Patient Information
Clinic Name Header
941 KAMEHAMEHA HIGHWAY, SUITE 206 PEARL CITY, HAWAII 96782-2516
PHONE: (808) 551-8947 | FAX: (860) 200-0935
EMAIL: NATALIEKITAMURAAPRN@GMAIL.COM | WEBSITE: WWW.IMIOLACLINIC.COM
Today's Date
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Month
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Day
Year
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Patient Name
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First Name
Middle Initial
Last Name
Gender
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Male
Female
Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
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example@example.com
Date of Birth
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Month
-
Day
Year
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Marital Status
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Single
Married
Divorced
Widowed
Home Phone
Format: (000) 000-0000.
Cell Phone
*
Format: (000) 000-0000.
Health Insurance Information
Primary Insurance
Primary Insurance Name
Primary Effective Date
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Month
-
Day
Year
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Primary Insured Name
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First Name
Last Name
Primary Insured Date of Birth
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Month
-
Day
Year
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Primary Policy Number
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Primary Group Number
Primary Plan Number
Primary Relationship to Insured
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Self
Spouse
Parent
Other
Secondary Insurance
I have Secondary Insurance
I have Secondary Insurance
Secondary Insurance Name
Secondary Effective Date
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Month
-
Day
Year
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Secondary Insured Name
Name on Health Insurance Card
Secondary Insured Date of Birth
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Month
-
Day
Year
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Secondary Policy Number
Secondary Group Number
Secondary Plan Number
Secondary Relationship to Insured
Self
Spouse
Parent
Other
Responsible Party (Guarantor) Information
Same as Patient Information
Same as Patient Information
Secondary Other (please specify)
Guarantor Name
First Name
Middle Initial
Last Name
Guarantor Address
Street Address
Apt#
City
State
Zip Code
Use P.O. Box instead of street address
Use P.O. Box instead of street address
P.O. Box Number
P.O. Box City
P.O. Box State
P.O. Box Zip Code
Guarantor Home Phone
Format: (000) 000-0000.
Guarantor Email
example@example.com
Guarantor Relationship to Patient
Self
Spouse
Parent
Other
Other
Guarantor Other (please specify)
Emergency Contact Information
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Home Phone
Format: (000) 000-0000.
Emergency Contact Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Relationship to Patient
*
Self
Spouse
Parent
Other
HIPAA Authorization & Consent
Emergency Other (please specify)
I authorize 'Imi Ola Health & Wellness Clinic to use and disclose my protected health information (PHI) for treatment, payment, and healthcare operations as permitted under HIPAA. I understand my information will be kept confidential and secure in accordance with federal HIPAA regulations.
Signature
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Date of Signature
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Month
-
Day
Year
Date
I have read and agree to the HIPAA Privacy Notice
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I have read and agree to the HIPAA Privacy Notice
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