Hyperbaric Oxygen Therapy New Patient Application Form

HIPAA Personal Health Information Release
I,Type Full Name*herby authorize Abundant Health Physical Medicine to discuss with and/or release information to the following people concerning my appointments, insurance, billing, and health treatment rendered.
Spouse

First NameLast Name
Significant Other

First NameLast Name
Parent/Legal Guardian

First NameLast Name
Child(ren)

First NameLast Name
Any Specified Person

First NameLast Name
INFORMATION IS NOT TO BE DISCUSSED WITH OR RELEASED TO ANYONE
No restrictionsOnly discuss my appointment time with the above-named individual(s).Only discuss issues concerning my account, including insurance and/or billing with the above-named individual(s).Only discuss the health treatment rendered to me with the above-named individual(s).
My HomeMy WorkMy Mobile Phone
I understand I may terminate this consent at any time by giving written notice to Abundant Health Physical Medicine. Any changes to this form will require a new consent to be completed, signed and dated.
Signature

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW TO ACCESS THIS INFORMATION. Please Review Carefully

Acknowledgement of Receipt of Notice of Privacy Practices
I acknowledge that I have reviewed the Notice of Privacy Practices of Abundant Health Physical Medicine.
YES, I wish to receive an electronic coy of Privacy NoticeNO, I do not request a copy of the Privacy Notice at this time. I acknowledge that I can request a copy at any time and the Privacy Notice is posted in the office.
If YES, Please enter the email address to where you'd like the Privacy Notice sent to.
example@example.com
I acknowledge that it is the policy of Abundant Health Physical Medicine to leave reminder messages on my answering machine, text messages or with another person in my home. I may make a request of an alternative means of communication (within reason) in writing.
I acknowledge that if I should have a problem or question in regard to my rights, I may speak with the Front Desk about my concerns to be forwarded to the appropriate department.
Signature
Should be Empty:

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Hyperbaric Oxygen Therapy New Patient Intake Form