Patient Registration Form

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      INSURANCE

      Primary Insurance

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        Tricare

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        Secondary Insurance

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          Family History (Check below if your child has had any of the following )

          DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

          BIRTH HISTORY

          Medical Records Release

          Records Release From

          Records Release To

          Jenny Welham MD LLC
          1401 S. Beretania St, Ste 370
          Honolulu, HI 96814
          Phone: 808-944-1844, Fax: 808-947-9987

          Authorization

          I authorize the third party named in the above section to disclose the protected health information about myself (or the patient) as described above. I understand

          2. I may revoke this authorization at any time by notifying Jenny Welham MD LLC in writing. If I revoke the authorization, I understand that it will have no effect on actions Jenny Welham MD LLC took in good faith before receiving the revocation.

          3. The information released may contain information related to AIDS or HIV infection drug or alcohol abuse behavioral health or psychiatric care, except for psychotherapy notes.

          4. Jenny Welham MD LLC may not withhold treatment or payment based on my completion of this form.

          5. Jenny Welham MD LLC reserves the right to verify my identity or guardianship.

          DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

          Acknowledgement of Notification of Privacy Policies (HIPAA)

          To better serve our patients, we have revised our policy notice effective October 1, 2017.

          PRIVACY POLICIES ACKNOWLEDGEMENT OF RECEIPT (HIPPA)

          I have read a copy of Jenny Welham, MD LLC's Notice of Privacy Policies with the effective date of July 1, 2016. If you would like a copy of the Notice of Privacy Policies, you may ask the receptionist at the front desk.

          INFORMATION UPDATE

          Upon checking in, please inform the office staff of any changes to your information (address, phone numbers, insurance, etc.) Any charges incurred to your account will be your responsibility if you do not inform us of any changes

          VACCINE ADMINISTRATION

          I have been provided a copy of the appropriate Vaccine Information Statement (V.I.S) prepared by the Center for Disease Control, and have read, or have explained to me, information about the diseases and the vaccine cited. I have had the chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of this vaccine, and ask that it be given to the person named below (for whom I am authorized to make this request).

          FORMS AND MEDICATION REFILLS

          Please give a minimum of 2 business days notice for completion of any medical forms/school forms/letters and requests for medication refills.

          APPOINTMENT "NO SHOWS" AND CANCELLATIONS

          There is a $25.00 fee per patient for any "No Show" or cancellation of visits with less than 24 hours of notice.

          COPIES OF MEDICAL RECORDS

          There is a $40.00 fee for release of personal copies of medical records. If medical records are being requested directly from another physician's office, there is no fee.

          PAYMENTS ON ACCOUNTS

          I have read a copy of Jenny Welham, MD LLC's Office Payment Policy with the effective date of July 1, 2016.We accept cash, check and credit card payments. Please make checks payable to Jenny Welham, MD LLC. Payment is due in full prior to services rendered if you have no insurance and/or if your visit is not a covered benefit of your insurance plan.

          I hereby authorize the release of medical information to my insurance carriers concerning my illness and treatment and hereby assign all payments for medical services to my doctor. I understand I am responsible for payment of any amount not covered by my insurance.

          I understand all of the information that has been provided to me as stated above.

          DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

          Your information will be encrypted.

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