ATLANTA INTERNATIONAL PHYSICAL THERAPY, INC.

Size: px
Start display at page:

Download "ATLANTA INTERNATIONAL PHYSICAL THERAPY, INC."

Transcription

1 .Specwtlfczlkuj Ut Pedlfltric. physical, occ.upflt«>ithl, Speech Therapy sen/tees PATIENT INFORMATION Patient Name (Nombre del paciente] Date of Birth (Fecha de nacimiento] Address (Direccion] City [Cuidad] State (Estado] '.. Zip Code (Codigo Postal] Insurance Carrier (Seauro de Saludl. Medicaid Peachcare Private insurance Peachstate Amerigroup Wellcare Medicaid Number (Numero de Medicaid] Parents and pediatrician information [Information de IPS padres vpediatra] Full mother's name (Nombre de la rnadre] Phone number [Telefono] Mobile [Celular]. Full father's name (Nombre del padre] Phone number (Telefono] Mobile (Celular]. Pediatrician name [Nombre del pediatraj Address (Direccion] City [Cuidad] State (Estado] Zip Code (Codigo Postal]. Phone (Telefono] Fax I authorize payment of medical benefits to undersigned physician or supplier for services provided in this office. [Yo autorizo elpago de beneficios medicos al doctor o compania por los servicios provefdos en este local). Signature [Firma] Date (FechaJ

2 spec.lallzlv(q in- periiatnc Physical, occupational, g speech Therapy services Norcross, GA _ Fax: ADULT PATIENT INFORMATION Patient Name (Nombre del Paciente]. Date of Birth [Fecha de Nacimiento] _ Address (Direccion) City (Cuidad) State (Estado) Zip (Codigo Postal). Home Phone (Telefono) Mobile (Celular) Insurance carrier [Seguro Medico):. Member ID# with Insurer (Numero de Identification):. Doctor Information Referring Doctor (Nombre de su Doctor) Address (Direccion) City (Cuidad) State (Estado) Zip (Codigo Postal). Phone [Telefono) Fax I authorize payment of medical benefits to undersigned physician or supplier for the services provided in this office. [Yo autorizo el pago de beneficios medicos al doctor o companfa con la cual en este rnomento firmo por los servicios en este local). Signature (Firma) Date (Fecha).

3 SpeciflUzu/wg LI^ Pediatric. Physical, octu-patioi/uil, a; speech Therapy sen/ices Appointment Cancellation Policies 1. If you know in advance that you will not be able to attend to your appointment please call us twenty four hours in advance so we may book another patient in that time slot. 2. If you or your child is ill the day of the appointment and are unable to attend please call us that morning and leave a message if no one answers. 3. If these policies are not adhered to we will charge a fee of $25 for the missed appointment. 4. If you consistently cancel your appointments with us, as stated above, we reserve the right to discharge you or your child from our practice for non compliance. Patient's name Signature of patient/guardian

4 , -Speaiatfekig w*. T>edt«tyift Pky steal, oeocpottataly speech Tfoerapw services 3985 Steve Reynolds Blvd. Suite G, Teh Morcross,CA Fax: NORMAS PARA CANCELAR TERAPIAS LjUsted Debera UamarCpn Al Menos48 Horas (2 Dias) Previo A Su cita Reservada. 2. ptras Citas Medicas o Dentales No Son Excusa Para Cancelar Las terapias De Su Hijo (A), Sabiendo con Anticipacion Su O'ta De La Terapia, usted Siempre Puede Solicitar Otros Dias Para i Sus Cftas Medicas. :; 3. Frecuentes Cancelaciones Por Cualquier razon Pueden Y Seran Causa De Canceiacion De Sus Terapias. 4. Problemas De transporte tampoco Son Causa de Canceladon Justificada. Usted Tiene Tiempo Suficiente Para Planear Su Transporte Previo A Su Cita.,,' 5. Si Usted Cancela Por Enfermedad De Su Hijo (A) Debera Presentar Alguna Prueba Que El Nine Fue Visto Por Su Pediatra, Asistio A La sala De Emergencias U otras Pruebas Aceptables Incluyen Prescription Medica, Carta De La Oficina Medica. 6. Al No Cumplir Con Estas Normas Basicas, Esta Oficina Penalizar A los Padres Por Un Total De U$25.00 (Veintitinco Dolares). 7. El Nino Podra Comenzar Con Sus Terapias Nuevamente Despues De La Canceiacion De La Malta, NoHay Excepdones. Nombre De padre o tutor Firma/Fecha

5 spe&lfluzwig ut vedlatrlc. Physical, 0c.cwf>«tk>i/u?l, g speech TVierapLj sen/tees Consent for Treatment I consent to the necessary treatment of (patient's name) Atlanta International Physical Therapy Inc. by Assignment of Benefits If I am entitled to benefits under Medicaid, Medicare, or any other insurance policy for services provided to me by Atlanta International Physical Therapy PT Inc. I assign transfer of and convey the benefits payable for services rendered. I authorize payment of benefits directly to Atlanta International Physical Therapy PT Inc applied to my bill. I am responsible for and agree to pay for charges not paid under this assignment including any insurance amount and deductibles. Patient Patient/Parent Signature Date Consent to the release of information I authorize the release of information to Atlanta International Physical Therapy, Inc. I also authorize Atlanta International Physical Therapy Inc. to release information to my referring physician and my insurance company for purposes of continued care or treatment and/or to any insurance company, service coordinator, or any other person financially responsible for my treatment for all purposes related to a claim for payment and/or for approval of services Guarantor/Patient/Parent Signature Relationship to patient Date Witness

6 spetializifv^ tw- Perfifltrie Physical, o&au.patw>i^l, g speech Therapy -Services 3985 Steve Reynolds'. Blvd. Suite G Tel: Summary of Notice of Privacy Practices Our legal duty; We have the duty to protect the confidentiality of medical information. The notice also describes your legal rights and our obligation regarding the disclosure of your medical information. Parties followine the notices: The notice will be followed by Atlanta International P.T. together with its health care providers and staff. How we mav use and disclosure medical information about you: We may use or disclose identifiable health information about you for many reasons including: Treament Payment Healthcare operations As required by law Appointment reminders Research Health oversight activities Lawsuits and disputes Law enforcement authorities To military command authorities Public health risk Auditing Your privacy rights: You have the following rights with respect to your health information: The right to request confidential communications and alternative notes of communication with you. Request restrictions or certain uses of your health information. Inspect and copy certain medical information that we maintain above you. Request an amendment of your health information. Changes to the notice; We reserve the right to change the notice. We will post any revised notice in the' office of AIPT, Inc. Complaints: If you believe your rights have been violated you may file a written complaint of AIPT, Inc. with the privacy officer of the US Department of Health and Human Services. Print name of client or parent/guardian Signature of client or parent/guardian

7 aaalpt I\V. ATLANTA INTERNATIONAL PHYSICAL THERAPY, INC. spec-la ILZLI/U;} in Pedlatric PhystGnU oc-cupatioi'ual,, g speech Therapy sen/ices AUTHORIZATION FOR THE DISCLOSING OF MEDICAL INFORMATION I hereby request and authorize ATLANTA INTERNATIONAL PHYSICAL THERAPY, INC 3985 STEVE REYNOLDS BLVD, SUITE G NORCROSS, GA To use and disclose the protected health information described below to I authorize the release of my complete health record (including permanent medical records/information to identify diagnosis and potential need for therapy services for the purpose of planning and providing essential and necessary). This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct. I understand that the Federal Privacy Rule (HIPPA) does not protect the privacy of information if re-disclosed and therefore request that all information obtained from the person or agency be held strictly confidential and not be further released by the upon provision of this authorization. I intent this document to be valid and remain in effect for the period necessary to complete all transaction on matters related to services provided to me. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that rny treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and my no longer be protected by federal or state law. Patient's name Signature of patient/parent/guardia» Date

DAMAR MEDICAL CENTER, INC

DAMAR MEDICAL CENTER, INC PATIENT INFORMATION TODAY S DATE: / / (INFORMACION DEL PACIENTE) MES/DIA /AÑO: / / PATIENT S NAME: NOMBRE Y APELLIDO: D.O.B.: / / FECHA DE NACIMIENTO / / ADDRESS: CITY: ZIP CODE DIRECCION CIUDAD: CODIGO

More information

PATIENT INFORMATION. Today s Date. I do not currently carry insurance (initial) Patient s Last Name: Patient s First Name: MEDICAL INSURANCE

PATIENT INFORMATION. Today s Date. I do not currently carry insurance (initial) Patient s Last Name: Patient s First Name: MEDICAL INSURANCE PATIENT INFORMATION Please present a Photo ID and ALL insurance cards to receptionist. If items are not presented, full payment will be due at time of service. Please know ALL Co-Pays are due at time of

More information

Today s Date: / /! / / Full Legal Name (First, Middle, Last) Date of Birth Age. Address City State Zip

Today s Date: / /! / / Full Legal Name (First, Middle, Last) Date of Birth Age. Address City State Zip Today s Date: / / / / Full Legal Name (First, Middle, Last) Date of Birth Age Social Security Number Marital Status Address City State Zip Out of State Address Phone: Home ( ) - Cell ( ) - Email: PREFERRED

More information

PATIENT'S INFORMATION REGISTRATION SHEET / INFORMACION DEL PACIENTE

PATIENT'S INFORMATION REGISTRATION SHEET / INFORMACION DEL PACIENTE DAN S. COHEN, M.D PATIENT'S INFORMATION REGISTRATION SHEET / INFORMACION DEL PACIENTE PLEASE PRINT CLEARLY / POR FAVOR ESCRIBA LEGIBLEMENTE TODAY S DATE / FECHA DE HOY: PATIENT'S NAME/NOMBRE DEL PACIENTE:

More information

PATIENT INFORMATION PATIENT NAME: BIRTHDATE: / / AGE: SOCIAL SECURITY # MARITAL STATUS: ( ) S ( ) M ( ) W ( ) D HOME TELEPHONE # CELLULAR # RELIGION:

PATIENT INFORMATION PATIENT NAME: BIRTHDATE: / / AGE: SOCIAL SECURITY # MARITAL STATUS: ( ) S ( ) M ( ) W ( ) D HOME TELEPHONE # CELLULAR # RELIGION: NEW PATIENT INFORMATION PRIMARY CARE DOCTOR: PCP # FAX # PATIENT NAME: BIRTHDATE: / / AGE: SOCIAL SECURITY # MARITAL STATUS: ( ) S ( ) M ( ) W ( ) D HOME TELEPHONE # _ CELLULAR # RELIGION: STREET ADDRESS:

More information

Patient Information NAME SOCIAL SECURITY # (NOMBRE) LAST/APELLIDO FIRST/PRIMER INITIAL (SEGURO SOCIAL)

Patient Information NAME SOCIAL SECURITY # (NOMBRE) LAST/APELLIDO FIRST/PRIMER INITIAL (SEGURO SOCIAL) 7887 North Kendall Drive Suite 210 Miami, Florida 33156 305.598.1555 office 305.598.1155 fax www.vascularandspine.com Patient Information NAME SOCIAL SECURITY # (NOMBRE) LAST/APELLIDO FIRST/PRIMER INITIAL

More information

Policies for Easter Seals South Carolina Therapy Services

Policies for Easter Seals South Carolina Therapy Services Policies for Easter Seals South Carolina Therapy Services It is our goal to serve you and your child with excellence. Please carefully read through the following policies. 1. During or prior to your initial

More information

Notice of Privacy Practices

Notice of Privacy Practices Effective May 1, 2013 Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

More information

Reason(s) For Referral: Current medications:

Reason(s) For Referral: Current medications: 1540 Sunday Drive Suite 200Raleigh, NC 27607 Office: 919-859-9040FAX: 919-859-9030 Name: Date Examined: Responsible Person: _ Birth Date: Address: Age: Sex: M F Marital Status: S M D W SSN: Home Phone:

More information

Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite 410 3495 Piedmont Road, NE Atlanta, GA 30305 404-495-5900 404-495-5901 (fax)

Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite 410 3495 Piedmont Road, NE Atlanta, GA 30305 404-495-5900 404-495-5901 (fax) PATIENT INFORMATION: Psychiatric Associates of Atlanta, LLC Twelve Piedmont Center, Suite 410 3495 Piedmont Road, NE Atlanta, GA 30305 404-495-5900 404-495-5901 (fax) Last Name: First: MI: Address: City:

More information

ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code

ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code ADULT REGISTRATION FORM Last Name First Name Middle Initial Date of Birth Age Identified Gender Street Address City State Zip Code Home Phone Cell Phone FINANCIALLY RESPONSIBLE PARTY (If different from

More information

BALANCE DUE 10/25/2007 $500.00 STATEMENT DATE BALANCE DUE $500.00 PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT

BALANCE DUE 10/25/2007 $500.00 STATEMENT DATE BALANCE DUE $500.00 PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT R E M I T T O : IF PAYING BY MASTERCARD, DISCOVER, VISA, OR AMERICAN EXPRESS, FILL OUT BELOW: XYZ Orthopaedics STATEMENT DATE BALANCE DUE 10/25/2007 $500.00 BALANCE DUE $500.00 ACCOUNT NUMBER 1111122222

More information

OFFICE OF COMMON INTEREST COMMUNITY OMBUDSMAN CIC#: DEPARTMENT OF JUSTICE

OFFICE OF COMMON INTEREST COMMUNITY OMBUDSMAN CIC#: DEPARTMENT OF JUSTICE RETURN THIS FORM TO: FOR OFFICIAL USE: (Devuelva Este Formulario a): (Para Uso Oficial) OFFICE OF COMMON INTEREST COMMUNITY OMBUDSMAN CIC#: DEPARTMENT OF JUSTICE (Caso No) STATE OF DELAWARE Investigator:

More information

Pediatric Ophthalmology Date: PLEASE PRINT: PATIENT NAME: Male: Female: AGE: First Middle Last BIRTH DATE: / / HOME PHONE: (

Pediatric Ophthalmology Date: PLEASE PRINT: PATIENT NAME: Male: Female: AGE: First Middle Last BIRTH DATE: / / HOME PHONE: ( Eye Consultants of Atlanta, P.C. Scottish Rite Office 5445 Meridian Mark Road, Suite 220, Atlanta, GA 30342 Phone: (404-255-2419) - Fax (404-255-3101) Zane Pollard, M.D. Marc F. Greenberg, M.D. Mark A.

More information

REGISTRATION FORM (Please print)

REGISTRATION FORM (Please print) REGISTRATION FORM (Please print) PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal name? If not so,

More information

Dear Parents: Welcome and thank you for choosing Coastal Pediatrics! We appreciate the opportunity to provide your child with the highest quality

Dear Parents: Welcome and thank you for choosing Coastal Pediatrics! We appreciate the opportunity to provide your child with the highest quality Dear Parents: Welcome and thank you for choosing Coastal Pediatrics! We appreciate the opportunity to provide your child with the highest quality pediatric care. Additionally, we promise to offer superior

More information

Harris County - Texas HIPAA Notice of Privacy Practices

Harris County - Texas HIPAA Notice of Privacy Practices Harris County - Texas HIPAA Notice of Privacy Practices Effective Date: September 23, 2013. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

More information

IRVING & ASSOCIATES IN BEHAVIORAL HEALTH, P.C. 5151 Mochel Drive, Suite 307 Downers Grove, IL 60515

IRVING & ASSOCIATES IN BEHAVIORAL HEALTH, P.C. 5151 Mochel Drive, Suite 307 Downers Grove, IL 60515 : / / Client Name: _ SSN: / / of Birth: Age: Sex: Male Female Address: City/State/Zip: Home Phone Number Is it okay to leave a message here? Y/N Work Number Is it okay to leave a message here? Y/N Cell

More information

Cardiology Consultants of Atlanta, P.C. 2801 N. Decatur Rd. Suite 395, Decatur GA, 30033 (404) 298-2220 phone (678) 904-5336 fax

Cardiology Consultants of Atlanta, P.C. 2801 N. Decatur Rd. Suite 395, Decatur GA, 30033 (404) 298-2220 phone (678) 904-5336 fax OFFICE POLICIES AND PROCEDURES Thank you for choosing Cardiology Consultants of Atlanta for your cardiovascular care. We realize that you have a choice in medical providers and are pleased that you have

More information

MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION

MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION MIGUEL GONZALEZ, MD, FCCP, FACP 303 S. Moorpark Rd. Thousand Oaks, Ca 91361 805-497-7508 Phone 805-495-6834 Fax PATIENT INFORMATION DATE: REFERRED BY: NAME: SEX: M / F MARITAL STATUS: BIRTHDATE: DRIVERS

More information

BILLING INFORMATION AND ASSIGNMENT OF BENEFITS

BILLING INFORMATION AND ASSIGNMENT OF BENEFITS BILLING INFORMATION AND ASSIGNMENT OF BENEFITS Facility: Northpoint Radiation Center Pro Physicians Clinic PA Physician: Timothy D. Nichols, M.D. PA, Board Certified Radiation Oncology Wilhelm J. Lubbe,

More information

Enrollment Forms Packet (EFP)

Enrollment Forms Packet (EFP) Enrollment Forms Packet (EFP) Please review the information below. Based on your student(s) grade and applicable circumstances, you are required to submit documentation in order to complete this step in

More information

If physical therapy is being sought due to an accident, please indicate the and of the accident

If physical therapy is being sought due to an accident, please indicate the and of the accident 2919 S. 120 th St. Omaha, NE 68144 Office Phone: (402) 504-3535 Cell Phone: (402) 630-9756 Fax: (402) 934-3866 OUTPATIENT THERAPY TREATMENT AGREEMENT If physical therapy is being sought due to an accident,

More information

This Notice describes Hill-Rom s practices regarding the use of your Protected Health Information, specifically including:

This Notice describes Hill-Rom s practices regarding the use of your Protected Health Information, specifically including: Original Effective Date: April 1, 2003 Effective Date of Last Revision: July 15, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS

More information

HIPAA Notice of Privacy Practices

HIPAA Notice of Privacy Practices HIPAA Notice of Privacy Practices Date of Last Revision: 09/20/2013 Effective Date: Immediately THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

More information

Sincerely yours, Rev. 06.10

Sincerely yours, Rev. 06.10 Welcome to RehabXperience. Thank you so much for choosing us. We recognize that you have a choice of physical therapy centers and greatly appreciate you for choosing us as your outpatient physical therapy

More information

INFORMATIONAL NOTICE

INFORMATIONAL NOTICE Rod R. Blagojevich, Governor Barry S. Maram, Director 201 South Grand Avenue East Telephone: (217) 782-3303 Springfield, Illinois 62763-0002 TTY: (800) 526-5812 DATE: March 4, 2008 INFORMATIONAL NOTICE

More information

THE WORLD OF PEDIATRICS. Medical Records/Health Information Release (Please fill out and fax or send to your current practice or pediatrician)

THE WORLD OF PEDIATRICS. Medical Records/Health Information Release (Please fill out and fax or send to your current practice or pediatrician) Medical Records/Health Information Release (Please fill out and fax or send to your current practice or pediatrician) Date: To: Fax: Please, release a copy of medical records for the following patient(s):

More information

HIPAA Notice of Privacy Practices Effective Date: 09/23/13

HIPAA Notice of Privacy Practices Effective Date: 09/23/13 HIPAA Notice of Privacy Practices Effective Date: 09/23/13 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW

More information

Marian R. Zimmerman, Ph.D.

Marian R. Zimmerman, Ph.D. Marian R. Zimmerman, Ph.D. Clinical Health Psychology www.mzpsychology.com 3550 Parkwood Blvd., 306 (214)618-1451 Phone Frisco, TX 75034 (214)618-2102 Fax Pre-Surgical Evaluation Patient Name: Age: Date

More information

PATIENT INFORMATION. Patient Name/Nombre

PATIENT INFORMATION. Patient Name/Nombre Patient Information Cont d PATIENT INFORMATION Patient Name/Nombre Birth date/fecha de Nacimeinto Age/Edad Sex/Sexo How do you prefer to be addressed by our physicians and staff? Como prefiere que le llamen

More information

IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR IF YOU NEED MORE INFORMATION, PLEASE CONTACT OUR PRIVACY OFFICER:

IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR IF YOU NEED MORE INFORMATION, PLEASE CONTACT OUR PRIVACY OFFICER: NOTICE OF PRIVACY PRACTICES COMPLETE EYE CARE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

More information

Columbia Associates in Psychiatry 2501 N. Glebe Rd Suite 303 Arlington, VA 22207 703-841-1290

Columbia Associates in Psychiatry 2501 N. Glebe Rd Suite 303 Arlington, VA 22207 703-841-1290 Columbia Associates in Psychiatry 2501 N. Glebe Rd Suite 303 Arlington, VA 22207 703-841-1290 Welcome to Columbia Associates in Psychiatry! Thank you for choosing us to take care of your behavioral health

More information

Kiran Mishra, Ph.D. Licensed Clinical Psychologist. Sugar Land, TX 77478 (832) 876-3232 TEXAS NOTICE FORM

Kiran Mishra, Ph.D. Licensed Clinical Psychologist. Sugar Land, TX 77478 (832) 876-3232 TEXAS NOTICE FORM Kiran Mishra, Ph.D. Licensed Clinical Psychologist 1111 Highway 6, Suite 235 Sugar Land, TX 77478 (832) 876-3232 TEXAS NOTICE FORM Notice of Psychologists Policies and Practices to Protect the Privacy

More information

New Patient Information Form

New Patient Information Form PATIENT INFORMATION New Patient Information Form Patient s Patient s Preferred Name Middle Initial Date of Birth SSN# Primary Language YES NO Email Address Race/Ethnicity Is patient of Hispanic Origin?

More information

EXCEL PHYSICAL THERAPY, INC.

