HIPAA Patient Questionnaire



1. Please list the family members or other person(s), if any, whom we may inform about your general medical condition and your diagnosis (including treatment, payment and health care operations):

 
 
 
 
 
 
 
 
 
 
 
 
2. Please list the family members or others, if any, whom we may inform about your medical condition ONLY IN AN EMERGENCY
 
 
 
 
 
 
 
 
 
 
 
 

3. Please print the address of where you would like your billing statements and/or correspondence from our office to be sent if other than your home. (CONFIDENTIAL COMMUNICATIONS)

5. Please include the telephone number or email address where you want to receive calls about your appointments, lab and x-ray results or other health care information if other than your home phone

 
 

7. I understand the Privacy Protection Act and have been offered a copy of the Organization's Notice of Privacy Practices updated for the HITECH Omnibus Rule of 2013.