New Patient Registration

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Cell Phone *

Email Address *

Emergency Contact Phone #

Emergency Contact Name

Relationship to the patient

Patients Gender

Date of Birth *

MM/DD/YYYY

Employed

Employed Unemployed Disabled Retired Student

Current Employer

Current University/College

Single

Single Married Divorced Widowed Other

Preferred Pharmacy

Preferred Pharmacy Phone

Pharmacy Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

How were you referred to our practice?

Insurance Information

Primary Insurance Company Name

Policy Number

Group Number

Subscriber Name

Subscriber Date of Birth

MM/DD/YYYY

Relationship to Subscriber

May we EMAIL via secure portal or leave voice messages regarding TEST RESULTS? *

Yes No

DISCLOSURE OF YOUR HEALTH INFORMATION. Would you like anyone besides yourself to receive information about your appointments, treatment, diagnostic results and/or information pertinent to your healthcare? *

No, I do not authorize my health information to be disclosed to any other parties EXCEPT TO ME THE PATIENT. Yes, I authorize the person(s) listed below to receive ALL HEALTH INFO about appts, treatment and/orinformation pertinent to my healthcare and/or payment for my healthcare. Name of person(s)/relation to patient

PATIENT’S CONSENT FOR TREATMENT: I hereby voluntarily request and authorize Hayley Nguyen, MD to examine and treat me. I authorize Hayley Nguyen, MD to release any information acquired during my examination or treatment to my insurance carrier for the purpose of medical claims payment. I authorize payment of medical benefits to Hayley Nguyen, MD. I understand that verification of benefits and filing of a claim does NOT guarantee payment. If my claim is denied, not covered, or remains unpaid by my insurance, I will be responsible for the balance due. *

Clear

NO SHOW POLICY

Patients who are unable to keep their appointments are requested to give 24-hour notice prior to their appointments. We realize this is not always possible and the practice will consider each individual case. If a patient fails to provide notice, it will be necessary to charge $25.00 fee that will be billed to his/her account.

CONSENT TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

How we may use and disclose your health information: Your protected health information will be used by Hayley Nguyen, MD or disclosed to others for the purpose of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice.

The notice of privacy practices: Hayley Nguyen, MD is required to provide to you a notice that describes how information about you may be used and disclosed. Additionally, we must provide you information on how you may get access to this information. These policies and practices are defined in our “Notice of Privacy Practices” packet provided to you.

You may place restrictions on the use or disclosure of your health information: You may request a restriction on the use or disclosure of your protected health information. However, Hayley Nguyen MD may or may not agree to your request to restrict the use or disclosure.

You may revoke this consent at any time: You may revoke this consent at any time; however, Hayley Nguyen, MD requires that you revoke this consent in writing. If you revoke this consent, the revocation will not affect use and disclosure of your information before the date of the request.

Changes to privacy practices: Hayley Nguyen, MD reserves the right to change or modify the privacy policies outlined in the Notice of Privacy Practices packet. You will be notified of changes via mail or verbally.

ADVANCE DIRECTIVE FORM

Advance directives are legal documents that allow you to convey your decisions about end-of-life care ahead of time. Patients may use advance directives to specify what actions should be taken for their health in the event they are no longer able to make decisions due to illness or incapacity. If you would like an advance directive form, please request one from our office.

I have reviewed this consent form, received the packet entitled “Notice of Privacy Practices” and give my permission to Hayley Nguyen, M.D. to use and disclose my health information inaccordance with this consent the notice provided. *

Clear