EXCEL PHYSICAL THERAPY, INC. EXCEL PHYSICAL THERAPY, INC. Medical History Form Name: Date of Birth: Date: Are you employed? YES NO Right Handed Left Handed If NO, last day worked? Do you smoke? YES NO #of packs/day Occupation: Height:

More information

Daytime Telephone Number (Número Telefónico) Date of Application (Fecha) County (Condado)

Daytime Telephone Number (Número Telefónico) Date of Application (Fecha) County (Condado) Borough of Matawan - Dept. of Vital Statistics $10.00 p/copy 201 Broad Street, Matawan, NJ 07747 Phone 732-566-3898 x625 Fax 732-566-0036 APPLICATION FOR A NON-GENEALOGICAL CERTIFICATION OR CERTIFIED COPY

More information

Notice of Privacy Practices

Notice of Privacy Practices Notice of Privacy Practices Pueblo Radiology Medical Group, Inc. Pueblo Radiology Associates, Inc. Central Coast Radiology Associates, Inc. Santa Barbara Women s Imaging Center Effective Date: September

More information

Colquitt County Schools Enrollment Packet. Request Forms Middle School

Colquitt County Schools Enrollment Packet. Request Forms Middle School Enrollment Packet Request Forms Middle School Statement of Objection to Use of Social Security Number for Student Identification Request I do not wish to provide the Social Security Number of my child/children.

More information

PATIENT INTAKE FORM PATIENT INFORMATION. Name Soc. Sec. # Last Name First Name Initial Address. City State Zip. Home Phone Work/Mobile Phone

PATIENT INTAKE FORM PATIENT INFORMATION. Name Soc. Sec. # Last Name First Name Initial Address. City State Zip. Home Phone Work/Mobile Phone PATIENT INTAKE FORM PATIENT INFORMATION Name Soc. Sec. # Last Name First Name Initial Address City State Zip Home Phone Work/Mobile Phone Sex M F Age Birth date Single Married Widowed Separated Divorced

More information

Virginia South Psychiatric & Family Services

Virginia South Psychiatric & Family Services All forms must be completed before seeing the Physician Information for Medical Records Patient s Name: Social Security #: Date of Birth: Sex: Male Female Marital Status: Single Married Divorced Widow

More information

Information with a person who is involved in your medical care or payment for your care, such as your family or a

Information with a person who is involved in your medical care or payment for your care, such as your family or a Notice of Privacy Practices Effective Date: September 23, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW

More information

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age:

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age: Intake for Services Today's Date Last name: First name: Birth date: Age: Gender: Address: City/State/Zip Email: Home Phone: Cell phone: Marital Status: No. of Children & ages: If presently married: Name

More information

APPLETREE PEDIATRICS, PA NOTICE OF PRIVACY PRACTICES

APPLETREE PEDIATRICS, PA NOTICE OF PRIVACY PRACTICES APPLETREE PEDIATRICS, PA NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

More information

Nicholas C. Lambrou, M.D., LLC 6200 Sunset Drive, STE 502, Miami, Florida 33143 4306 Alton Road, 3 rd Floor, Miami Beach, Florida 33140

Nicholas C. Lambrou, M.D., LLC 6200 Sunset Drive, STE 502, Miami, Florida 33143 4306 Alton Road, 3 rd Floor, Miami Beach, Florida 33140 DATE: Fecha: DRIVER'S LICENSE# Numero De Licencia De Conducir: PATIENT NAME: BIRTH DATE: Nombre del paciente Fecha de nacimiento HOME ADDRESS: SOCIAL SECURITY: Direccion del hogar: Seguro Social CITY/STATE/ZIP:

More information

HIPAA NOTICE OF PRIVACY PRACTICES

HIPAA NOTICE OF PRIVACY PRACTICES HIPAA NOTICE OF PRIVACY PRACTICES Marden Rehabilitation Associates, Inc. Marden Rehabilitation Associates of Ohio, Inc. Marden Rehabilitation Associates of West Virginia Health Care Plus Preferred Care

More information

Bradley D. Powell, PhD NOTICE OF PRIVACY PRACTICES: Effective June 1, 2004

Bradley D. Powell, PhD NOTICE OF PRIVACY PRACTICES: Effective June 1, 2004 Bradley D. Powell, PhD NOTICE OF PRIVACY PRACTICES: Effective June 1, 2004 A Summary of the Provisions of the Health Insurance Portability and Accountability Act ( HIPAA ) Privacy Rule (45 C.F.R. parts

More information

HIPAA PRIVACY NOTICE PLEASE REVIEW IT CAREFULLY

HIPAA PRIVACY NOTICE PLEASE REVIEW IT CAREFULLY HIPAA PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. INTRODUCTION PLEASE REVIEW IT CAREFULLY Moriarty

More information

HI *Home Phone: Alternate Phone: Driver License No.: Email Address: INSURANCE COVERAGE & SUBSCRIBER INFORMATION (person that has the insurance policy)

HI *Home Phone: Alternate Phone: Driver License No.: Email Address: INSURANCE COVERAGE & SUBSCRIBER INFORMATION (person that has the insurance policy) HAWAII PHYSICAL THERAPY INC. -- PATIENT REGISTRATION FORM Please fill out this form to register as a patient of Hawaii Physical Therapy Inc. All fields with an asterisk (*) are REQUIRED. We cannot register

More information

NOTICE OF PSYCHOLOGIST S POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION

NOTICE OF PSYCHOLOGIST S POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION Effective Date: 09/23/2013 Paul Beljan, PsyD, ABPdN, ABN Alison E.F. Reuter, PhD, ABPdN Laura Wingers, PsyD Kate Bree, PsyD Vanessa Berens, PhD Jacob Boney, PsyD, BCBA-D 9835 E. Bell Rd., Ste. 140 Scottsdale,

More information

Patient or Guardian Signature

Patient or Guardian Signature Co Payment Policy According to the regulations of individual insurance carriers, patients are responsible for paying co payments at the time of each office visit. PAYMENT POLICY FOR SERVICES RENDERED If

More information

9525 Katy Freeway, Suite 312 Houston, Texas 77024 Phone (713) 463-9449 Fax (713) 463-7181 www.bhchouston.com. Welcome Friend!

9525 Katy Freeway, Suite 312 Houston, Texas 77024 Phone (713) 463-9449 Fax (713) 463-7181 www.bhchouston.com. Welcome Friend! 9525 Katy Freeway, Suite 312 Houston, Texas 77024 Phone (713) 463-9449 Fax (713) 463-7181 www.bhchouston.com Welcome Friend! Thank you for your interest in pursuing counseling services in this office.

More information

4765 Carmel Mountain Rd. Ste 202, San Diego, CA 92130 Phone (848) 847-0055 Fax (858) 847-9944

4765 Carmel Mountain Rd. Ste 202, San Diego, CA 92130 Phone (848) 847-0055 Fax (858) 847-9944 4765 Carmel Mountain Rd. Ste 202, San Diego, CA 92130 Phone (848) 847-0055 Fax (858) 847-9944 Dear Patient, Your insurance may pay your total bill for services rendered by Pilates People Torrey Hills.

More information

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - 4425 Ponce de Leon Blvd., Suite 115 Email:info@ Dr. Mercedes Gonzalez, Pediatric Dermatologist Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one)

More information

BORIS RUBASHKIN, MD DONNA EDWARDS, RN, MSN, PMH- NP BERNADATTE WILLIAMS, PMH-NP

BORIS RUBASHKIN, MD DONNA EDWARDS, RN, MSN, PMH- NP BERNADATTE WILLIAMS, PMH-NP BORIS RUBASHKIN, MD DONNA EDWARDS, RN, MSN, PMH- NP BERNADATTE WILLIAMS, PMH-NP 9525 Katy Freeway, Suite 312 Houston, Texas 77024 Phone (713) 463-9449 Fax (713) 463-7181 www.bhchouston.com Welcome! Thank

More information

National Home Health Care HIPAA Notice of Privacy Practices

National Home Health Care HIPAA Notice of Privacy Practices Effective Date: THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have any questions about

More information

MULTICARE ASSOCIATES OF THE TWIN CITIES, P.A. NOTICE OF PRIVACY PRACTICES

MULTICARE ASSOCIATES OF THE TWIN CITIES, P.A. NOTICE OF PRIVACY PRACTICES MULTICARE ASSOCIATES OF THE TWIN CITIES, P.A. NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

More information

NORTHSTAR DERMATOLOGY, PA NOTICE OF PRIVACY PRACTICES

NORTHSTAR DERMATOLOGY, PA NOTICE OF PRIVACY PRACTICES NORTHSTAR DERMATOLOGY, PA NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT

More information

GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM

GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM DATE: CHART#: GUARANTOR INFORMATION LAST NAME: FIRST NAME: MI: ADDRESS: HOME PHONE: ADDRESS: CITY/STATE: ZIP CODE: **************************************************************************************

More information

HIPAA NOTICE of Privacy Practices

HIPAA NOTICE of Privacy Practices HIPAA NOTICE of Privacy Practices South River Pediatrics 224 Mayo Road Edgewater, Maryland 21037 410-956-6302 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW

More information

Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,

Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Medical History Existing or Relevant Previous Conditions Allergies Yes No Dizzy Spells Yes No MRSA Yes No Anemia Yes No Emphysema/Bronchitis Yes No Multiple Sclerosis Yes No Anxiety Yes No Fibromyalgia

More information

SOUTHLAKE DERMATOLOGY 1170 N. Carroll Ave. Southlake, TX 76092 www.southlakedermatology.com Main 817-251-6500 Fax 817-442-0550

SOUTHLAKE DERMATOLOGY 1170 N. Carroll Ave. Southlake, TX 76092 www.southlakedermatology.com Main 817-251-6500 Fax 817-442-0550 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. EFFECTIVE September 15, 2014 This Notice of

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES NOTICE OF PRIVACY PRACTICES In 1996, the U.S. Congress passed the Health Insurance Portability and Accountability Act (HIPAA). Among others, the Act applies to health care providers and hospitals; it is

More information

REGISTRATION AUTISM TREATMENT SERVICES

REGISTRATION AUTISM TREATMENT SERVICES 559 Zor Shrine Place Madison, WI 53719 P: 608.833.0123 F: 608.833.0126 www.ids -wi.com CLIENT INFORMATION (First, MI, Last) (Street, City, State, Zip) REGISTRATION AUTISM TREATMENT SERVICES of Birth Home

More information

Effective Date of This Notice: September 1, 2013

Effective Date of This Notice: September 1, 2013 Rev.10-2013-KB P-drive-HR Forms NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED BY United Cerebral Palsy of Miami (UCP) and

More information

Summer Employment Application 2014

Summer Employment Application 2014 Summer Employment Application 2014 Thank you for your interest in the North Shore Youth Career Center s Summer Youth Program 2014. The next step in the process is to complete this application and include

More information

Athens Neuro & Balance Rehabilitation

Athens Neuro & Balance Rehabilitation Acknowledgement of Receipt Of Notice of Privacy Practices Patient Name & Address: I have a received a copy of the Notice of Privacy Practices for the above named practice. Signature For Office Use Only

More information

Cell Phone / Best Number To Reach You: Your e-mail address: Race: C AA Asian Other. Copay: Copay:

Cell Phone / Best Number To Reach You: Your e-mail address: Race: C AA Asian Other. Copay: Copay: DUS Family Medical Practice, LLC 7525 Greenway Center Drive, Suite # 105 Greenbelt, MD 20770 Phone: (301)313-0425 Fax: (301)313-0435 Patient s Last Name: First Name: MI: Address: City: State: Zip Code:

More information

I have received a copy of the Notice of Privacy Practices True Health.

I have received a copy of the Notice of Privacy Practices True Health. Sign-in Time: I have received a copy of the Notice of Privacy Practices True Health. Signature of Patient/Patient Representative Relationship of Patient Representative to Patient 2400 State Road 415 11881-A

More information

ACE PHYSICAL THERAPY & SPORTS MEDICINE INSTITUTE PATIENT REGISTRATION

ACE PHYSICAL THERAPY & SPORTS MEDICINE INSTITUTE PATIENT REGISTRATION ACE PHYSICAL THERAPY & SPORTS MEDICINE INSTITUTE PATIENT REGISTRATION ALEXANDRIA FAIRFAX FALLS CHURCH LEESBURG HERNDON TYSONS CORNER PATIENT INFORMATION (Please Print Clearly) Name Last First Middle of

More information

San Antonio Arthritis Care Centers

San Antonio Arthritis Care Centers Thank you for choosing San Antonio Arthritis Care Centers. We look forward to seeing you on: Day: Date: Time: With: Dr. Stolow Dr. Feinstein Dr. Des Rosier At this location: 8527 Village Dr., Suite 104,

More information

If you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment.

If you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment. Welcome to POST Physical Therapy Brookline. We strive to provide our patients with excellent service and quality care. Our commitment to your well-being and health care is something that we at POST Physical

More information

INTEGRITY WELLNESS CENTER NOTICE OF PRIVACY PRACTICES

INTEGRITY WELLNESS CENTER NOTICE OF PRIVACY PRACTICES INTEGRITY WELLNESS CENTER NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YU CAN GET ACCESS TO THIS INFORMATION- PLEASE REVIEW IT CAREFULLY

More information

Nephrology Associates New Patient Registration Forms

Nephrology Associates New Patient Registration Forms Registration Information Authorization form: Last First Middle Address: City: State: Zip: DOB: / / - - Home # ( ) - - Cell # ( ) - - Email Address: Alternate Contact Information Phone Number Relationship

More information

Physical Therapy Services Medical History Form

Physical Therapy Services Medical History Form Physical Therapy Services Medical History Form Last Name First Name DOB Age Diagnosis: Physician: Check Yes or No. If yes, please explain in the space provided. Yes No Are you pregnant? Yes No Currently

More information

BOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES

BOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES BOWLING GREEN INTERNAL MEDICINE AND PEDIATRICS ASSOCIATES TREATMENT AUTHORIZATIONS AND FINANCIAL POLICIES Patient Name: Date: FINANCIAL POLICY FOR PATIENTS Effective July 10, 2000 our office has established

More information

Student Name Nombre del Estudiante Grade/Grado School/Escuela. Relationship to student Relacion con el estudiante

Student Name Nombre del Estudiante Grade/Grado School/Escuela. Relationship to student Relacion con el estudiante LSNC Summer Camp 2015 Camper Enrollment Form This form must be completed and signed by the parent or guardian of a student enrolling in the Summer Camp STUDENT INFORMATION/INFORMACION DEL ESTUDIANTE Student

More information

Keweenaw Holistic Family Medicine Patient Registration Form

Keweenaw Holistic Family Medicine Patient Registration Form Keweenaw Holistic Family Medicine Patient Registration Form How did you first learn of our Clinic? Circle one: Attended Lecture Internet KHFM website Newspaper Sign in window Yellow Pages Physician Friend

More information

Salt Lake Community College Employee Health Care Benefits Plan Notice of Privacy Practices

Salt Lake Community College Employee Health Care Benefits Plan Notice of Privacy Practices THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Date: June 1, 2014 Salt Lake Community College

More information

Notice of Privacy Practices. Human Resources Division Employees Benefits Section

Notice of Privacy Practices. Human Resources Division Employees Benefits Section Notice of Privacy Practices Human Resources Division Employees Benefits Section THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

More information

PATIENT INFORMATION PATIENT FIRST NAME PATIENT LAST NAME D.O.B. SEX LANGUAGE ETHNICITY RACE

PATIENT INFORMATION PATIENT FIRST NAME PATIENT LAST NAME D.O.B. SEX LANGUAGE ETHNICITY RACE PATIENT INFORMATION 1. 2. 3. PATIENT FIRST NAME PATIENT LAST NAME D.O.B. SEX LANGUAGE ETHNICITY RACE MOTHER S FIRST NAME MOTHER S LAST NAME D.O.B PATIENT LIVE WITH? YES / NO SOCIAL SECURITY NUMBER: _-

More information

Welcome To Our Physical Therapy Department

Welcome To Our Physical Therapy Department Welcome To Our Physical Therapy Department Our entire staff is dedicated to providing our patients with the best possible care and service while keeping the costs to you from increasing at an unreasonable

More information

Notice of Privacy Practices

Notice of Privacy Practices Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. About this notice

More information

Patient Information. Mailing Address Street City State Zip. Contact Number Home Mother Mobile Father Mobile

Patient Information. Mailing Address Street City State Zip. Contact Number Home Mother Mobile Father Mobile TOO Patient Information Name of Minor/Child Last Name First Name Middle Name Nickname Sex: Male Female Date of Birth Social Security Mailing Address Street City State Zip Contact Number Home Mother Mobile

More information

Monterey County Behavioral Health Policy and Procedure

Monterey County Behavioral Health Policy and Procedure Monterey County Behavioral Health Policy and Procedure 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Policy Number 144 Policy Title Disclosure of Unlicensed Status for License

More information

Community Health of South Florida, Inc. 10300 SW 216 th Street Miami, FL 33190. Notice of Privacy Practices

