Update Patient Forms – Sanson Family Walk-In Clinic

Patient Information

Name(Required)

First Middle Last Preferred

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Number

Home Number

Sex(Required)

Male

Female

Date of Birth(Required)

SSN(Required)

Driver's License(Required)

Language(Required)

Race(Required)

Employer(Required)

Occupation(Required)

Payment Information

Person Responsible for Payment(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Relationship to Patient(Required)

SSN(Required)

Date of Birth

Insurance Information

Insurance Company

Policy Number

Policy Holder's Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Relationship to Patient

2nd Insurance

Policy Number

Policyholder's Name

First Last

Patient's Contact

Pharmacy(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Legal Guardian

First Last

Relationship

Emergency Contact(Required)

First Last

Phone(Required)

Relationship(Required)

May we release medical info to your Emergency Contact?

Yes

Do you have a living will?

Yes

Date

Signature(Required)

Consent For Disclosure of Protected Health Information
The Standards for Privacy of Individually Identifiable Health Information (Privacy Rule) establishes a set of national standards for the protection of certain health information. The U.S. Department of Health and Human Services issued the Privacy Rule to implement the requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPPA). HIPPA's privacy rules generally give you the right to request a restriction on uses and disclosures of your protected health information (PHI). You are also provided the right to request confidential communication or the request that a communication of PHI be made by alternative means, such as sending corresponding to your office instead of your home. To better serve you, please complete the following:
Please contact me in the following manner:
Verbal Communication

Home

Cell

Work
Preferred Phone
Message Type

Leave message with detailed information

Leave message with callback number only
Written Communication

Mail

Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email

Family Member(s) or Friend(s) with whom we may discuss your medical condition:
Name
First Last
Phone
Relationship

Name
First Last
Phone
Relationship

Consent
I understand that it is my responsibility to provide this office with written changes concerning the release of my PHI
Printed Name

Signature
Date
MM slash DD slash YYYY

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Now Open 7 Days a Week

Patient Information

Payment Information

Insurance Information

Patient's Contact

Authorization For Use and Disclosure of Protected Health Information

Specific Authorization to Disclose Sensitive Records

Please Note: This form must be completed in its entirety. Thank you for your compliance.

Consent For Disclosure of Protected Health Information

Please contact me in the following manner:

Family Member(s) or Friend(s) with whom we may discuss your medical condition:

Monday	7:30AM–6PM
Tuesday	7:30AM–6PM
Wednesday	7:30AM–6PM
Thursday	7:30AM–6PM
Friday	7:30AM–6PM
Saturday	7:30AM–6PM
Sunday	12:00PM – 6PM