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  • Patient Intake Form

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  • Medical History

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  • NOTICE OF PRIVACY PRACTICE ACKNOWLEDGMENT:

  • I understand that under Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected information.

    • Conduct, plan and direct my treatment and follow-ups among multiple healthcare providers who may be involved in that treatment directly and indirectly.
    • Obtain payment from third-party payers.
    • Conduct normal healthcare operations such as quality assessments and physician certifications.

    I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosure of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations.

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  • RETURNED CHECK FEE:

  • Any check returned for insufficient funds, will be subject to a $35 fee. Additionally, subsequent forms of payment will ONLY be accepted in the form of a money order, cash or credit card.
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