mitchellderm.com - Patient Information and Hipaa Policy

Mitchell Dermatology Patient Information and HIPAA Policy
Patient name*

First NameMiddle NameLast Name
Nickname
Mailing address*

Street # and name

Apt / Lot #

CityState / Province

Postal / Zip Code
Patient Date of Birth*

MonthDayYear
Sex*
Marital Status*
SSN*
Primary policy holder name
Date of Birth

MonthDayYear
Secondary policy holder name
Date of Birth

MonthDayYear
Parent name (If patient under 18)

First NameLast Name
Date of Birth

MonthDayYear
SSN
Release of Information
Please tell us how you wish to be contacted. Check all that apply*

Cell PhoneHome Phone
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number*
Please enter a valid phone number.
(Please note that mobile text messaging will provide the quickest communication between the Mitchell Dermatology team and yourself)
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number*
Please enter a valid phone number.
OK to leave a message with detailed informationLeave a message with call back number/name onlyDo not leave any type of messageOK to mail correspondence to my homeOK to email to
Mailing address*

Street # and name

Apt / Lot #

CityState / Province

Postal / Zip Code
Email*
example@example.com
I do not want to receive phone calls regarding appointments, results, others.
Please tell us with whom we are allowed to discuss and/ or disclose your Personal Health Information; please note this does not include the Personal Health Information to entities as stated in section A (Uses and Disclosures) of the Mitchell Dermatology’s Notice of Privacy Practices.
Select all that apply
FianceSpouseAdult ChildrenParentsSiblingOther
Fiance: Name*
Spouse: Name*
Adult Children: Name*
Parents: Name*
Sibling: Name*
Other*
Do you have Primary Care Physician?*

YesNo
Primary Care Physician Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
If at any time you wish to change the information provided on this form, please ask for a new form prior to your appointment so your chart can be updated. Please do not hesitate to ask if you have any questions regarding the HIPAA regulations.

In compliance with HIPAA regulations, we are required to have confirmation that you have been offered a written copy of Mitchell Dermatology’s Notice of Privacy Practices. My signature below indicates that I have been given an opportunity to review a copy of Mitchell Dermatology’s Notice of Privacy Practices. My signature below authorizes the release of medical information to my primary care or referring physician and to process insurance claims/ applications prescriptions and lab work. The patient information included on this form is true to the best of my knowledge. I hearin authorize payment of medical benefits by my insurance carrier to the physician for the services rendered when an assigned claim is filed. (TO FILE INSURANCE, YOUR SIGNATURE IS REQUIRED)
Patient / Responsible Party Signature *

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Should be Empty:

Mitchell Dermatology Patient Information and HIPAA Policy

Release of Information