Primary Care Registration Form

Step 1 of 5

Today’s Date

PCP

Patient Information

Name

First Middle Last

Marital Status

Former Name

First Last

Date Of Birth

Sex at Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Occupation

Referred to Clinic by

Gender Identity

Language

Gender Identity Other

Race

Pronouns

Consent the call

Consent the text

INSURANCE INFORMATION

Please give insurance card to receptionist)

Person Responsible for Bill

Date of Birth

Address If Different

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Is the Responsible Party a Patient

Yes

Responsible Party Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Responsible Party Employer Phone Number

Is This Patient Covered by Insurance?

Yes

Please Indicate Primary Insurance

Name of Insurance

First Last

Subscriber ID

Group #

Subscribers Name

First Last

Subscriber DOB

Patient’s Relationship to Subscriber

Self

Spouse

Child

Other

MEDICATION LIST

Allergies and Reactions

Pharmacy Name

Pharmacy Phone

Pharmacy Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Signature

Date

THIS FORM MUST BE COMPLETED IN IT’S ENTIRETY BY THE PATIENT OR PATIENT’S AUTHORIZED REPRESENTATIVE THE HEALTH EXPERIENCES PRIMARY CARE Authorization For Disclosure Of Protected Health Information

Phone Number

Date Of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

1. Provider Making Disclosure I authorize:

(referred to as “Health Care Provider”) to release my/the patient’s individually identifiable health information as described below.

2. Recipient of Health Information: I authorize The Health Care Provider to release the information described in this authorization:

3. Information To Be Released: Describe information you want to be disclosed pursuant to the Authorization:

A. Medical Records: (check “All Medical Records Or Other)

All Medical Records

Other I only want the following parts of my medical record to be disclosed

Other

B. Billing Records: (Check if you want billing records released)

Billing Records

C. Dates Of Treatment: (Check “All dates of Treatment” or Specific dates of treatment”)

All dates of Treatment

Specific dates of treatment: I only want records for the following dates of treatment disclosed

Other

Your refusal to sign this authorization: The Health Care Provider may not condition treatment on whether or not you sign this authorization. If you refuse to sign this Authorization, the health care provider will not withhold treatment from you and will not release the information to the person or organization specified above.
Purpose for the use of disclosure: The purpose for the disclosure is at the patient’s request.
Oral Communication: I understand that this authorization allows the Health Care Provider and its employees to discuss my individually identifiable health information described herein with the recipient of the information.
Re-Disclosure: I understand that the information used and/or discussed pursuant to this Authorization may be re-discussed by the recipient of the information and may no longer be protected by Federal law. However, if the information disclosed pursuant to the Authorization includes alcohol or drug treatment records, the person(s) receiving such disclosure is hereby notified that this information has been disclosed from confidential records protected from disclosure by Ohio law. Ohio law prohibits such person(s) from making any further disclosure of this information without the specific written and informed release of the patient to whom it pertains, or as otherwise permitted by Ohio law. A general authorization for the release of medical or other information is not sufficient for the purpose of the release of HIV test results or diagnosis.
Revocation: I understand that I may revoke this authorization at any time by notifying the Health Care Provider in writing by sending a letter to the attention of the Manager of the medical records department at the Health Care Provider's mailing address. I understand that if I revoke this authorization it will not affect any actions that the Health Care Provider took before it received my revocation letter.

9. Expiration: This Authorization will expire one year after the date below, or sooner by choice, in which case this Authorization will expire on

(if applicable, insert date)

Note You may not indicate there is no expiration. However, if the records to be used or disclosed pursuant to this Authorization concern psychiatric, psychological and/or mental health treatment, this Authorization will expire 90 days after the date below, or sooner by choice, in which case this authorization will expire on

(if applicable, insert date)

Note: You may not indicate there is no expiration date.

Signature of Patient or Patient’s Representative

Date

Printed Name of Patient and/or Patient’s Representative

Date

Patient Consent for Use and Disclosure of Protected Health Information

If “legal guardian” or “Other,” legal documentation of Representative’s authority must accompany this authorization.

PLEASE NOTE: THERE MAY BE A CHARGE TO COPY RECORDS.

THE HEALTH CARE PROVIDER MAY USE A COPY SERVICE AND IT MAY BILL YOU DIRECTLY.

THE HEALTH EXPERIENCES

I hereby give my consent for THE HEALTH EXPERIENCES to use and disclose Protected Health Information (PHI) about me to carry out treatment, payment, and health care operations (TPO). A Notice of Privacy Practices provided by THE HEALTH EXPERIENCES describes such uses and disclosures more completely.

I have the right to review the Notice of Privacy Practices prior to signing this consent. THE HEALTH EXPERIENCES reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy may be obtained by forwarding a written request to:

199 William Howard Taft Road, Cincinnati, Ohio 45219

With this consent, THE HEALTH EXPERIENCES may:

Call my home or other alternative location and leave a message on voicemail or in person regarding items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any calls pertaining to my clinical care, including laboratory test results.
Mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements, as long as they are marked “Personal and Confidential.”
Email to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements.

I have the right to request that THE HEALTH EXPERIENCES restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to allow THE HEALTH EXPERIENCES to use and disclose my PHI to carry out TPO. I may revoke my consent in writing, except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, THE HEALTH EXPERIENCES may decline to provide treatment to me.

Signature of Patient or Legal Guardian

Date

Print Patient’s Name and/or Printed Name of Guardian

TELE MEDICINE CONSENT FORM

Patient Name

First Last

DOB

Telemedicine Consent Form

I understand that my health care provider wishes me to engage in a telemedicine consultation.

My health care provider has explained to me how the video conferencing technology will be used to conduct such a consultation. I understand that a telemedicine consultation will not be the same as a direct patient/health care provider visit since I will not be in the same room as my health care provider.

I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the video conferencing connections are not adequate for the situation.

I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation besides my health care provider and consulting health care provider to operate the video equipment. The above-mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and will have the right to:

Omit specific details of my medical history/physical examination that are personally sensitive to me;
Ask non-medical personnel to leave the telemedicine examination room;
Terminate the consultation at any time.

I have had the alternatives to a telemedicine consultation explained to me, and in choosing to participate in a telemedicine consultation, I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider.

In an emergent consultation, I understand that the responsibility of the telemedicine consulting specialist is to advise my local practitioner, and that the specialist’s responsibility will conclude upon the termination of the video conference connection.

I understand that billing will occur from both my practitioner and as a facility fee from the site from which I am presented.

I have had a direct conversation with my doctor, during which I had the opportunity to ask questions regarding this procedure. My questions have been answered, and the risks, benefits, and any practical alternatives have been discussed with me in a language that I understand.

By Signing This Form, I Certify

That I have read or had this form read and/or had this form explained to me

That I fully understand its contents including the risks and benefits of the procedure(s).

That I have been given many opportunities to ask questions and that any questions have been answered to my satisfaction.

Patient’s/Parent/Guardian Signature(

Date

HIPAA Information and Consent Form

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office.

What this is all about:

Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protection to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

Patient information will be kept confidential except as it is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, and health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI, and other documents or information.
It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and recent technology that you might find valuable or informative.
The practice utilizes several vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
Your confidential information will not be used for the purposes of marketing or advertising of products, goods, or services.
We agree to provide patients with access to their records in accordance with state and federal laws.
We may change, add, delete, or modify any of these provisions to better serve the needs of both the practice and the patient.
You have the right to request restrictions in the use of your protected health information and to request changes in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

Date

Primary Care Registration Form

Patient Information

INSURANCE INFORMATION

IN CASE OF EMERGENCY

MEDICATION LIST

Patient Consent for Use and Disclosure of Protected Health Information

THE HEALTH EXPERIENCES

TELE MEDICINE CONSENT FORM

Telemedicine Consent Form

HIPAA Information and Consent Form

What this is all about:

We have adopted the following policies:

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