PATIENT REGISTRATION FORM

Your answers to the following questions will help us reach you quickly and discreetly with important information.

Responsible Party – If different from patient, please complete for the individual responsible for payment.

MY AUTHORIZATION TO USE OR DISCLOSE PHI FOR THE PURPOSE OF INSURANCE REIMBURSEMENTS, TREATMENT AND ENROLLMENT:

Notice of Privacy Practices - summary: https://waikikihc.org/wp-content/uploads/NOTICE-OF-PRIVACY-PRACTICES-SUMMARY.pdf

I understand that Waikiki Health is an integrated clinic with both medical and behavioral health services. I authorize and consent to any diagnostic and/or medical and/or behavioral health treatment under the instructions of the attending provider for which my dependent or I have sought care.

Waikiki Health keeps a record of health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record. Waikiki Health will not disclose your record to others unless you direct us to do so or unless the law authorizes or requires us to do so. You may see your record or get more information about it by contacting the Privacy Officer at (808) 922-4787. Waikiki Health’s Notice of Privacy Practices describes in detail how your health information may be used and disclosed and how you can access your information.

By my signature below, I acknowledge receipt of the Waikiki Health’s Notice of Privacy Practices:

I certify that everything on this form is true and complete. I understand that falsification may result in the disqualification of services at Waikiki Health for me and my family. I grant Waikiki Health permission to verify this information with income sources listed above.

I understand that I do not have to sign this authorization in order to get health care benefits. However, I do have to sign an authorization form to permit the Waikiki Health to bill my insurance. Once health care information is disclosed, the person or organization that receives it may redisclose it. I may revoke this authorization in writing. If I did, it would not affect any disclosures already made by Waikiki Health resulting from this authorization. I may not be able to revoke this authorization if its purpose is to obtain insurance. To revoke this authorization, I can write a letter to Waikiki Health; ATTN: Compliance Officer, 277 Ohua Avenue, Honolulu, HI 96815. Waikiki Health reserves the right to modify the Notice of Privacy Practices. The current version is available at www.waikikihealth.org or through the reception staff. You have the right to view the full version of this policy prior to signing this consent.

By signing this form you are granting permission for your provider to communicate with the individuals listed below on any and all health information, medications, tests results, recommended therapy or tests, which he/she deems necessary for them to know while they are involved with your care. Your signature below is voluntary and you can withdraw consent at any time for the following listed individuals to receive your health information. Anyone who inquires about your health status who is not on this list will be referred to contact you. This includes individuals who are calling in to make, confirm or cancel appointments on your behalf.

You can also designate one person with whom we may discuss your billing on your behalf. Please indicate their name here

To release to: