Combined intake forms

Intake Form – English + AUTHORIZATION TO RELEASE MEDICAL INFORMATION

Step 1 of 14

Name

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Patient Registration

Your Name

First Middle Last

Date of Birth

Patient Address

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

Sex:

Male

Female

Age

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Name of Spouse

Home Phone

Alternate Contact/Cell:

Social Security #

Employer

Occupation

Primary Care Doctor

Office Phone

Fax Number

Preferred Pharmacy

Phone

Fax

Patient Name
First Last
DOB:
PATIENT AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION BY SHADOW PARTICIPANT
Dr. Paul Perito / Perito Urology is a urological training facility. Dr. Perito trains physicians, residents, nurses and/or officers who are interested in healthcare, are pursuing careers in the medical field or desire an educational experience. These individuals are referred to as “shadow participants.”

I understand the shadow participant/s has signed a confidentiality statement that provides patient protections in connection with use and disclosure of their health information, in addition to those protections that already exist under state law. Dr. Perito is committed to protecting the privacy or our patients’ health information.

By signing below, I am voluntarily authorizing Dr. Perito to disclose my health information to these medical participants. This authorization extends for all medical services, including evaluations, procedures and surgeries performed in office or at any other facility.

I understand the terms of this authorization and I have had an opportunity to ask questions about the disclosure of my health information.
Signature
Your Name
Your Name
Your Name
Date

Date

Patient Name
First Last
DOB
I understand I have the option of going to my insurance specified lab for venipuncture and lab work, but I have chosen to have my labs drawn at Dr. Perito’s office and agree to pay a convenience / administrative fee of $15. I understand this service will not be billed to my insurer.
Signature
Your Name
Your Name
Your Name
Fecha

Nombre
First Last
Fecha de Nacimiento

Firma del Paciente
Your Name
Your Name
Your Name
Yo entiendo que tengo la opcion de ir a el laboratorio que sugiere mi sugero para el proceimiento de laboratorio pero he decidido que me hagan los analisis en la oficina. Estoy de acuerdo en pagar el cargo de conveniencia / administrativo de $15. Estos servicios no seran cargados a mi aseguradora.

Intake Form – English + AUTHORIZATION TO RELEASE MEDICAL INFORMATION

Patient Registration

Insurance Information

In Case of Emergency, Please call:

Patient's Medical History

Males Only

Females Only

Please check if you have now or have had in the past any of the following:

Patient Acknowledgment and Consent for Use and Disclosure of Protected Health Information

Assignment of Benefits

Release of Information

Cancellation Policy

Release of Information

Sexual Health Inventory for Men (SHIM)

PATIENT INSTRUCTIONS

Telemedicine Consent

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

SECTION A: Patient Giving Consent

SECTION B: To the Patient – Please read the following statements carefully

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

PATIENT AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION BY SHADOW PARTICIPANT

Intake Form – English + AUTHORIZATION TO RELEASE MEDICAL INFORMATION

Patient Registration

Insurance Information

In Case of Emergency, Please call:

Patient's Medical History

***Males Only***

***Females Only***

Please check if you have now or have had in the past any of the following:

Patient Acknowledgment and Consent for Use and Disclosure of Protected Health Information

Assignment of Benefits

Release of Information

Cancellation Policy

Release of Information

Sexual Health Inventory for Men (SHIM)

PATIENT INSTRUCTIONS

Telemedicine Consent

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

SECTION A: Patient Giving Consent

SECTION B: To the Patient – Please read the following statements carefully

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

PATIENT AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION BY SHADOW PARTICIPANT

Males Only

Females Only