information serves as:
    ❖ A basis for planning my care and treatment.
    ❖ A means of communication among the healthcare professionals who contribute to my care.
    ❖ A source of information for applying my diagnosis and treatment information to my bill.
    ❖ A means by which a third-party payer can verify that services billed were actually provided.
    ❖ A tool for routine healthcare operations such as assessing care quality and reviewing the
    competence of healthcare professionals.
    I understand that I have the right:
    ❖ To object to the use of my health information for directory purposes.
    ❖ To request restrictions as to how my health information may be used or disclosed to carry out treatment,
    payment or healthcare operations – and that the organization is not required to agree to the restrictions
    requested.
    ❖ To revoke this consent in writing, except to the extent that the organization has already taken action in
    reliance thereupon.
    I acknowledge that I have received a copy of the Privacy Policy
    (optional) I request the following restrictions to the use of disclosure of my health information:

    X_______________________________ ____________
    Patient Signature or Legal Representative Date

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