New patient packet

American Medical Associates
PATIENT INFORMATION
Date *

Month Day Year
Date
Name *

First Name Last Name
(M.I.)
Date of birth *

Month Day Year
Date
Gender *

F M Other
Social Security # *
Take a picture of your driver license (Front)

Cancel of
Preferred Name
Marital Status (check one) *

Divorced Married Separated w/ Partner Widow(er) Single
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone # *
Employer/School
Occupation
Work Phone Number
Please enter a valid phone number.
Work Extension
E mail Address *
example@example.com
May we take your Picture for your Electronic Medical Record? *

No Yes
File Upload

Cancel of
Preferred method of contact:

reminder calls, lab results, diagnostic results, or any other health related information.
Check ALL that apply

Home Cell Phone Work
Ok to leave message on voicemail *

No Yes
Race/Ethnicity *

Native Hawaiian/ Pacific Islander Asian White Black/African American Hispanic/Latino American Indian/ Alaskan Native Other Decline to report
Preferred Language
Name of Emergency Contact *
Relationship
Phone Number of Emergency Contact
If patient is a minor, name of Legal Parent/Guardian/Representativefilling out form.
Relationship to minor
(Signature of Legal Parent / Guardian / Representative)
Signature *

Clear
How did you hear about US? (Please check one) *

Google Mailer Referred by: Online Ad Yelp Social Media Other
If Referred someone by please put there name below

First Name Last Name
INSURANCE / PHARMACY /ADVANCED DIRECTIVES
Do you wish to pay out of pocket or with insurance *

Out of pocket Insurance
INSURANCE INFORMATION

Primary Insurance Information
Insurance Name
ID Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Group Number
Phone #
Subscriber's Name
Date

Month Day Year
Date
Relationship to patient
Upload insurance card (front)

Cancel of
Upload insurance card (Back)

Cancel of
INSURANCE INFORMATION

Secondary Insurance Information
Insurance Name
ID number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Group number
Phone number
Subscriber's Name
Upload insurance card

Cancel of
Upload insurance card (Back)

Cancel of
Date

Month Day Year
Date
Relationship to patient
PHARMACY INFORMATION

Retail Pharmacy
Retail Pharmacy Name *
Cross Streets (Ex.Alma School, Queen-creek) *

Street 1 Street 2
Phone number *
Fax number
PHARMACY INFORMATION

Mail Order Pharmacy
Mail order pharmacy name
Phone number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Advance Directives

(living Will)
have previously executed the following:
Health Care Power of Attorney:

NO YES
Name of Representative
Representative Phone Number
Living Will

NO YES
Pre - Hospital Medical Directive *

NO YES
(If you answered "Yes". please submit your orange card to the receptionist
(Signature of Patient or Legal Parent / Guardian / Representative)

Clear
FINANCIAL POLICY /CANCELLATION POLICY AGREEMENT
All insurance providers have different coverage and benefit levels depending on what you have chosen to purchase or what your employer has chosen. It is your responsibility to be aware of your benefits. We strongly encourage you to be in contact with your insurance agent to determine the level of coverage your plan provides, as well as have an understanding of the financial figures you will be responsible for.

We participate with most insurance plans. If you are an HMO patient, you must choose Dr. Ehreema Nadir, MD as your primary care physician. This can be done by calling your insurance company before your appointment and having them list our physician as the PCP. You will be responsible for the visit if Dr. Ehreema Nadir, MD is not listed as the PCP, or you will have to reschedule to a later date when the physician is effective. As a courtesy, we will submit your claim for all services to your insurance company. Please remember your health insurance policy is a contract between you and your insurance company and we are not a party to that contract. Be aware that some services may not be covered by your insurance policy. By presenting for care, you agree that you are responsible for all services and charges regardless of your insurance status. Should any provided services not be covered by your insurance, we will not alter your claim, change your diagnosis, or report a different service than what was performed so that your insurance will cover the charge. This constitutes fraud and will not be done and you will be responsible for the balance. All co-pays, balances, and deductibles are due at the time of service. We file your insurance and then any balances that are due by you must be paid within 90 days unless prior arrangements have been made with the billing department. If you have a billing or insurance-related question, please contact our billing office at (480) 306-5151 and they will be happy to assist you. We ask patients to refrain from discussing billing questions with the physicians, nurse practitioners, or physician's assistants as they devote their time and expertise to your health care and cannot answer billing questions. Any account left unpaid after 90 days will be turned over to an outside collection agency. Any collection fees necessary for this debt will be added to the outstanding balance. Please keep in mind that should your account go into collections, any arrangements/payments will need to be made directly with the collection agency. In addition, once an account has been turned over to the collection agency, the patient may receive a letter of discharge from our practice.

Cancellation Policy

Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. You MUST give our office 24 hours' notice before your scheduled appointment. Multiple "No-Shows" in any 12 months may result in termination from our practice. "No-Show" fees will be billed to the patient. This fee is NOT covered by any insurance plan and will be your responsibility. Our practice fees are listed below.

$50.00 - Request to complete Disability, FMLA, Life, and various other types of independent health forms. Forms MUST be present at the time of visit, or you will be asked to be rescheduled.

$25.00 - Returned checks for non-sufficient funds will have a processing fee that will be charged back to the patient. We will be unable to accept any personal checks after the first occurrence.

$50.00 - Charge for missed appointments or appointments canceled with less than 24-hour notice with the Physician, Nurse Practitioner, or Physicians' Assistant.

$75.00 - Charge for missed appointments or appointments canceled with less than 24-hour notice with the Psychiatric Nurse Practitioner and Nephrologist. By signing below, I acknowledge that I have read and understood the financial and cancellation policies of American Medical Associates and agree to the policies set forth.
(Signature of Patient or Legal Parent/Guardian/Representative) *

Clear
(Relationship to patient)
PATIENT MEDICAL REVIEW

Allergies
Do you have ANY Allergies, Sensitivities and/ or reactions to the following?
Latex *

NO YES
Shellfish *

NO YES
Iodine *

NO YES
Environmental? (If yes, please list below):
Drugs (list all Drug Allergies) *
Any Food Allergies ? (if yes, please list below):
For FEMALE patients only. Please answer the following:
Are you pregnant, or possibly pregnant?

NO YES
Are you breastfeeding?

NO YES
Number of pregnancies
Number of living children
Number of miscarriages
Number of abortions
last Pap

Normal Abnormal
Date of last Pap

Month Day Year
Date
Date of last Mammogram

Month Day Year
Date
Was the Mammogram

Normal Abnormal
Do you self exam

No Yes
Date of Last menstrual period

Month Day Year
Date
For MALE patients only. Please answer the following:
Last PSA screen

Month Day Year
Date
Last PSA screen

Normal Abnormal
Last Testicular Exam

Normal Abnormal
Date

Month Day Year
Date
Do you self exam(Testicular)

No Yes

Please List ALL Major Illnesses:

	Dates	Procedures or Conditions
1
2
3
4
5

Please List ALL Hospitalizations & Surgeries :

	Dates	Procedures or Conditions
1
2
3
4
5

Immunizations: (If you have a copy of your immunization record, please give it to the medical assistant to make a copy for your chart)

Immunizations

	Immunizations	Date
Influenza
Shingles
Hepatitis A
Hepatitis B
MMR
Pneumovax
Gardisil
Tetanus
dTap
Covid
Other

Screenings

	Immunizations	Date	Normal	Abnormal
Stool Cards
Bone Density
Colonoscopy

Medical History
Do you have any other condition(s) NOT listed above?
Check if you have had the following (check ALL that apply): *

Crohn's Disease Heart Murmur Pelvic Infection Lupus Anemia Alcoholism/Addiction Pneumonia Heart Valve Lyme's Disease Drug Dependency Hemochromatosis Measles Diabetes: Type I or Il Psoriasis Arthritis Rheumatic Fever Hepatitis A, B or C Meningitis Dialysis Diverticulitis Asthma Hiatial Hernia Migraines/Headaches Rheumatoid Arthritis Auto-Immune Disorder(s) Scarlet Fever MTHFR High Cholesterol Eczema Emphysema Scleroderma Multiple Sclerosis Bleeding Disorder Epilepsy Hysterectomy Mumps Shingles Cataracts Fibromyalgia Osteoarthritis Hormone Replacement Hypertension Gall Bladder Disease Osteoporosis Chicken Pox Pacemaker Gallstones Joint Replacement Clotting Disorder PCOS Stroke Kidney Disease Gastroparesis Colitis Glaucoma POTS Kidney Stones Anxiety/Depression Auto-Immune Disorder(s) Cancer Cataracts Chicken Pox Clotting Disorder Colitis Congestive Heart Failure Connective Tissue Disorder Heart Disease Gout COPD Joint Replacement Gall Bladder Disease Kidney Disease Kidney Stones Leg Cramps Liver Disease Pacemaker PCOS Polio POLIO Prostate Condition HIV/AIDS Stent Placement STD/STI Stomach Ulcers Stroke Thyroid Disorder Tuberculosis Vitiligo NONE
Health Habits & Personal Safety:
Have you ever smoked? *

No YES
If yes, how many packs/day?
How long have you been smoking, if you smoke
Any other tobacco, Vap or E-Cigarettes? *

No Yes
If yes, please describe
Do you drink caffeinated beverages / coffee? *

No Yes
If yes, How many ounces / day?
Do you drink alcohol? *

No Yes
If yes, How much?
How often?
What Kind?
Do you exercise?

No Yes
If yes, How often?
Do you sleep well?

No Yes
How many hours of sleep do you get?
Do you follow any special diet?

No Yes
If yes, What type?
Do you currently use recreational drugs? *

No Yes
Do you currently use illegal street drugs? *

No Yes
If yes, please describe
Are you sexually active? *

No Yes
If yes are you trying to conceive

No Yes
If not trying to conceive, please list contraceptive barrier method used
Are you at risk for HIV *

No Yes
Any discomfort with intercourse? *

No Yes
If no, who do you reside with?
Do you have frequent falls? *

No Yes
Do you have hearing loss? *

No Yes
Do you have vision loss? *

No Yes
Do you live alone?

No Yes
Do you have concerns with any skin lesions or any other skin concerns? *

No Yes
PATIENT MEDICAL REVIEW
Mental Health
Do you have any concerns with memory loss? *

No Yes
Do you feel depressed? *

No Yes
Do you cry frequently? *

No Yes
Do you have little interest or pleasure in doing things

Not at all Several Days More then half the days Nearly every day
Felling Down, depressed, or hopeless

Not at all Several Days More then half the days Nearly every day
Trouble falling or staying asleep, or sleeping too much

Not at all Several Days More then half the days Nearly every day
Feeling tired or having little energy

Not at all Several Days More then half the days Nearly every day
Poor appetite or overeating

Not at all Several Days More then half the days Nearly every day
Feeling bad about yourself or that you are a failure, or have let yourself or family down

Not at all Several Days More then half the days Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television

Not at all Several Days More then half the days Nearly every day
Moving or speaking so slowly that other people could have noticed; or the opposite , being so fidgety or restless that you have been moving around a lot more then usual

Not at all Several Days More then half the days Nearly every day
Thoughts that you would be better off dead or of hurting your self in some way

Not at all Several Days More then half the days Nearly every day
Is stress a major problem for you? *

No Yes
Do you panic when stressed? *

No Yes
Have you ever attempted suicide or seriously thought about hurting yourself? *

No Yes
Do you have problems with eating or your appetite? *

No Yes

Family Medical History *

	Mother	Father	Maternal Grandparents	Paternal Grandparents	Siblings	Child(ren)
Alcoholism/Addiction
Bleeding Disorder
Cancer
Diabetes
Heart Attack
High Blood Pressure
High Cholesterol
Kidney Disease
Mental Health Disorders
Stroke
Tuberculosis
N/A

Mother living? *

NO YES
If no, cause of death?
Father living? *

NO YES
If no, cause of death?
MEDICATION LIST

List All Medications

	Medications	Dose (milligrams)	How Often	Prescribing Physician
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.

I certify that the above information is to be true and to the best of my knowledge.
(Relationship to patient)
Signature *

Clear
Notice of Privacy Practices
The Notice of Privacy Practices describes how this practice may use and disclose your medical information, as well as your rights to access your medical information. The HIPAA Privacy Rule permits this practice to disclose your protected health information to carry out Treatment, Payment, or other Healthcare Operations. We may also disclose your health information for purposes required by law. HIPAA also grants you the right to access and control your protected health information. We must abide by the information outlined in the Notice of Privacy Practices. As HIPAA evolves, we reserve the right to update our Notice of Privacy Practices at any time.

