New Patient and HIPAA Applications

HIPAA RELEASE OF INFORMATION
Patient Name:*
Date of Birth:*

MonthDayYear
Date
Energy Workers Medical Services, LLCOther
Patient Policies Acknowledgement
Bill of Rights AcknowledgementI acknowledge that I have received, read, and understand the Patient Bill of Rights and Responsibilities provided by EWMS. I understand my rights as a patient and my responsibilities regarding the use and care of the medical equipment provided.Financial Responsibility AgreementFor patients covered under the DEEOIC Program (Division of Energy Employees Occupational Illness Compensation), there is no financial responsibility for approved Durable Medical Equipment (DME) under the program, except for items outside the scope of coverage.Acknowledgement of Non-Participation in Medicaid/MedicareI acknowledge that EWMS does not participate in Medicare or Medicaid. I understand that I am responsible for all charges related to the equipment and services provided, as these programs will not cover them.
This Release of Information will remain in effect until terminated by me in writing.
Patient Signature:*
Date:*

MonthDayYear
Date
Witness Printed Name:
Witness Signature:
Date:

MonthDayYear
Date
Energy Workers Medical Services (EWMS)
551 East State Rd, Suite 203
American Fork, UT 84003

Phone: 801-841-4490
Toll Free: 800-999-5450
Fax: 801-820-7702
Should be Empty: