PATIENT INFORMATION UPDATE

PATIENT INFORMATION UPDATE
Date

MonthDayYear
Date
PATIENT NAME

First NameLast Name
GENDER

MaleFemale
DATE OF BIRTH:

MonthDayYear
Date
NAME of Parent/ Custodian/ Spouse:
HOME ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
BEST CONTACT NUMBER
CELL / HOME / WORK
SS#
EMAIL ADDRESS
example@example.com
EMERGENCY CONTACT NAME
Please enter a valid phone number.
EMERGENCY PHONE #
Please enter a valid phone number.
ETHINICITY:
RACE:
PRIMARY LANGUAGE
INSURANCE
POLICY NUMBBER
POLICY HOLDER’S NAME

First NameLast Name
DATE OF BIRTH:

MonthDayYear
Date
EMPLOYER :

MonthDayYear
Date
OCCUPATION /TITLE:

MonthDayYear
Date
EMPLOYER PHONE #
Please enter a valid phone number.
PREFERED PHARMACY
PHARMACY’S PHONE NUMBER
Please enter a valid phone number.
RELEASE OF CONFIDENTIAL INFORMATION
This is to inform you, that for your protection, it is our office policy not to release any information regarding your medical history or care to anyone without your permission. All medical information is kept confidential and in accordance to HIPPA Privacy Law, and practices. This includes spouses, parents of adult children, regardless of who is responsible for payment. We will, however, release information to other medical providers at their request, for continuity of medical care. If it is your desire that we discuss your medical care with someone other than yourself, please indicate below. Please list individuals in space provided below.
PLEASE CHECK ONE:

I DO NOT wish you to discuss my medical care with anyone other than myself.You have my permission to discuss my medical care with the following individual(s):
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
I authorize to receive email/text/ voice mail messages for appointment reminders and general health reminders/feedback/ information

YESNO
AUTORIZATION TO RELEASE OR OBTAIN MEDICAL INFORMATION
I hereby authorize Winter Park Family Physicians to release or obtain information that may be medically necessary in order to manage my care and/or process insurance benefits to or from other providers and/or medical facilities. I authorize direct payments of medical benefits for services to be rendered and I am aware, I am financially responsible for any balance that may not be covered by insurance (either copays or total amount of charges) if insurance does not pay.
ALL COPAYS ARE DUE AT TIME OF VISIT. IF NON INSURSED, PAYMENTS MUST BE TO BE PAID IN FULL PRIOR TO VISIT
Patient ‘s Signature:

Clear
Date

MonthDayYear
Date
Should be Empty: