WELCOME TO THE HEALTH CENTER

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1 WELCOME TO THE HEALTH CENTER PATIENT REGISTRATION FORM (Please Print Clearly) 1. PATIENT INFORMATION Last Name: First Name: Middle: Please Check One of the Following: African American White Asian Pacific Islander Native Hawaiian Native American More Than One Race Unknown Hispanic origin Yes No If Hispanic please check ethnicity: Mexican, Mexican American, Chicano Cuban Puerto Rican Central/South American Spanish Have You Ever Used Another Name? Yes No If Yes, List Other Names Used: Date of Birth: / / Age: Social Security Number: - - Sex: Male Female TG Mother s Maiden Last Name: Street Address: Apartment #: City: State: County: Zip Code: Home Phone: Cell Phone: Alternate Phone: I authorize the office to contact me at: Cell Phone SMS/Text Home Phone Work Phone Preferred Language: English Spanish Other: Martial Status: Single Significant Other Married Divorced Separated Widow/Widower Are You A Veteran of The US Armed Forces? Yes No If The Child Is Under 18 and Receiving Vaccines Please Complete The Following: Mother s First Name: Mother s Maiden Name: Date of Birth: / / 2. INSURANCE INFORMATION (Please Give Your Insurance Card To the Receptionist) Is This Patient Covered By Insurance? Yes No (If you checked No please skip this section) Please Indicate Primary Insurance: Medicaid Medicare CHIP CHIP Perinatal Private Ins. Other : Person Responsible for Charges: Date of Birth: / / Address (if different): Home Phone: Employer: Employer Phone: Policy Holder: Patient s SSN: Date of Birth: / / Group Number: Policy Number: Co-Payment: $ Patient s Relationship To Subscriber: Self Spouse Child Other

2 Secondary Insurance: Subscriber s SSN: Subscriber s Name: Date of Birth: / / Group Number: Policy Number: Patient s Relationship To Subscriber: Self Spouse Child Other 3. IN CASE OF EMERGENCY Name of Local Friend or Relative: Address: City, State: Zip Code: Relationship to Patient: Home Phone: Work Phone: 4. MEDICAL POWER OF ATTORNEY Name of Person With Durable Medical Power of Attorney: Relationship to Patient: Phone: Alternate Phone: Address: 5. HOW DID YOU HEAR ABOUT US? Advertising: Newspaper Magazine Internet (website Radio Flyer Other Social Media: Facebook Twitter Other Other: Friend Referred Primary Provider Referral Workshop/Conference Other (Please be Specific) Emergency Room ANNUAL SALARY $ $11,490 $11,491 - $14,283 $14,284 $17,076 $17,077 - $19,869 $19,870 - $22,662 $22,663 - OVER PATIENT S OR AUTHORIZED PERSON S SIGNATURE: DATE: FOR OFFICE USE ONLY MR#: Reviewed By: Staff Initials:

3 Confidential Medical History Form Page 1 Patient Name: Date of Birth: Reason for Visit: Prior Care: Please Check and Identify Relationship if any Relative (parent, sibling, grandparent, child, etc.) has had any of the following conditions. Condition Family History Relationship Condition Family History Relationship High Blood Pressure Stroke Cancer Emphysema Ulcers Sickle Cell Tuberculosis Anemia Mental Health Conditions Other Serious Illness (Please list): Kidney Disease Bleeding Tendencies Seizures Heart Disease Sugar Diabetes Asthma Colitis Gout Substance Abuse Other Serious Illness (Please list): Please Check Any of the Following Illnesses that you have experienced: (*) Date of First Illness Measles Whooping Cough Scarlet Fever Rubella (German Measles) Tonsillitis Chickenpox Diphtheria Mumps Asthma * Glaucoma Cancer * Angina Pectoris Ulcer * Bladder or Kidney Infection Mononucleosis Poliomyelitis Bronchitis Tuberculosis * Anemia * Malaria Seizures Hepatitis (A, B, and/or C) * Ear Infections * Other Tropical Diseases High Blood Pressure * Heart Attack HIV/AIDS * Diabetes Hives Goiter/Thyroid Disease Allergies Rheumatic Fever Eczema Pleurisy Influenza Phlebitis Typhoid * Sexually Transmitted Infection * Meningitis Heart Murmur Low Blood Pressure * Kidney Stones Depression * Anxiety * Other Serious Illness (Please Explain):