HIPAA Permits and requires additional uses and disclosure that may be made without your authorization or opportunity to agree or object. These situations include:

Disclosures Required By Law & Workers Compensation:

We are permitted to use or disclose your protected health information to the extent that the law requires the use or disclosure. We will maintain compliance with the law and will limit the disclosure to the minimum necessary. If required, you will be notified of any disclosure. We are permitted to disclose your protected health information as authorized to comply with workers' compensation laws and other similar established programs.

Your protected health information may be used and disclosed by your physician, our office staff, and others who are involved in your treatment, payment, or other healthcare operations. The following are common examples that our practice is

Abuse or Neglect:

We believe abuse or Reflect to be a serious issue. We may disclose your protected health information to a public health authority authorized to receive reports of child abuse or neglect. Way also discloses your information if, in our best judgment, we believe you have been a victim of abuse, neglect, or domestic violence. When disclosing protected healthier formation in cases of abuse or neglect, we will follow applicable state and federal laws.

Treatment:

Our practice will use and disclose your protected health information to provide, coordinate, or manage your health care. This includes the coordination or management of your healthcare with another provider. We will disclose protected health information to any other physicians who may be treating you. We may also disclose your protected health information to another physician or healthcare provider) such as a laboratory, which becomes involved in your treatment.

Payment:

Our practice will use and disclose health information, to obtain] payment for your services performed by the US or by another provider. This may include disclosures to health insurance plans, insurance providers, and collection agencies.

Business Associates:

We will share your protested health information with third, party business associates that perform various activitiés on Examples of a business associate incléde, billing services, transcription services, and legal services. Before disclosing any protected health information with a búshness associate, we will establish a written contract that contains the térms that will protect the privacy of your information. Business Associates and their subcontractors must also comply with HIPAA Privacy and Security Regulations Health Care Operations: Our practice will use and disclose your protected health information to support our practice's business activities. Examples include, but are not limited to, quality assessment, employee reviews, medical student training, licensing, fundraising, and conducting or arranging for other business activities.

Públic Health & Communicable Diseases:

We are permitted to disclose your protected health information for public health purposes or to a public health authority that is permitted by law to collect or receive the information. Examples may include disclosure to prevent or control disease, or injury. We are permitted to disclose your protected health information, if authorized by law, to a person who may have unexposed to a communicable disease. We may disclose your information if said person may be at risk of contracting or spreading the disease or condition. Research & Health Oversight: We are permitted to disclose your protected health information to researchers when an institutional review board that has reviewed the research proposal, as well as established protocols to ensure the privacy of your information has approved their research. We are permitted to disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.

Legal Proceedings:

We are permitted to disclose protected health information in connection with any judicial or administrative proceeding, subpoena, or in responding toa

Law Enforcement:

We may also disclose protected health information, under lawful conditions to law enforcement. Permitted law enforcement purposes include; 1 Legal processes and otherwise required by law, 2 Limited information requests for identification and location purposes, 3 About the victim of a crime; 4 Suspicion that death has occurred as a result of criminal conduct; 5 If a crime occurs on the premises of our practice, and 6 Medical emergencies associated with a crime.

1915 E Chandler Blvd. Ste. 1, Chandler, AZ 85225

20928 N John Wayne Pkwy Ste. C-4, Maricopa, AZ 85139

www.AmericanMedicalAssociatesAZ.com
Organ Donation, Coroners, & Funeral Directors: We are permitted to disclose protected health information to a coroner or medical examiner to perform other duties. Disclose may be made in reasonable anticipation of death. Protected health may be used and disclosed for cadaveric organ, eye, or tissue donation purposes. Military Activity & National Security: We are permitted to use or disclose protected health information of individuals who are Armed Forces personnel under the following circumstances; 1 For activities deemed necessary by appropriate military command authorities; 2 For a determination by the Department of Veteran Affairs of your eligibility for benefits, or 3 To foreign military authority if you are a member of that foreign military services. We are also permitted to disclose your information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protected services to the President or others legally authorized. Written Authorization: Unless required by law, your written authorization will be required for all other uses and disclosures of your protected health information. You may revoke the authorization at any time, by written request. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Note: We are unable to undo any disclosures previously made with your authorization. Opportunity to agree or object: The following are examples of instances where we may use and disclose your protected health information; however, you have the opportunity to agree or object) to the use or disclose of all or part of the disclosure. If you arégot present or can agree or object to the use or disclosure, then we may use professional judgment, to determine whether the disclosure is In your best interest.

