Patient 18+ Info and Acknowledgement

Patient Information & Acknowledgement For 18 Years and Older
Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
*Patient's Phone #: Phone Number *Patient's Email: Email
Address

Address

Street Address Line 2

CityStateZipState / Province

Postal / Zip Code
Appointment Reminder Preference (Please select ONE):

Phone CallText MessageEmail
***We need you to provide us with a copy of your Driver's License and Insurance Card today.***
As you read the below section, check the boxes as acknowledgement of the information provided.

I have carefully read the office and financial policies of Clinical Pediatric Associates of North Texas (CPANT), understand and agree to the terms and conditions as stated.I have received a copy of the office and financial policies of CPANT.I have received a copy of the Privacy Practices.I understand that CPANT reserves the right to modify the privacy practices outlined in the notice.I understand that I can request a copy of the updated Notice of Privacy Practices by calling my physician's office or requesting a copy in person at my appointment.
Patient Signature Signature Date:Date
AUTHORIZATION TO RELEASE INFORMATION
I authorize CPANT to release any of my medical information to:

Insurance company(s) as needed to process any claims, to pay CPANT directly for covered medical and/or surgical services.The following names are people I would like to be involved in or have access to my protected health information on a routine basis. I give permission for CPANT to sharemy protected health information with:
Name Name of Authorized Relationship to Patient Relationship
Name Name of Authorized Relationship to Patient Relationship
Name Name of Authorized Relationship to Patient Relationship
Name Name of Authorized Relationship to Patient Relationship
Patient Signature Signature Date:Date
Should be Empty:

Patient Information & Acknowledgement For 18 Years and Older

***We need you to provide us with a copy of your Driver's License and Insurance Card today.***

AUTHORIZATION TO RELEASE INFORMATION

We need you to provide us with a copy of your Driver's License and Insurance Card today.