Patient Registration Authorization for Release of Information Patient Name(Required) Date of Birth(Required) Month Day Year I authorize the use or disclosure of the above named individual’s health information as described below. The following individual(s) or organization(s) are authorized to make the disclosure: HealthWorks Family Medicine 2331 New Holt Road Paducah, KY 42001 Phone (270) 441-4777/Fax (270) 441-4780 The type of information to be used or disclosed is as follows:Dates: From MM slash DD slash YYYY To MM slash DD slash YYYY Record Release Option Entire Record Other DISCLOSURE REQUIRING SPECIAL CONSENTMy signature below specifically authorizes the release of healthcare information relating to testing, diagnosis, or treatment for: Mental Health/Psychiatric Treatment Sexually Transmitted Disease HIV/AIDS Virus Drug/Alcohol Abuse Treatment The information identified above may be used by or disclosed to the following individuals or organization(s):Name Address PhoneFax I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Privacy Officer. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.Unless I specify differently, this authorization will expire: Month Day Year If I fail to specify an expiration date or event, this authorization will expire six months form the date on which it was signed. I understand that once the above information is disclosed it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations. I understand authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to ensure health care treatment. Signature or Patient or Representative(Required)Date(Required) MM slash DD slash YYYY If signed by Representative, relationship to patient: Signature of WitnessDate MM slash DD slash YYYY Patient Information Patient Name(Required) Last Name MI First Name Address(Required) Street Address City State / Province / Region ZIP / Postal Code Date of Birth(Required) Month Day Year Sex(Required) Male Female Home PhoneCell PhoneWork PhonePreferred Number for Appointment Reminder Calls: Home Cell Email Address(Required) *For access to the office patient portalMarital Status(Required) Divorced Married Single Widowed Other Race(Required) American Indian or Alaska Native Asian Native Hawaiian Black or African American White Hispanic Other Race Prefer Not to Answer Ethnicity(Required) Hispanic or Latin Non-Hispanic Prefer Not to Answer Language(Required) English Spanish Other Patient Employer Employer Phone #Emergency Contact Name Emergency Phone #Spouse Name Spouse Employer Pharmacy Information Local Pharmacy Name(Required) Location/City(Required) Mail Order Pharmacy Name (if applicable) Primary Insurance Information Self-Pay Check if Self-PayPrimary Insurance Name If policy holder of the insurance is different than patient please complete:Policy Holder Name Date or Birth Month Day Year Relationship to Patient Secondary Insurance Information Secondary Insurance Not Applicable Check if N/ASecondary Insurance Name Privacy Act and Medical Records Release for Insurance and Referring Physicians I, [PATIENT NAME], have received the brochure regarding the patient privacy act and understand that my records cannot be released without my written permission. I also authorize the release of all medical records to referring physicians and to my insurance company. I further authorize insurance payments to be made directly to HealthWorks Family Medicine and understand that copays/patient balances are due at the time of service.Patient Name(Required) Date(Required) MM slash DD slash YYYY Signature of Patient or Guardian of minor(Required) Consent to Use and Disclosure of Health Information For Treatment, Payment, or Healthcare Operations Today's Date(Required) MM slash DD slash YYYY Patients Name(Required) Date of Birth(Required) Month Day Year Guarantors Name I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination, and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as: A basis for planning my care and treatment. A means of communication among the many health professionals who contribute to my care. A source of information for applying my diagnosis and surgical information to my bill. A means by which a third party payer can verify that services billed were actually provided. A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals. I have reviewed the office policies and payment policies of the office of HealthWorks Family Medicine. I understand that noncompliance to the policies may result in discharge from the practice of HealthWorks Family Medicine. In accordance with HIPAA, I wish to be contacted in the following manner (check all that apply):Cell Phone Option Cell Phone Leave message with detailed information Leave message with call back number only Written Communication Option Written Communication OK to mail to home address Home Phone Option Home Telephone Leave message with detailed information Leave message with call back number only Work Phone Option Work Telephone Leave message with detailed information Leave message with call back number only Patient Signature(Required)Date(Required) MM slash DD slash YYYY Guarantor Signature (If under the age of 18)(Required) Please list below those whom you would allow us to release test results and medical information to (i.e.: spouses, children, parents, friends): Name/Relationship Phone NumberName/Relationship Phone NumberName/Relationship Phone NumberCAPTCHA
