Authorization to Release and Disclose Patient Protected Health Information

Patient Information Form

Lamoille-500.34C
Patient Name:
Date of Birth:

MonthDayYear
Patient HOME Address:
Is your Mailing address the same as your Home address?

YesNo
Mailing Address:
Patients Preferred Contact Method
Select Contact Method:

Cell PhoneHome PhoneWork Phone
Cell Phone Number:
May we leave a Message for you? (Cell Phone)
Would you like Appointment Reminders by Text Message?
Home Phone Number:
May we leave a Message for you? (Home Phone)
Work Phone Number:
Responsible Party Information
Who is responsible for paying the bills:
Address:
Date of Birth:

MonthDayYear
Relationship to Patient:
Home Phone Number:
Work Phone Number:
Cell Phone Number:
Primary Care Physician:
Patients Date of Birth:

MonthDayYear
Patient Information
Patient Sexual Orientation:

Lesbian/GayStraightBisexualSomething ElseDon’t Know/OtherDecline to Disclose
Patient Gender Identification:

MaleTransgender Female (Male-To-Female)FemaleTransgender Male (Female-To-Male)Decline to Disclose
Patients Legal Sex:

MaleFemaleDecline to Disclose
Sex Listed on Patients Insurance Card:

MaleFemale
Marital Status:

MarriedDivorcedLegally SeparatedWidowhoodSingleN/A Minor Child
Social Security Number:
Patients Employer
Name:
Address:
Patients Emergency Contact Name
Name:
Relationship:
Contact Number:
Please enter a valid phone number.
Primary Insurance Information
Insurance Effective Date:

MonthDayYear
Policy Number:
Group Number:
Plan Name:
Subscriber’s Name:
Subscriber’s DOB:

MonthDayYear
Secondary Insurance Information
Insurance Effective Date:

MonthDayYear
Policy Number:
Group Number:
Plan Name:
Subscriber’s Name:
Subscriber’s DOB:

MonthDayYear
Tertiary Insurance Information
Insurance Effective Date:

MonthDayYear
Policy Number:
Group Number:
Plan Name:
Subscriber’s Name:
Subscriber’s DOB:

MonthDayYear
Patient Name:
DOB:

MonthDayYear
Can we Verbally share medical information about you or the care received with your Emergency Contact?

YesNo
Patients Pharmacy Information
Pharmacy Name:
Pharmacy Location:
Provide your E-mail Address For access to:

Adult Patient Portal AccessLimited Minor Access (Under 11)
Email
example@example.com
**As a patient of Lamoille Health Partners you can save money on home delivery brand name and generic medications by using Community Health Pharmacy. Ask the Front Desk for the Community Health Pharmacy Form if you are interested.
FOR PATIENTS UNDER THE AGE OF 18 PRIMARY CAREGIVER:
Does the Minor Patient live with you?

YesNo
Are you the Parent/Legal Representative/Guardian of the Patient?

YesNo
What is your relation to the patient?
***If you have Sole Legal Responsibility (Ability to make decisions regarding education, non-emergency medical and dental care, religion and travel) and only YOU can make these decisions for the Minor Please bring a copy of the Court Document stating this for our records.

Patient Information Form

Patients Preferred Contact Method

Responsible Party Information

Patient Information

Patients Employer

Patients Emergency Contact Name

Primary Insurance Information

Secondary Insurance Information

Tertiary Insurance Information

Patients Pharmacy Information

FOR PATIENTS UNDER THE AGE OF 18 PRIMARY CAREGIVER:

Lamoille Health Partners has my permission to verbally disclose the following Medical and Billing information about me to: