Patient Registration Sheet - Lebauer Allergy & Asthma Page 2

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LeBauer Medical Center
Allergy, Asthma & Sinus Care
R
S
, MD
M
A. W
, MD
R. C
V
W
, MD
ANJAN
HARMA
EG
HELAN
HRISTOPHER
AN
INKLE
Authorizations
Patient Name:__________________________________________
Patient Date of Birth:____________________
MISSED APPOINTMENT POLICY
I understand that LeBauer Medical Center does REQUIRE 24 hours advanced notice to cancel
or re-schedule an appointment. I understand a fee may be charged to my account for missed
appointments or appointments cancelled with less than the required notice.
FORM FEES
I understand that LeBauer Medical Center will charge for the completion of forms that require
either staff or physician time to complete. The charge for this service will start at $10 depending
on the complexity and time required. This includes, but is not limited to school forms, medication
forms, letters, and FMLA forms. The fees may be waived (excludes FMLA) if the form is
presented at an appointment to see the doctor or at a visit for the patient to receive an allergy shot
and is picked up.
CONSENT TO OBTAIN EXTERNAL PRESCRIPTION HISTORY:
I authorize LeBauer Medical Center and it's providers to view my external prescription history via
Surescripts prescription service. I understand that prescription history from multiple other
unaffiliated medical providers, insurance companies, and pharmacy benefit managers may be
viewable the staff here, and it may include prescriptions back in time for several years. I
understand this will allow my providers to better coordinate my care and medication history to
maximize the effectiveness and safety of my treatment plan.
I certify that I read and understand the scope of my consent and that I authorize the access.
CONSENT TO CONTACT VIA EMAIL:
To the extent that our new Medical Record software allows it, we may be able to contact you via
email to remind you of appointments or to share other pertinent information about your healthcare.
I authorize LeBauer Medical Center to use the email address I provided above to contact me
in regards to my healthcare. I consent that protected healthcare information may be transmitted to
me via this email address.
CONSENT TO COMMUNICATE PROTECTED HEALTH INFO
At my request, I also authorize LeBauer Medical Center to communicate my protected health
information (including appointment reminders) to me via the following methods:
Detailed message on my home answering machine
Detailed message on my personally identifiable voice mail at work
Detailed message on a personally identifiable cell phone voice mail
TEXT MESSAGING
It may be possible to contact you via text message for appointment reminders or other important
communications. If you agree to receive messages please check the box and specify your
preferred number (
)_______________.
Patient or Responsible Party Signature__________________________
Today's Date:___________

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