Hipaa Registration Form Guarantor Information Page 2

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Date of Birth: ___________ / ___________ / ___________ Sex:
□
□
Male
Female
Social Security Number: ___________ - ________ -
___________
Home Phone: ( _______ ) ____________________ Work Phone: ( _______ ) ____________________ Cell Phone: ( _______ )
____________________
Relationship to Patient: ________________________________ Email Address:
_____________________________________________________________
Communication Preference
In order for our office to better serve you, please indicate your communication preferences:
May we communicate with you by email? □ Yes
What is your primary phone contact?
□ No
□ Cell Phone □ Home Phone □ Work Phone
May we send you text messages (i.e. appt
reminders?) □ Yes □ No
Acknowledgement of Notice of Privacy Practices
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. We are required by
law to maintain the privacy of your health information and to inform you of your rights. The Notice contains a section describing your rights under the
law related to your personal health information. You have a right to review our Notice of Privacy Practices before signing this consent.
By signing below, I acknowledge that I have reviewed or had explained to me PPCP Notice of Privacy Practices and agree to continue
my care with Palmetto Primary Care Physicians under said terms.
I authorize the following person(s) to obtain medical information about me or my child and allow medical services to be rendered in my absence
Name: ________________________________ Relationship to Patient: __________________________ Phone Number: ( _______)
_______________
Name: ________________________________ Relationship to Patient: __________________________ Phone Number: ( _______)
_______________
______________________________________________________________
________ / ____________ / _____________
Patient or Guarantor Signature
Date
Insurance Authorization and Financial Responsibility Disclosure

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