Patient Information Form - St. John Providence

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Patient Information Form
Patient Information:
Name__________________________________________________ Select One:
Male
Female
nd
Date of Birth____________ Age _____ SS# _________________ Phone#: _____________________ 2
#: ___________________
Address: ______________________________City:______________________________________ State: _______Zip: ____________
Emergency Contact: _______________________________________ Phone _____________________Relationship_______________
Is this exam Workman Compensation or Auto related?
YES
NO (Select One)
PLEASE LIST ANYONE BY NAME THAT YOU WOULD LIKE TO RECEIVE YOUR MEDICAL INFORMATION
FROM OPEN MRI OF MICHIGAN:
No one other than Myself: ________ Spouse (list name) ___________________________________
Other individuals (list names): _________________________________________________________
Fax#: _____________________________________________________________________________
I authorize Open MRI of Michigan or any other associate of Cornerstone Medical Group to discuss my protected health information
with the above mentioned persons.
I will provide written notice when I choose to revoke or modify any of the above.
Patient Signature: ____________________________________________________________ Date: ________________
Printed Name: _______________________________________________________________
Witness Signature: ___________________________________________________________
Dear Patient:
In order to provide better healthcare for you, it is important to know your race, ethnicity and preferred language. Many medical
conditions affect certain populations more than others.
We appreciate your cooperation in helping us collect this information.
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unreported/Refused to report
Race:
Asian
Native Hawaiian
Other Pacific Islander
Black/African American
American Indian/Alaska Native
White
More than one race
Unreported/Refused to report
Preferred Language:
English
Other
Indian (including Hindi & Tamil)
Spanish
Russian

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