• SOMERS EYE CENTER

    PATIENT HEALTH HISTORY
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  • CONTACT INFO:

  • ALTERNATIVE CONTACT PERSON:

  • PRIMARY INSURANCE CARRIER:

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  • RESPONSIBLE PARTY NAME (if not yourself):

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  • PRIMARY CARE PHYSICIAN NAME:

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  • PATIENT HEALTH HISTORY

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  • FAMILY MEDICAL HISTORY:

     

    PLEASE INDICATE BY CHECKING THE BOX WHICH FAMILY MEMBER HAD THE MEDICAL CONDITION(S):

    LEGEND

    M - MOTHER

    GM - GRANDMOTHER SS - SISTER A - AUNT D - DAUGHTER
    F - FATHER GF - GRANDFATHER B - BROTHER U - UNCLE S - SON
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  • THANK YOU FOR COMPLETING THESE FORMS AND
    HELPING US PROVIDE YOU WITH THE BEST CARE POSSIBLE!

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  • SOMERS EYE CENTER HIPAA COMPLIANCE AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH CARE INFORMATION

  • By signing this form I authorize the use and disclosure of my health information as described in the Notices of Privacy Practices. I have been given a copy of the Notice of Privacy Practices to read and keep if I desire.

    To revoke this authorization, I must do so in writing and send it to:

    SOMERS EYE CENTER

    Attention: HIPAA Compliance Officer

    2790 Clay Edwards Dr. Ste 1240

    North Kansas City, MO 64116

    I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the federal Privacy Standards.

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