For Office Use Only
MRN #: ____________________
Personal Information:
Patient Name: First _____________________ Last _______________________ MI _____ Previous Name _______________________
Mailing Address _____________________________________________ City _____________________ State ________ Zip _____________
DOB ___________________
Sex _____Male ______ Female
Marital Status: _______Married ________ Single _______ Divorced _______ Widowed
SS # _________________________________
Home Phone _____________________________
Email address ____________________________________________________________
Cell _____________________________
Race: _______________________________ Ethnicity: (circle one) Hispanic/Latino or Non Hispanic/Latino
Employer _______________________________________Work Phone _______________________________ Ext _________________
Minor Child: Mother Name _____________________________________________
Father Name ______________________________________________
Guardian Name ___________________________________________
Emergency Contact: Name ______________________________________________
Phone # ___________________________________________
Relationship to patient ___________________________
Preferred Pharmacy: Name: ___________________________________________
Phone # ________________________________________
Responsible Party: First Name _______________________________ Last Name ______________________________________
Relationship to Patient _________________________________________
DOB: _________________________ Phone #: _____________________________________
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Patient Name: _________________________
Patient DOB: ___________________________
Do you have insurance? _________ Yes _________ No
Primary Insurance Information:
Name of Insurance: _______________________________________ Address ____________________________________________________
ID # ____________________________________________ Group # _______________________________________________________________
Name of Insured: ____________________________________________ Relationship to Patient: ________________________________
Insured DOB: __________________________________
Insured SS#: ____________________________________________
Secondary Insurance Information:
Name of Insurance: _______________________________________ Address ____________________________________________________
ID # ____________________________________________ Group # _______________________________________________________________
Name of Insured: ____________________________________________ Relationship to Patient: ________________________________
Insured DOB: __________________________________
Insured SS#: ____________________________________________
Tertiary Insurance Information:
Name of Insurance: _______________________________________ Address ____________________________________________________
ID # ____________________________________________ Group # _______________________________________________________________
Name of Insured: ____________________________________________ Relationship to Patient: ________________________________
Insured DOB: __________________________________
Insured SS#: ____________________________________________
The information provided is correct to the best of my knowledge. I authorize Firm Foundations Healthcare
Clinic to provide medical services to my minor child. I authorize my insurance company to pay all benefits
otherwise payable to me for all services rendered. I authorize Firm Foundations Healthcare Clinic to use
this signature on all signature claims.
Signature of Patient or Legal Guardian: __________________________________________ Date: __________________________
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Patient Name: ____________________________________________
DOB: ________________________________
In general the HIPPA Privacy Rule gives individuals the right to request a restriction on uses and
disclosures of their protected health information (PHI). The individual is also provided the right to
request confidential communication or that a communication of PHI be made by alternative means.
It is important to note that communication may not always be secure. E-mails and text messages can
be intercepected or corrupted by unintended parties. However, I would still prefer my provider
contact me with results by the following means.
Telephone Message
Preferred number(s):
__________________________________________
2. E-mail Message
Primary e-mail address: _________________________________________
3. Text Message
Preferred mobile number: _________________________________________
1.
Yes
No
Yes
No
Yes
No
I understand that my provider or his/her staff will make an attempt to contact me by the primary
telephone number or e-mail I have chosen to list. I also understand that by choosing not to list a
phone or e-mail communication I will need to schedule an appointment to review my test results
with my provider.
Persons allowed to call for records, receive reports/messages on my behalf, or that may pick up
medications: (Initial all that apply and specify name(s)
_____ Spouse
_________________________________ Phone # _____________________________________
_____ Children
_________________________________
Phone # ____________________________________
_____ Parents
_________________________________
Phone # ____________________________________
_____ Grandparents _________________________________
Phone # ____________________________________
_____ Other
Phone # ____________________________________
_________________________________
_________________________________
_______________________________________________
Print patient name
Signature of patient/legal guardian
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____________________
Date
REQUEST FOR MEDICAL SERVICES AND ACKNOWLEDGEMENT OF RECEIPT OF NOTICE
OF HEALTH INFORMATION PRIVACY PRACTICES
Before you give your consent, be sure you understand the information given below. If you have any questions, we
will be happy to talk about them with you. You may ask for a copy of this form.
I understand that I must tell the staff if language interpreter services are necessary to my understanding of the written
or spoken information given during my health care visits. I understand that free interpretive services may not be
immediately available and Firm Foundations Healthcare Clinic may need to refer me to another healthcare facility to
provide the services necessary for my care.
I have been given information about the test(s), treatment(s), procedure(s), and contraceptive method(s) to be
provided, including the benefits, risks, possible problems/complications, and alternate choices. I understand that I
should ask questions about anything I do not understand.
No guarantee has been given to me as to the results that may be obtained from any services I receive. I know that it
is my choice whether or not to have said services. I know that at any time, I can change my mind about receiving
medical services at Firm Foundations Healthcare Clinic.
I understand that if tests for certain sexually transmitted infections are positive, reporting of positive results to public
health agencies is required by law.
I understand that some conditions and disease states require advanced healthcare services not provided at Firm
Foundations Healthcare Clinic. In these instances, I will be given referrals to see specialists and/or orders for special
testing and procedures which may include, but are not limited to, CT, MRI, Ultrasound, EEG, Colonoscopy,
Mammogram, or Bone Density. I understand that if my provider orders or recommends any of the above, I will
assume responsibility for obtaining and paying for this care. I understand that if I have questions about these
referrals or testing I should contact Firm Foundations Healthcare Clinic for assistance. I have also been notified that
in the case of emergency I should seek care at an urgent care clinic, an emergency room, or call 911 for immediate
assistance.
I understand that confidentiality will be maintained as described in the Notice of Health Information Privacy Practices.
I understand that confidentiality may be broken if I cannot be contacted when a life-threatening condition is
suspected or detected. I consent to the use and disclosure of my health information as described in Notice of Health
Information Privacy Practices.
I understand that the providers, staff and I are all working as a team for my best health. I understand that I am part of
this team and must be diligent in helping my provider care for me. This includes, but is not limited to, keeping my
follow up appointments, taking my medications as prescribed, notifying my provider of any changes in medication
other providers have made since my last visit, requesting refills in a timely manner (3 days prior to running out),
making an effort to follow lifestyle changes recommended by my provider, and completing any additional testing my
provider recommends. I understand that my provider will provide me with a printed Rx or send a secure electronic
Rx to enabled pharmacies if it is needed for my treatment. In extreme circumstances, if I am not able to do this or
my provider thinks the patient/ provider team is not functioning to optimally provide me with the best care possible, I
will receive written notice to find another provider. Firm Foundations Healthcare Clinic will continue to fill required
medications or see me as needed for 30 days until I can locate another provider.
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I hereby acknowledge receipt of Firm Foundations Healthcare Clinic’s notice of health information
privacy practices.
Signature of patient _______________________________________________Date _______________________
I witness the fact that the patient received the above mentioned information and said she/he read and understood
same and had the opportunity to ask questions.
Signature of witness _______________________________________________Date _______________________
CHECK HERE IF PATIENT’S GUARDIAN OR RELATIVE IS LEGALLY REQUIRED TO SIGN BELOW
Signature of any other person consenting ___________________________________Date ___________________
Relationship to patient __________________________________
I witness the fact that the patient’s legal guardian (or person consenting in her behalf) received the above mentioned
information and said she read and understood same.
Signature of witness __________________________________________________Date _____________________
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