New Patient Registration Form

PARENT / GUARDIAN INFORMATION

EMERGENCY CONTACTS

INSURANCE INFORMATION

PRIMARY INSURANCE

SECONDARY INSURANCE

PREFERRED METHOD OF APPOINTMENT CONFIRMATION

PREVIOUS PHYSICIAN

REFERRED BY

MEDICAL HISTORY

PREGNANCY HISTORY

BIRTH HISTORY

DISEASES/DIAGNOSIS/CONDITIONS

SURGICAL HISTORY

HOSPITALIZATIONS

CURRENT MEDICATIONS

ALLERGIES

FAMILY HISTORY

Patient Consent and Acknowledgement of Receipt of Privacy Notice

I understand that as part of the provision of healthcare services, Fairway Pediatrics, LLC creates and maintains health records and other information describing among other things, my health history, symptoms, examination and test results, diagnoses, treatment and any plans for further care or treatment.

I have been provided with a Notice of Privacy Practices that provides a more complete description of the uses and disclosures of certain health information. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their Notice and Practices and prior to implementation will mail a copy of any revised notice to the address I have provided. I understand that I have the right to object to use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operation (quality assessment and improvement activities, underwriting, premium rating, conducting or arranging for medical review, legal services, and auditing functions, etc.) and that the organization is not required to agree to the restrictions requested.

By signing this form, I consent to the use and disclosure of Protected Health Information about me for the purposes of treatment, payment and healthcare operations. I have the right to revoke this consent in writing, except where disclosures have already been made in reliance on my prior consent. This consent is given freely with understanding that:

1. Any and all records, whether written, oral, or in electronic format, are confidential and cannot be disclosed for reasons outside of treatment, payment, or healthcare operations without my prior written authorization, except as otherwise provided by law.
2. A photocopy or fax of this consent is valid as this original.
3. I have the right to request that the use of my Protected Health Information, which is used or disclosed for the purposes of treatment, payment, or healthcare operations be restricted. I also understand that the Practice and I must agree to any restriction in writing that I request on the use and disclosure of my Protected Health Information; and agree to terminate any restrictions in writing on the use and disclosure of my Protected Health Information which have been previously agreed upon.

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