New Patient Information Form Page 2
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3Spouse or Responsible Party Information
The following is for:
the patient's spouse
the person responsible for payment
Name:
Male
Female
Married
Single
Child
Other
Social Security #: ________________________________ Birth Date:
Phone (Home): ________________ (Work): ________________ Ext:______ Best time to call:
Address:
Street
Apartment #
City
State
Zip Code
Employment Information
The following is for:
the patient
the person responsible for payment
Employer Name:
Occupation:
Address:
Street
City
State
Zip Code
Insurance Information
Primary
Name of Insured: _______________________________________________ Is insured a patient?
Yes
No
Last
First
MI
Insured's Birth Date: _________________ ID #: _____________________ Group #:
Insured's Address:
Street
City
State
Zip Code
Insured's Employer Name:
Address:
Street
City
State
Zip Code
Patient's relationship to insured:
Self
Spouse
Child
Other___________________
Insurance Plan Name and Address:
Secondary
Name of Insured: _______________________________________________ Is insured a patient?
Yes
No
Last
First
MI
Insured's Birth Date: _________________ ID #: _____________________ Group #:
Insured's Address:
Street
City
State
Zip Code
Insured's Employer Name:
Address:
Street
City
State
Zip Code
Patient's relationship to insured:
Self
Spouse
Child
Other___________________
Insurance Plan Name and Address:
Consent For Use And Disclosure Of Health Information
Patient’s Name:___________________________________________________________________________
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out
treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this
Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and
disclosures we may make of your protected health information, and of other important matters about your protected health information.
A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy
practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your
protected health information that we maintain.
Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation. Please
understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your
revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.
SIGNATURE: I, _____________________________, have had full opportunity to read and consider the contents of this Consent form
and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and
disclosure of my protected health information to carry out treatment, payment activities and health care Operations.
Signature: ______________________________________________________________ Date: _____________________
Signature of Guardian and/or Representative: __________________________________ Date: _____________________
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