Patient Information and HIPAA

ROBBINS NATURAL HEALTH
9225 S TOLEDO AVE, TULSA, OK 74137

PH: (918) 488-0444

FAX: (405) 561-4967
Patient Information
Date

MonthDayYear
Date
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Other Phone
Please enter a valid phone number.Format: (000) 000-0000.
Gender
Age
Date of Birth

MonthDayYear
Date
Email
example@example.com
Employer
Occupation
Name of Spouse/Partner or Parent
Marital Status
Whom may we thank for referring you?
In case of emergency who should we contact?
What is their phone number?
Please enter a valid phone number.Format: (000) 000-0000.
Have you consulted with Dr. Robbins before?
If the patient is a minor, please fill out the following information:
I,blanks, do hereby grant my permission for Robbins Natural Health doctors to examine and/or treat (minor's name),blank as deemed necessary.
My relationship to minor:
Signature of above minor statement.
Date of signature

MonthDayYear
Date
HIPAA PRIVACY NOTICE
This notice describes how protected health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Robbins Natural Health is committed to protecting patient confidentiality. No information regarding our patients is shared or distributed with any other person or organization, except as specified below, without the patient's signed authorization.
- We may disclose protected health information about you to people outside the practice who may be involved in your treatment, such as family members or others we use to provide services (e.g., labs.)
- We may disclose protected health information about you so that the services you receive may be billed to and payment may be collected from you, an insurance company, or a third party, such as a family member responsible for such costs.
- We will disclose protected health information about you when required to do so by federal, state, or local law.
You have the right to:
- inspect and copy protected health information that may be used in your care.
- request that we amend protected health information you feel is incorrect or incomplete.
- request an accounting of disclosures we have made of your protected health information.
- request a restriction or limitation on the protected health information we use or disclose about you to someone who is involved in your care or payment for your care.
- request that we communicate with you about health matters in a certain way or at a certain location.
- revoke your permission to use or disclose protected health information about you.
- receive a copy of this notice.
Any requests, questions, comments, or complaints may be directed, in writing, to our Office Manager, 9225 S Toledo Ave, Tulsa, OK 74137
The Privacy Rule under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires us to: (1) maintain the privacy of your medical information, (2) provide notice of our legal duties and privacy practices, and (3) abide by the terms of the notice that is currently in effect. We reserve the right to modify this policy as necessary.
10/31/23

ROBBINS NATURAL HEALTH

Patient Information

If the patient is a minor, please fill out the following information:

HIPAA PRIVACY NOTICE

HIPAA PRIVACY NOTICE