4 Please list the dates and results (if known) of the following: Confidential Medical History Form Page 2 Last TB Skin Test: Last X-ray: Last EKG: Last Blood Count: Last Exam by Doctor: Last Tetanus Vaccine: Last Pneumonia Vaccine: Last Influenza Vaccine: Last Hepatitis A Vaccine: Last Hepatitis B Vaccine: Last Mammogram: Last Colonoscopy: Last PSA/Rectal Exam: Last Pap Smear: Any History of Dysplasia? Yes No Any Treatment for Dysplasia? Yes No Please check any symptoms you are currently experiencing: Weight Loss Fainting Spells Abdominal Pain Loss of Energy Nausea/Vomiting Poor Hearing Fever/Chills Hot Flashes Constipation Loss of Appetite Muscle Pain Blood in Stool Headache Joint Pain Painful Urination Dizziness Blurred Vision Swollen Glands Rash Abnormal Moles Depression/Anxiety Sore Throat Numbness/Tingling Vaginal/Penile Discharge Please list any medications, prescription and over-the-counter, that you are currently taking: Please list any vitamins or nutritional supplements you are currently taking: Have you ever been hospitalized? Yes No If so, when, where, and for what reason? Do you drink alcohol or use any drugs? Yes No If so, what do you use, how much, and how frequently? Do you smoke cigarettes? Yes No If so, how many cigarettes do you smoke per day? Are you interested in quitting? Yes No

5 Pain Screening Are you experiencing any type of pain? Yes No If yes, in what areas: Confidential Medical History Form Page 3 Please mark an X as to what your level of pain you are experiencing today: Nutrition Screening PLEASE CHECK YES or NO Yes No Have you lost or gained at least 10 pounds within the last six months? Have you notice a change in the distribution of fat in your body within the last six months? Have you been informed that your cholesterol levels have increased from the time of your last medical appointment? Do you need information regarding nutritional supplements and how to access them? Please mark an X as to what your level of appetite you are experiencing today: Patient/Family Choice of Personal Clinician Please mark an X on the type of provider you are currently seeking services for today: Family Practice/Internal Medicine OB Gyn Podiatry Nurse Practitioner Other NAME OF PROVIDER: Ongoing Abuse Screen 1. Are you presently emotionally or physically abused by your partner or someone important to you? Yes No 2. Are you presently being hit, slapped, kicked, or otherwise physically hurt by your partner or someone important to you? Yes No 3. Are you presently forced to have sexual activities? Yes No 4. Are you afraid of your partner or anyone of the following? Yes No (circle if appropriate): husband/wife ex-husband/ex-wife boyfriend/girlfriend stranger 5. (If pregnant) Have you ever been hit, slapped, kicked, or otherwise physically hurt by your partner or someone important to you during pregnancy? Yes No

6 PAYMENT POLICY Houston Area Community Services, Inc. (HACS) is a private not for profit healthcare center. Standard charges have been established for all services provided. HACS is not a city or county clinic. Any additional costs including labs and X-rays will be an additional cost to the patient. If I request sliding scale, I will be charged based on the total family income and the number of people in my household. If I have Medicaid or Medicare the charges for my visit and the services received will be submitted to Medicaid/Medicare for reimbursement to the healthcare center and assignment must be accepted. I will bring my current Medicaid/Medicare certification letter with me each time I visit the healthcare center. I authorize my insurance benefits be paid directly to the healthcare center. Also, I understand that I am financially responsible for any balance due. My signature below authorizes HACS and/or my insurance company to release any information required to process my claims. I understand that HACS offers a sliding fee scale for individuals and families with economic hardships. It is my responsibility to provide HACS with the appropriate financial documentation requested to determine my eligibility for this discount. Also, I understand that I must update my financial information if a change occurs between visits. I have read and I understand HACS payment policy. Patient s Signature (Parent/Guardian if Patient is Under 18) Date

7 GENERAL CONSENT FOR MEDICAL TREATMENT I agree to have and receive services provided by Houston Area Community Services, Inc. (HACS) providers, and to follow their instructions. I understand that my medical information is confidential and protected to the extent of the law. My medical records are confidential and are released with my own written consent. I hereby consent for care and treatment at Houston Area Community Services, Inc. (HACS). I do not hold the health center or its employees responsible for any unusual effects resulting from the center s care. I certify that I have received, read, and understand HACS : Mission and Values Financial Policy Childcare Policy HACS Services Client Rights & Responsibilities Client Information Handbook Complaint and Grievance Policy Notice of HIPAA and Privacy Practices Special Provisions to Applicable Grant Funded Programs (if eligible) Advance Directives Information Signature of Client or Legal Representative: If signed by Legal Representative, Relationship to Client: Print Name Including Title and Staff Signature: Client Code: Consent Expires: (one year from date of signature, unless otherwise specified) Staff initials:

8 SLIDING FEE DISCOUNT FORM Immediate Family Members Monthly Income: $ Number of People in Household: Last Name First Name Relation to Head of Household SEX M/F/TG SSN # Date of Birth Income Documentation Collected: Documentation Date Staff Initial Photo ID Copies of Three Months Paycheck Stubs Copy of Income Tax Return Welfare Coupons SSI/SSDI Alimony Stipends Child Support Workman s Compensation Homeless HIV/AIDS Status Letter of Support Sliding Scale Discount: % The patient has been approved to receive discounted fees under the HACS sliding scale based on the information they have provided to us. HACS Staff Date

9 Houston Area Community Services, Inc West 18 th Street, Suite 300 Houston, Texas PATIENT HIPAA CONSENT FORM I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize Houston Area Community Services, Inc. to use and disclose my protected health information to carry out: Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment); Obtaining payment from third party payers (e.g. my insurance company); The day-to-day healthcare operations of your practice. I have also been informed of and given a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that this consent has no expiration date. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected. Print Patient Name: Signature: Relationship to Patient:

10 Authorization to Exchange, Release, and/or Disclose Protected Health Information (PHI) for Treatment, Payment, or Healthcare Operations Page 1 of 3 I understand that once Houston Area Community Services, Inc. (HACS) discloses my protected health information (oral and/or written) pursuant to my request, it cannot guarantee that the recipient will not re-disclose my health information to a third party. The recipient or the third party may not be required to abide by this Authorization or applicable federal and state laws governing the use and disclosure of my health information. I may make a request in writing at any time to HACS to inspect and/or obtain a copy of my health information maintained at any of HACS sites as provided in the Federal Privacy Rule 45 CFR This Authorization will remain in effect until I provide a written notice of revocation of this Authorization to HACS Privacy Officer. If I revoke this Authorization, HACS may not be able to reverse the use or disclosure of my health information while the Authorization was in effect. I may make a request in writing at any time to HACS to inspect and/or obtain a copy of the Protected Health Information (PHI) maintained at this facility to be used or disclosed as provided in Federal Privacy Rule 45 CFR I understand that my records are protected under federal regulations governing Confidentiality of Alcohol and Drug Patient Records 42 CFR Part 2, 33 of Public Law as amended by Public Law , Texas Health and Safety Code and Chapter 611, and Texas Administrative Code and all other applicable state and local laws, rules, regulations, and cannot be disclosed without my written consent unless provided within these laws or regulations. If I have any questions about the disclosure of my health information, I can contact HACS Privacy Officer at I also understand that as part of my health care, HACS originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as: A basis for planning my care and treatment A means of communication among the many health professionals who contribute to my care, A source of information for applying my diagnosis and surgical information to my bill, A means by which a third-party payer can verify that services billed were actually provided, and A tool for routine healthcare operations such as assessing quality and reviewing the competence of the healthcare professionals. I have been provided with HACS Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges: The right to object to the use of my health information for directory purposes, and The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations. I understand that HACS is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section of the Code of Federal Regulations. I further understand that the agency reserves the right to change its notice and practices and prior to implementation, in accordance with Section of the Code of Federal Regulations. Should the agency change its notice, it will send a copy of any revised notice to the address I have provided (whether Facsimile, U.S. mail or, if I agree, ). Client Providing Authorization Client Signature and 11 Digit Character Code: Staff initials:

