Patient Intake Form

Personal History - Confidential Information
Date*

MonthDayYear
Date
Name*

PrefixFirst NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Home Phone Number*

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
SSN
Gender
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age
Occupation
Marital Status*

MarriedSingleWidowedDivorced
Spouse Name

First NameLast Name
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Relationship to Patient
Primary Care Physician*
Physician Phone Number*

Area CodePhone Number
How did you hear about us?*

MailNewspaperPromotional callRadioInsuranceYellow pagesSponsored eventHealth/senior fairWebsiteEmployerReferred by a friendReferred by a physicianOther
Reason for appointment*
Patient Consent for Use and Disclosure of Protected Health and Financial Information
I hereby give consent for Jacobs Audiology, LLC to use and disclose protected health information (PHI) about me, to carry out treatment, payment, and healthcare operations (TPO).

With this consent Jacobs Audiology, LLC many call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist this clinic to carry out TPO, such appointment reminder cards and patient statements and other notices.

With this consent Jacobs Audiology, LLC may email to my home or other alternative location any items that assist this clinic in carrying out TPO, such as appointment reminder cards and patient notifications and/or patient notification and/or statements.
- In addition, I authorize the use of this form on ALL my insurance submissions.
- I authorize the release of information to all my Insurance Companie(s).
- I understand that I am responsible for my bill.
- I authorize Jacobs Audiology, LLC to act as my agent in helping me obtain payment from my Insurance Companie(s).
- I authorize payment direct to Jacobs Audiology, LLC.
- I permit a copy of this authorization to be used in place of the original.
Signature*

Clear
Date*

MonthDayYear
Date
Insurance Information
Primary Insurance
Insurance Name *
Insureds name and DOB*
ID Number*
Group Number*
Secondary Insurance
Insurance Name
Insureds name and DOB
ID Number
Group Number
Please read carefully and sign below

I give permission for Jacbos Audiology, LLC to release information, verbal and written, contained in my medical record and other related information, to my insurance company, rehab nurse, case manager, attorney, employer, related healthcare providers, assignees and/or beneficiaries and all other related persons. Information without patient identifiers may be used for quality purposes.

I acknowledge that I have received and reviewed the Health Insurance Portability & Accountability Act (HIPAA) policy of this office.

I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account for professional services or purchases rendered.

I have read all the information on this sheet, completed the paperwork and certify this information is true and correct to the best of my knowledge and hereby give Jacobs Audiology, LLC permission to treat my concerns.

I have read and understand all the above information.

A copy of this signature is as valid as the original
Signature*

Clear
Date*

MonthDayYear
Date
HIPAA Patient Consent Form
I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and follow-up among multiple Healthcare Providers who may be involved in that treatment directly and indirectly.
- Obtain payment from third-party payers.
- Conduct normal healthcare operation such as quality assessments and physician certifications.
I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to changes it's Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a correct copy of the Notice of Privacy Practice.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

I understand that you may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.
Patient Name*

First NameLast Name
Relationship to Patient (if applicatble)
Patient Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Personal History - Confidential Information

Patient Consent for Use and Disclosure of Protected Health and Financial Information

Insurance Information

Primary Insurance

Secondary Insurance

HIPAA Patient Consent Form