Patient Registration Form

Today's Date:

Patient Full Name:

Patient Date of Birth

Address:

City:

State:

Zip Code:

Cell Phone:

Gender:

Male Female

Email:

Marital Status

Married Single Divorced Other

Preferred Language:

English Other

If Other, Please Specify

Ethnicity:

Hispanic/LatinoCaucasian African American Asian Prefer not to answer

Parent/Guardian Information (if patient is under 18 years of age)

Parent/Guardian Name:

Relation to Patient:

Address:

City:

State:

Zip Code:

Cell Phone:

Email:

Insurance Information

Primary Insurance Company:

Address:

City:

State:

Zip Code:

Member ID#:

Group #

Guarantor Full Name:

Guarantor Date of Birth:

Guarantor’s Address

City:

State:

Zip Code:

Guarantor’s Phone:

Guarantor’s Relationship to Patient:

Secondary Insurance Company:

Address:

City:

State:

Zip Code:

Member ID#:

Group #

Guarantor Full Name:

Guarantor Date of Birth:

Guarantor’s Address

City:

State:

Zip Code:

Guarantor’s Phone:

Guarantor’s Relationship to Patient:

Other Information

Pharmacy Name:

Address:

City:

State:

Zip Code:

Pharmacy Phone:

Pharmacy Fax:

Primary Doctor

Name:

Address:

City:

State:

Zip Code:

Doctor Phone:

Doctor Fax:

Referred by:

How did you hear about us?

Friend Family Doctor Flyer Community Event Internet Search Facebook www.oit101.org

HIPAA Acknowledgement and Consent Forms

I. Acknowledgement of Practice’s Notice of Privacy Practices*

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient’s Rights section describing your rights under the law.

You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, or healthcare operations. You have the right to revoke this Consent in writing, signed by you. However, such a revocation will not be retroactive.

This Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

By signing this form, I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
The Practice reserves the right to change the Notice of Privacy Practices as allowed by law.
The patient has the right to restrict the uses of their information but the Practice does not have to agree to the restrictions.
The patient may revoke this Consent in writing at any time and all future disclosures will then cease.
The Practice may condition receipt of treatment upon execution of this Consent.

This consent was signed by:

Patient Name:

Date of Birth:

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

Signature of Patient or Parent/Guardian/Responsible Party

Date:

II. Request to Receive Confidential Communications by Alternative Means*

As provided by Privacy Rule Section 164.522(b), I hereby give permission for Freedom Allergy to communicate to me about appointments, lab results, and/or patient care by phone messages, texts, email, or fax.

Phone Number:

Email:

Fax:

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

Signature of Patient or Parent/Legal Representative

Date

III. Adult Consent to Share Medical Information*

I agree that the Freedom Allergy may disclose certain pieces of my health information to a person of my choosing, since such person is involved with my healthcare or payment relating to my healthcare. I give permission for Freedom Allergy to disclose the following information:

Scheduling appointments

Lab Results

All information regarding assessment, diagnosis, and treatment of my medical condition, including oral immunotherapy, immunotherapy, and other allergic treatments.

Other

If Other, Please specify

The indicated information may be disclosed either phone or email to:

Add another

Patient’s Name:

DOB:

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

Patient’s Signature:

Date:

*Patient signature is required for patients who are 18 years or older, or who have emancipated minor status, or a special condition as defined by law.
*Patient can cancel this authorization in writing at any time.

Your information will be encrypted.