11 Authorization to Exchange, Release, and/or Disclose Protected Health Information (PHI) For Treatment, Payment, or Healthcare Operations Page 2 of 3 Entity Authorized to Exchange, Release and/ or Disclose PHI Houston Area Community Services, Inc. (HACS) Phone Number: (713) Address: 2150 West 18 th Street, Suite 300 Houston, TX Purpose of Disclosure: Coordination of Care Date(s) of Service: Records to be Exchanged, Released and/ or Disclosed Please Note: Initial only the documents you want exchanged, released and/or disclosed. If you want all records identified below exchanged, released and/or disclosed, only initial the first blank next to All Medical and Billing Records. I authorize the exchange, release and/or disclosure of the following PHI: All Medical & Billing Records Discharge Summary History & Physical Consultations Operative Reports Treatment Plans & Medications Progress Notes Pathology Reports Radiology Reports Lab Reports Psychiatric Records CPCDMS Forms HIV/AIDS Status/Records Communicable Disease Records Mental Health Records Alcohol/Drug Treatment Records Billing Information Other Records as specified: Entities With Which PHI may be Exchanged, Released and/ or Disclosed I give HACS permission to release, exchange, and/or disclose the above identified PHI to the entities identified on the attached list entitled Authorized Entities. (Please Note: If you do not wish HACS to exchange release and/or disclose PHI to entities identified on the attached list, place a single line through the entity s name and place your initials next to crossed out entity.) This authorization will remain in effect for one year after the date of my signature or until revoked by me in writing. A photocopy of this Authorization shall be considered valid as the original. I understand that as part of this organization s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax. I fully understand and accept the terms of this consent. Attached as an exhibit and incorporated herein is a list of the entities with which my PHI may be exchanged, released or disclosed. Authorization expires: (one year from date of signature, unless otherwise specified). Client or Legal Representative Signature Date Client Name Printed Agency Staff Signature Date Staff Name Printed Title

