Name: First Name Last Name Same contact information as patient Address: Street Address Address Line 2 City State Zip Phone (home) Area Code Phone Number Phone (work) Area Code Phone Number Phone (cell) Area Code Phone Number Relationship to Patient: Relationship to patient
Primary Insurance Provider: Insurance Provider Effective Date: Effective DateWho is the policy holder? Patient Other Person If Policy Holder is separate person, please provide the information below: Name: First Name Last Name DOB of policy holder: Date of birth of policy holder Policy Holder Relationship to Patient: Policy Holder Relationship to Patient
Secondary Insurance Provider (if applicable): Insurance Provider Effective Date: Effective DateWho is the policy holder? Patient Other Person If Policy Holder is separate person, please provide the information below: Name: First Name Last Name DOB of policy holder: Date of birth of policy holder Policy Holder Relationship to Patient: Policy Holder Relationship to Patient
Emergency Contact: Name: First Name* Last Name* DOB: DOB Phone Number: Phone Number* Relationship: Relationship*
Please initial one of the following: Initial I authorize Manhattan Primary Care to correspond with me with email that is not encrypted and not HIPAA Compliant. Initial I authorize Manhattan Primary Care to ONLY use encrypted/HIPAA compliant email the correspond with me.
Please initial:Initial* I have been given the opportunity to read the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).Initial* I have read, understand, and agree to the Payment Policy outlined by Manhattan Primary Care (MPC). Initial* I have been given the opportunity to read the vaccine policy outlined by Manhattan Primary Care.
Initial I authorize Manhattan Primary Care to leave health information message on the below phone number(s). Area Code Phone Number Area Code Phone Number Area Code Phone Number
Sharing of Medical Information. If left blank, we cannot share medical information with any person.Initial I authorize Manhattan Primary Care to discussion my medical health information with Name, DOB, Relationship .Initial I authorize Manhattan Primary Care to discussion my medical health information with Name, DOB , Relationship.