New Pt Intake Packet

Forms

New Patient Intake Form

FILL AND SUBMIT

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"*" indicates required fields

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PERSONAL INFORMATION

Patient Name*
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Gender*
Address*
Pharmacy Address*

INSURANCE INFORMATION

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EMERGENCY CONTACT

These questions are included to comply with new Federal Health guidelines – we are required to ask for this information

Ethnicity (check one)*
Race (check one)*
Preferred Language (check one)*
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For use and/or disclosure of Protected Health Information (PHI) to carry out treatment, payment, and healthcare operations.

, hereby states that by signing this consent, agrees and acknowledges:

The Diablo Digestive Care, Inc., Privacy Notice has been offered to me to review prior to my signing this consent. The Privacy Notice includes a description of the uses and/or disclosures of my Protected Health Information (PHI) which is necessary for the facility to provide treatment to me, and also necessary for the facility to obtain payment for treatment and to carry out normal operations. I understand that the Privacy Notice will be available to me in the future upon request. The facility has further explained that it is my right to obtain a copy of the Privacy Notice prior to signing this consent, and has encouraged me to read the Privacy Notice carefully prior to my signing this consent. The facility reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with applicable law.

I understand that, and consent to, the following appointment reminders that will be used by the facility:

  1. A postcard or letter mailed to me at the address provided by me; and/or
  2. Telephoning my home and leaving a message on my answering machine or with the individual who answers the phone.
  3. Email to the email address I have listed in my account.
I understand that, and consent to, a detailed message regarding test results/treatment plan being left on a voicemail system:
A message will be left requesting you call the office.
Consent*

The facility may use and/or disclose my PHI (which includes information about my health or condition, and the treatment provided to me) in order for the facility to treat me and obtain payment for that treatment, and as necessary for the facility to conduct its specific health care operations.

I understand that I have a right to request that the facility restrict how my PHI is used and/or disclose to carry out treatment, payment and/or health care operations. However, the facility is not required to agree to any restrictions that I have requested. If the facility agrees to a requested restriction, then the restriction is binding on them.

I understand that this consent is valid for one (1) year. I further understand that I have the right to revoke this consent, in writing, at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent that the facility has already taken action in reliance on this consent. I understand that if I revoke this consent at any time, the practice has the right to refuse to treat me.

I understand that if I do not sign this consent evidencing my consent to the uses and disclosures described to me above and contained in the Privacy Notice, then the Practice cannot treat me.

I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way that I can understand.

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