12 Authorization to Exchange, Release, and/or Disclose Protected Health Information (PHI) for Treatment, Payment, or Healthcare Operations Page 3 of 3 Authorized Entities AIDS Foundation Houston (AFH) all programs Houston Community Voice Mail The Recovery Center Montrose/Galveston American Red Cross Homeless Court Recovery Houston Institute Assoc. Advancement of Mexican Americans (AAMA) Harris County PHES Reliant Energy Bay Area Council on Drugs & Alcohol, Inc (BACODA) Harris County Social Services The Resource Group Bellaire Hospital Hospice at the Texas Medical Center The Right Step Bering Omega Community Services Houston Area Women s Center River Oaks Health Association HELP House Bethel House Houston HELP Corder Place Apartments Riverside General Hospital Brentwood Baptist Church Project WAITT Houston Recovery Campus Salvation Army Bridge Over Troubled Waters Houston Volunteer Lawyers Program SAMHSA Bristol Myers Squibb Patient Assistance Programs Hunstville Memorial Hospital Sam Houston State University Casa Juan Diego y Maria Intracare Hospital Santa Maria Hostel Career and Recovery Resource Center LabCorp of America SEARCH Homeless Project Catholic Charities Legacy Community Health Services Second to None Resale Center for Disease Control and Prevention (CDC) Kroger Pharmacy All Locations Sisters of Serenity Center for AIDS (CFA) MD Anderson Social Security Administration Christian Community Service Center Memorial Assistance Ministries (MAM) Southeast Texas Legal Clinic Coalition for the Homeless Houston Memorial Hermann Hospital Systems Southside Pharmacy City of Houston, Bureau of HIV/STD Memorial Hermann PaRC Southwest Area Ministries Community Endowment Foundation Mental Health Mental Retardation Auth. Saint Hope Foundation, Inc. (MHMRA) Council on Alcohol & Drugs Houston Methodist Hospitals Saint Joseph s Hospital Covenant House Metropolitan Transit Authority (METRO) Saint Luke s Hospital CVS Pharmacy all locations Montgomery County Sheriff s Department Saint Pius V Catholic Church DAPA Montgomery County Health Department Saint Vincent de Paul Society Department of Health & Human Services (Texas) Montgomery/Walker County Council Star of Hope Transitional Living Center Department of State Health Services (Texas) Montrose Counseling Center STAR Drug Court Department of Veterans Affairs Medical Center NAACP Statscript Pharmacy DePelchin Children s Center NAMI Target Pharmacy All Locations EMD Serono Patient Assistance Programs New Directions Texas Board of Pardon/Parole (TDCJ) Extended Aftercare (EAI) New Hope Counseling Texas Children s Hospital Family Services of Greater Houston New Hope Housing Texas Department of Health HIV Medication (ADAP) First Presbyterian Church: Operation ID North Houston Imaging Center Texas Department of Criminal Justice/Parole (TDCJ) Fort Bend Family Health Center Northwest Assistance Ministries Texas House, Inc. Joseph Gathe, MD Housing Corporation of Greater Houston Texas Women s Hospital Goodwill Industries Odyssey House Texas Dept. of Assist. & Rehab. Services (DARS) Gilead Sciences Patient Assistance Programs Open Door Mission Foundation Transgender Foundation of America (TFA) Gulf Coast Community Services Operation ID UTMB Galveston and Conroe Harris Co. Community Dev. Agency (HCCDA) Palmer Drug Abuse Program All Sites UT Health Science Center, Houston Harris Co. Comm. Sup. & Correc. Dep. (HCCSCD) Park Plaza Hospital Visiting Nurse Association (VNA) Harris County Psychiatric Center (HCPC) Planned Parenthood Volunteers of America (VOA) All Programs Harris County Sheriff s Department (HCSD) Plaza Home Care Walgreens Pharmacy All Locations Harris County STAR Drug Court Plaza Medical Center Pharmacy Walmart Pharmacy All Locations Harris County Hospital District (HCHD) all clinics Pride Hospital WAM Foundation Houston Housing and Community Development Ryan White Grant Administration (RWGA) Wellsprings Houston Police Department (HPD) Ryan White Planning Council (RWPC) West Oaks Hospital Client Signature & Date Client Name & Code Staff Initials & Date

