• Manhattan Primary Care

    Manhattan Primary Care

    Bradley K. Harrison, MD, FAAFP | Kyle E. Platz, DO Kerri Maxcy PA-C | Michelle Oehm, APRN-C
  • Manhattan Primary Care-New Patient Demographic

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  •  Name:       
             
    Address:                
    Phone (home)         
    Phone (work)         
    Phone (cell)       
    Relationship to Patient:           




  • Primary Insurance Provider:
    Effective Date:
    Who is the policy holder?      
    If Policy Holder is separate person, please provide the information below:
    Name:       
      DOB of policy holder: Pick a Date   
      Policy Holder Relationship to Patient:    

  • Secondary Insurance Provider (if applicable):
    Effective Date:
    Who is the policy holder?      
    If Policy Holder is separate person, please provide the information below:
    Name:       
      DOB of policy holder: Pick a Date   
      Policy Holder Relationship to Patient:    

  • Emergency Contact:
    Name:  *   *     DOB: Pick a Date  
    Phone Number: *   Relationship: *

  • Please initial one of the following:
         I authorize Manhattan Primary Care to correspond with me with email that is not encrypted and not HIPAA Compliant.
          I authorize Manhattan Primary Care to ONLY use encrypted/HIPAA compliant email the correspond with me.

  • Please 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).
    * I have read, understand, and agree to the Payment Policy outlined by Manhattan Primary Care (MPC). 
    * I have been given the opportunity to read the vaccine policy outlined by Manhattan Primary Care.      

  • I authorize Manhattan Primary Care to leave health information message on the below phone number(s).
             
            
             

  • Sharing of Medical Information. If left blank, we cannot share medical information with any person.
    I authorize Manhattan Primary Care to discussion my medical health information with ,   ,   .

    I authorize Manhattan Primary Care to discussion my medical health information with ,     ,
    .

  • Clear
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