SoFHA
Patient Forms

HIPAA


Description:

FirstChoice Pediatrics HIPAA paperwork.


Code:

5.102

Issued:

11/20/2018

Revision:

1

Revised:

N/A





If no, what other number (i.e. cell phone, private work number) may we try to reach you to leave a message?






Emergency Contact Number other than YOUR home phone number: (Please note, you are giving permission for this emergency contact to receive your personal health information if necessary.)




I have been given the opportunity to review the Notice of Privacy Practices and understand that the Notice describes how my protected medical information may be used and disclosed and how I may get access to this information. I have also been given the opportunity to take a copy of the Notice of Privacy Practices for further review.

If for some reason the facility needs to relay my protected health information, i.e. lab results or billing issues, you can either leave or discuss the information with the following individual(s):

















ACCESS YOUR MEDICAL INFORMATION ONLINE, 24/7 ANYWHERE, ANYTIME!




By typing my name in the signature fields below, I agree to the fore mentioned statements. I furthermore agree that my submission of this form, via the "Submit Form" button, shall constitute the execution of this document in exactly the same manner as if I had signed, by hand, a paper version of this agreement.