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HIPAA Patient Questionaire

Please make sure all required fields are filled.

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

Name: Relation: Phone Number:

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

Name: Phone Number:

Please print the address of where you would like your billing statements and/or correspondence from our office to be sent if other then your home.

Check box if its the same mailing address

Alternative Address:

Please print the telephone number or email address where you want to receive calls about your appointments, lab and x-ray results or other health information.

Phone Number:

Email Address:

Can confidential messages (ie., appointments reminders) be left on your telephone answering machine ot voicemail?

Yes No

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.

Patient Name:

First Name ✓ Last Name ✓ Date ✓

Patient Signature

Full Name

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