Dr's. Allen and Harris - Patient Forms

Form: HIPAA Omnibus Rule

Patient Information

FIRST Name

LAST Name

MI

PATIENT ACKNOWLEDGEMENT FORM FOR RECIEPT OF NOTICE OF PRIVACY PRACTICES

CONSENT/LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgement and authorization. In refusing we may not be allowed to process your insurance claims.

PATIENT ACKNOWLEDGEMENT FORM FOR RECIEPT OF NOTICE OF PRIVACY PRACTICES

Please list any other parties who are actively involved in your health care and who can have access to your health information (this includes step parents, grandparents and any care takers who can have access to this patient's records):

I authorize contact from this office to confirm my appointments, treatment and billing information via:

Cell Phone confirmation

Text messages to my cell phone

Home phone confirmation

Email confirmation

Work phone confirmation

All of the above

I’ve checked all above that apply ^*

I authorize information about my health be conveyed via:

Cell phone confirmation

Text messages to my cell phone

Home phone confirmation

Email confirmation

Work Phone Confirmation

All of the above

I’ve checked all above that apply ^*

I approve being contacted about special services, events, or new health info

Phone message

Text message

Email

All of the above

None of the above (opt out)

I’ve checked all above that apply ^*

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive their party remuneration from these affiliated companies. We under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.

MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/FACILITIES IN THE FUTURE.

I understand and acknowledge my rights as detailed in the Notice of Privacy Practices Presented here.

Patient or Legal Guardian/Authorized Representative

Name

Form: HIPAA Omnibus Rule

Patient Information

PATIENT ACKNOWLEDGEMENT FORM FOR RECIEPT OF NOTICE OF PRIVACY PRACTICES

I authorize contact from this office to confirm my appointments, treatment and billing information via:

I authorize information about my health be conveyed via:

I approve being contacted about special services, events, or new health info

Patient or Legal Guardian/Authorized Representative

Sign Form