CJHS Notice of Privacy Practices

Notice of Privacy Practices
Notice of Privacy Practices Receipt

I acknowledge that I was provided with the Notice of Privacy Practices of Central Jersey Hand Surgery.
Name of Patient*

First NameLast Name
Date*

MonthDayYear
Date
Social Security Number
SSN 9 digits
Signature of Patient*

Clear
Is form being filled out by the personal representative of the patient?

YesNo
Name of Personal Representative

First NameLast Name
Date

MonthDayYear
Date
Signature of Personal Representative

Clear
Relationship to patient
For practice use only:

Signature of practice employee ___________________________________ Date: _____________________
The following is an authorization for miscellaneous services this office uses. We will make every effort to abide by your instructions. Please provide the following information:

Appointment Reminders/ Test Results (laboratory, x-rays, etc.):
If we need to reach you regarding an appointment or test results, we will make every effort to reach you personally. If we cannot reach you personally, we will only leave a message asking you to call our office during regular business hours. Please check all items below that apply to you.
May we call to remind you of an appointment or regarding your test results*

YesNo
Please call me at the following number(s):
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email Address
example@example.com
If we get an answering machine, may we leave a message?*

YesNo
If we get a family member, may we leave a message?*

YesNo
Policy for discussing your medical information with family members.
Our office will never discuss your medical information with a family member unless you have authorized us to do so. Please indicate the family members authorized to discuss your medical care by providing their name(s) where applicable.
Spouse or Partner

First NameLast Name
Parent

First NameLast Name
Parent

First NameLast Name
Child

First NameLast Name
Child

First NameLast Name
Child

First NameLast Name
Brother or Sister

First NameLast Name
Brother or Sister

First NameLast Name
Other

First NameLast Name
Other

First NameLast Name
Should be Empty:

Notice of Privacy Practices

Notice of Privacy Practices Receipt

For practice use only:

Please call me at the following number(s):

Policy for discussing your medical information with family members.

Our office will never discuss your medical information with a family member unless you have authorized us to do so. Please indicate the family members authorized to discuss your medical care by providing their name(s) where applicable.