Community Health of South Florida, Inc. 10300 SW 216 th Street Miami, FL 33190. Notice of Privacy Practices Community Health of South Florida, Inc. 10300 SW 216 th Street Miami, FL 33190 Effective Date: April 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN

More information

EMERALD COAST CANCER CENTER 1024 MAR WALT DRIVE 7720 HWY 98 WEST STE 240 FT. WALTON BEACH, FL 32547 DESTIN, FL 32550

EMERALD COAST CANCER CENTER 1024 MAR WALT DRIVE 7720 HWY 98 WEST STE 240 FT. WALTON BEACH, FL 32547 DESTIN, FL 32550 EMERALD COAST CANCER CENTER 1024 MAR WALT DRIVE 7720 HWY 98 WEST STE 240 FT. WALTON BEACH, FL 32547 DESTIN, FL 32550 NEW PATIENT INFORMATION FORM - PLEASE PRINT LEGIBLY - THANK YOU. PATIENT S NAME DATE

More information

2015 Annual Patient Paperwork Update for Existing Patients

2015 Annual Patient Paperwork Update for Existing Patients 2015 Annual Patient Paperwork Update for Existing Patients DATE: ͺͺͺͺ ŚĞĐŬ WƌĞĨĞƌƌĞĚ ůŝŷŝđ &ƚ tăljŷğ 'ƌğğŷǁžžě

More information

UNITED HEALTHCARE INSURANCE COMPANY CERTIFICATE OF COVERAGE FOR

UNITED HEALTHCARE INSURANCE COMPANY CERTIFICATE OF COVERAGE FOR UNITED HEALTHCARE INSURANCE COMPANY GROUP VISION CARE INSURANCE CERTIFICATE OF COVERAGE FOR MATTRESS FIRM, INC. GROUP NUMBER - 704140 Effective Date: October 1, 2008 Offered and Underwritten by UNITED

More information

Atlanta Diabetes Associates Patient Registration Form. Patient Name: First Middle Last. Address: City: State: Zip Code:

Atlanta Diabetes Associates Patient Registration Form. Patient Name: First Middle Last. Address: City: State: Zip Code: Atlanta Diabetes Associates Patient Registration Form : Chart #: Which Doctor are you seeing today: _ Patient Name: First Middle Last Address: City: State: Zip Code: _ Home Phone: Work Phone: of Birth:

More information

Inland Valley Medical Center Rancho Springs Medical Center Requesting Copies of Your Medical Record

Inland Valley Medical Center Rancho Springs Medical Center Requesting Copies of Your Medical Record Inland Valley Medical Center Rancho Springs Medical Center Requesting Copies of Your Medical Record Per Federal and State laws and regulations, patient information is kept in strict confidence and only

More information

Notice of Privacy Practices Walter L Cohen High School School-based Health Center. Effective as of August 6, 2004

Notice of Privacy Practices Walter L Cohen High School School-based Health Center. Effective as of August 6, 2004 Effective as of August 6, 2004 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We are required

More information

DALLAS ALLERGY & ASTHMA CENTER

DALLAS ALLERGY & ASTHMA CENTER DALLAS ALLERGY & ASTHMA CENTER Gary N. Gross, MD Michael E. Ruff, MD 5499 Glen Lakes Dr., Suite 100 Dallas, TX 75231 Dania A. Wierzbicki, MD Phone: (214) 691-1330 Jane Zepeda, PA-C FAX: (214) 691-6405

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES Effective Date: September 23, 2013 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. OUR PLEDGE

More information

HIPAA-ACKNOWLEDGEMENT OF RECEIPT Notice of Privacy Practices

HIPAA-ACKNOWLEDGEMENT OF RECEIPT Notice of Privacy Practices PEDIATRIC ENDOCRINE ASSOCIATES, P.C. 8200 E. Belleview Avenue, Suite 510E Greenwood Village, CO 80111 303-783-3883 HIPAA-ACKNOWLEDGEMENT OF RECEIPT Notice of Privacy Practices Printed Patient Name: Patient

More information

REHAB XCEL, LLC. NEW PATIENT INFORMATION

REHAB XCEL, LLC. NEW PATIENT INFORMATION REHAB XCEL, LLC. NEW PATIENT INFORMATION DATE: NAME: LAST: FIRST: MID: MAIL ADDRESS: HOME PHONE: CELL PHONE: WORK PHONE: DATE OF BIRTH: SS# SEX: M OR F EMERGENCY CONTACT: PHONE: MARITAL STATUS: M OR S

More information

HIPAA Omnibus Notice of Privacy Practices Effective Date: March 03, 2012 Revised on: July 1, 2015

HIPAA Omnibus Notice of Privacy Practices Effective Date: March 03, 2012 Revised on: July 1, 2015 HIPAA Omnibus Notice of Privacy Practices Effective Date: March 03, 2012 Revised on: July 1, 2015 Mobile Physician Group PC 231 High Street Suite 1, Mount Holly, NJ 08060 1-855-MPG-DOCS THIS NOTICE DESCRIBES

More information

Notice of Health Information Privacy Practices Radiology Associates of Norwood, Inc.

Notice of Health Information Privacy Practices Radiology Associates of Norwood, Inc. Notice of Health Information Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE

More information

Polk Medical Center Notice of Privacy Practices

Polk Medical Center Notice of Privacy Practices Polk Medical Center Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

More information

DAVID LAWRENCE CENTER Restoring & Rebuilding Lives

DAVID LAWRENCE CENTER Restoring & Rebuilding Lives Restoring & Rebuilding Lives Health Insurance Portability & Accountability Act (HIPAA) Notice of Privacy and Security Practices & Notice of Client Rights Abbreviated Statement For more than 40 years David

More information