13 Consent for Services Care Services Page 1 of 2 I, wish to receive services provided by Houston Area Community Services, Inc., (HACS) an agency participating in the Centralized Patient Care Data Management System (CPCDMS) for Ryan White CARE Act and Department of State Health Services funded services and is maintained by Harris County Public Health & Environmental Services - HIV Services Office and Government Performance Reporting Act (GPRA) for CMHS/CSAT funded services maintained by the Substance Abuse Mental Health Services Administration (SAMHSA). I understand that key activities include assessing my eligibility and needs; providing me with requested services; networking with other participating agencies within the CPCDMS and GPRA, as applicable, and ensuring the coordination, monitoring and quality of services received. I understand that the services provided by HACS may be provided by a variety of disciplines. I understand that my identity and my participation in the CPCDMS and GPRA are confidential. I understand that no information or records associated with my case will be knowingly released to anyone or any agency that is not currently participating in the CPCDMS or GPRA without my informed written consent, or a subpoena, court order or legal statute. By my signature below, I give permission for information pertaining to my demographics and services to be entered into the CPCDMS and, as applicable, GPRA. The centralized databases can only be accessed by authorized personnel to assess the system s provision of services for planning, program development, statistical reporting and research purposes. No identifying information, such as my name, address or social security number will be stored at the Ryan White central site, however, authorized data system administrators may view such information stored at the HACS site. If the services HACS provides me are funded by SAMHSA, identifying information is stored at the SAMHSA central site. If I have concerns about this data being entered into one or both of these systems, I agree it is my responsibility to let HACS know in writing. I understand that using my name and social security number is voluntary and that receipt of services is not contingent on submission of this information. I acknowledge the following topics were explained to me during admission: (1) the nature of the proposed care, treatment services, medications, interventions, and/or procedures, (2) potential benefits, risks, or side effects, including potential problems related to recuperation, the likelihood of achieving care, treatment, and services goals, (3) reasonable alternatives to the proposed care, treatment, and services, (4) the relevant risks, benefits, and side effects related to alternatives, including the possible results of not receiving care, treatment, and services, (5) when indicated, any limitations on the confidentiality of information learned from or about the client, and (6) the medical record can be reviewed by funding sources and other applicable regulatory, accrediting agencies (e.g. JCAHO). I am giving this consent of my own free will. This consent will remain in effect until I provide a written statement revoking my consent. By placing my initials, I agree to allow information about me and my services to be entered into CPCDMS Yes No By placing my initials, I agree to allow information about me and my services to be entered into GPRA Yes No By placing my initials, I agree to allow information about me and my services to be entered into HMIS Yes No By placing my initials, I agree to allow information about me and my services to be entered into Powersource Yes No I fully release and hold the entity(ies) administering the funding for the service(s) listed above; Harris County Public Health & Environmental Services, who is the entity responsible for overseeing and maintaining the CPCDMS; SAMHSA who is the entity responsible for overseeing and maintaining the GPRA, as applicable; Department of State Health Services; Centers for Disease Control and Prevention, The Resource Group, City of Houston, HUD, City of Houston Housing and Community Development and HOPWA and Public Services and, HACS, Inc.; their Officers, Directors, Board Members, Donors, employees and agents (i.e.: volunteers, students) harmless from any and all damages, losses,

14 Consent for Services Care Services Page 2 of 2 liabilities (joint or several), payments, obligations, penalties, claims, litigation, demands, defenses, judgments, suits, proceedings, costs, disbursements or expenses (including without limitation, fees, disbursements and expenses of attorneys, and other professional advisors and of expert witnesses and costs of investigation and preparation) of any kind or nature whatsoever resulting from, relating to or arising out of my receipt of services or inadvertent disclosure of Protected Health Information. Signature of Client or Legal Representative: If signed by Legal Representative, Relationship to Client: Print Name Including Title and Staff Signature: Client Code: Consent Expires: (one year from date of signature, unless otherwise specified) Staff Initials:

15 Patient Single Consent to Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations I,, understand that as part of my health care, Houston Area Community Services, Inc. (HACS) originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as: A basis for planning my care and treatment, A means of communication among the many health professionals who contribute to my care, A source of information for applying my diagnosis and surgical information to my bill, A means by which a third-party payer can verify that services billed were actually provided, and A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals I understand and have been provided with HACS Notice of Privacy Practice that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges: The right to review the notices prior to signing this consent, The right to object to the use of my health information for directory purposes, and The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations. I understand that HACS is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section of the code of Federal Regulations. I further understand that the agency reserves the right to change their notice and practices and prior to implementation in accordance with Section of the Code of Federal Regulations. Should the agency change their notice, it will send a copy of any revised notice to the address I have provided (whether Facsimile, U.S. mail or if agree, ). I wish to allow HACS to exchange my health information with the following individuals: Name: Relationship: Emergency Contact Person Contact phone/address: List of medical conditions that can be discussed with contact person: I understand that as part of this organization s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax. I fully understand and accept the terms of consent. This consent will expire: (one year from the date of my signature, unless otherwise specified or revoked in writing by myself). Client or Legal Representative Signature Date Client Name Printed Agency Staff Signature Date Staff Name Printed Title

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