Unless you object, we may disclose to a member o your family, a relative, or à close friend, your protected health information that directly relates to that person's involvement in your We may use or disclose protected health information to notify or assist in notifying family members personal représentative or any other pérson that is responsible for the care of your location, genéral condition or death. Finally, we may use or discloséyour information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your care. Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your general condition, and your religious affiliation. This information, except religious affiliation, will be disclosed to individuals who ask for you by name You're religion will only be given to a member of the clergy, such as a priest or rabbi.

You have the right to inspect and copy your protected health information. As long as we are maintaining your protected health information, you may inspect and obtain a copy of your protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physicians use for health care decisions. As permitted by federal or state law, we may charge you a "reasonable copy fee" for a copy of your records. However, federal law prohibits you from inspecting or copying: Psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access. You have the right to appeal the denial. Please contact our Practice Manager if you have any Lesions. You have the right to request a restriction of your protected health information. You may ask the US not to use or disclose any part of your protécted health Information 1 For treatment, health care operations, or payment; 2 to family members or friends who may be involved in your care or 3 For notification purposes as described in this Notice of Privacy Practices. Your written request must state the specific restriction requested and to whom you want the restriction to apply. We are NOT required to agree to restrictions that you request unless your account has been paid in full. However, if your physician does not agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction other than emergency treatment situations. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We strive to accommodate all reasonable requests. As a condition, we may ask for additional information, such as payment, alternative address, or additional contact information. We will not request an explanation for the request. Notify our Practice Manager in writing for all requests. You have the right to receive an accounting of certain disclosures made. This right applies to disclosures for purposes other than treatment, payment, or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized the US to make the disclosure, for a facility directory, to a family member(s) or friend (s) involved in your care. Or for notification purposes, national security or intelligence, law enforcement or correctional facilities, as part of a limited data set disclosure. You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions, and limitations. You may request an amendment of your protected health information in a designated record set for so long as we maintain this information. We may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement and we may provide you with a copy of any rebuttal. Please contact our Practice Manager if you have questions

1915 E Chandler Blvd. Ste. 1, Chandler, AZ 85225

20928 N John Wayne Pkwy Ste. C-4, Maricopa, AZ 85139

www.AmericanMedicalAssociatesAz.com
HIPAA CONSENT/RECIEPT OF ACKNOWLEDGEMENT FORM
The Health Insurance Portability and Accountability Act (HIPAA) provide safeguards to protect your privacy.

Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, and/ or health insurance payers as is necessary and appropriate for your care. The patient hereby waives his/her confidentiality right should collection action become necessary. You have the right to request restrictions in the use of your protected health information and to request changes in certain policies used within this office. However, we are not obliged to alter internal policies to conform to your request.

My protected health information may be released to the following people:
Name

First Name Last Name
Relationship
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone #
Name

First Name Last Name
Relationship
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone #
Relationship
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone #
HIV/AIDS/STD: This form authorizes the release of medical information including HIV-related. Confidential HIV-related information is any information indicating that a person has had an HIV-related test, or has an HIV infection, HIV-related illness or AIDS, or any information that could indicate a person has been potentially exposed to HIV.
Please check one *

I DO I DO NOT
Consent to the release of any positive or negative test result for AIDS/ HIV or STD infection, antibodies to AIDS, or infection with any other causative agent of AIDS with the rest of my medical records.

With this consent, I give American Medical Associates permission to call my home or other alternative location provided in the patient information form and leave a detailed message on voicemail or in person with someone listed above about the items that assist the Practice in carrying out treatment, payment, and health care operations, such as appointment reminders, insurance items, and any calls about my clinical care such as lab and diagnostic results. 1 understand that it is office policy that I update this form yearly. I understand this consent expires 1 year after my initial signature and date.
(Relationship to Patient)
(Signature of Patient or Parent / Guardian / Legal Representative) *

Clear
HIPAA CONSENT/RECIEPT OF ACKNOWLEDGEMENT FORM
Acknowledgement of Receipt of Notice of Privacy Practices
HIPAA - Notice of Privacy Practices:

I have been provided with a copy of American Medical Associates Privacy Practices. I understand that the Notice may be changed at any time. I may request a new copy of American Medical Associates Privacy Practices in person or by writing to the Practice Manager, American Medical Associates, 1915 E Chandler Blvd. Ste. 1, Chandler, AZ 85225 I understand that if any changes need to be made to my authorization as to whom my protected health information may be released to, must be done in person and a new form submitted.
(Signature of Patient or Parent/Guardian/Legal Representative) *

Clear
(Relationship to Patient)
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
I give permission to release the health information of: (One patient per form/ one facility perform)
Purpose of Release (Check reason):

Insurance Further Medical Care Disability Worker's Compensation Legal Purposes Patient Use Other
From
To:
Fax #
Release information From:
Facility
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone #
Hospital (Check all that may apply):

History & Physical Progress Notes Discharge Summary Emergency Record Operative Reports Cardiac Reports / EKG Consultation Reports Laboratory Reports Diagnostic Results Medications Pathology Reports Physicians Orders Allergies Radiology Reports Billing information Physician orders Other
Office/Clinic (check all that may apply)

Office Visits Physical exam Consultation Reports Diagnostic Test Reports Laboratory Reports Radiology Reports Medication Billing Information Other
Format

Electronic copy CD (PDF viewer, charges may apply) Paper Copy Other
Delivery Method

Registered US Mail Pick- up Fax Other
I understand that: I can cancel this permission at any time. I must cancel in writing and send or deliver cancellation to releasing facility or practice named above. Any cancellation will apply only to information not yet released by facility or practice. This is a full release including information related to behavioral/mental health, drug and alcohol abuse treatment (in compliance with 42 CFR Part 2), genetic information, HIV / AIDS, and other sexually transmitted diseases unless limited by the above selections. Refusing to sign this form will not prevent my ability to receive treatment. I have a right to receive a copy of this form upon request.
This permission expires 90 days after the date of my signature unless another date or event is written here

Month Day Year
Date
(Signature of Patient or Legal Parent/Guardian/Representative) *

Clear
(Relationship to patient)
PROTECTED HEALTH INFORMATION 2
I give permission to release the health information of: (One patient per form/ one facility per form)
Purpose of Release (Check reason):
From
To
Facility
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone #
Fax #
Hospital (Check all that may apply):

History & Physical Progress Notes Discharge Summary Emergency Record Operative Reports Cardiac Reports / EKG Consultation Reports Laboratory Reports Diagnostic Results Medications Pathology Reports Physicians Orders Allergies Radiology Reports Billing information Physician orders Other
Office/Clinic (check all that may apply)

Office Visits Physical exam Consultation Reports Diagnostic Test Reports Laboratory Reports Radiology Reports Medication Billing Information Other
Format

Electronic copy CD (PDF viewer, charges may apply) Paper Copy Other
Delivery Method

Registered US Mail Pick- up Fax Other
Paper copy (charges may apply)

I understand that: I can cancel this permission at any time. I must cancel in writing and send or deliver cancellation to releasing facility or practice named above. Any cancellation will apply only to information not yet released by facility or practice. This is a full release including information related to behavioral / mental health, drug and alcohol abuse treatment (in compliance with 42 CFR Part2), genetic information, HIV / AIDS, and other sexually transmitted diseases, unless limited by the above selections. Refusing to sign this form will not prevent my ability to receive treatment. I have a right to receive a copy of this form upon request.
(Relationship to patient)
(Signature of Patient or Legal Parent/Guardian/Representative *

Clear
1915 E. Chandler Blvd. Ste. 1, Chandler, AZ 85225

20928 N. John Wayne Pkwy Ste. C-4, Maricopa, AZ 85139

www.AmericanMedicalAssociatesAZ.com
Should be Empty:

American Medical Associates

PATIENT INFORMATION

Preferred method of contact:

INSURANCE / PHARMACY /ADVANCED DIRECTIVES

INSURANCE INFORMATION

INSURANCE INFORMATION

PHARMACY INFORMATION

PHARMACY INFORMATION

Advance Directives

FINANCIAL POLICY /CANCELLATION POLICY AGREEMENT

PATIENT MEDICAL REVIEW

Medical History

PATIENT MEDICAL REVIEW

MEDICATION LIST

Notice of Privacy Practices

HIPAA CONSENT/RECIEPT OF ACKNOWLEDGEMENT FORM

HIPAA CONSENT/RECIEPT OF ACKNOWLEDGEMENT FORM

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

Release information From:

PROTECTED HEALTH INFORMATION 2