URICK MED ANNUAL HIPAA

ANNUAL HIPAA RENEWAL FORM
Patient Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Todays Date

MonthDayYearHourMinutesAM/PM Option
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient E-Mail
HEALTH INSURANCE INFORMATION

Even though Dr Urick does not bill insurance, we want to keep an updated insurance card/information on file. For those who may need a prior authorization for testing, labs, meds etc. You can type your information below and YOU CAN UPLOAD A PICTURE OF THE FRONT AND BACK OF YOUR CARD HERE but are not required to do so.
Name of Insurance Company (UPMC, highmark, Aetna, etc)
MEMBER ID NUMBER:
GROUP NUMBER:
Emergency Contact Information

If this has changed, feel free to update here. If there are not any changes then there is no need to complete this.
UPDATE EMERGENCY CONTACT INFORMATION (*** IF THIS HAS CHANGED SINCE YOU LAST SAW DR URICK)
IF WE ARE UNABLE TO CONTACT YOU, THIS NAMED PERSON HAS PERMISSION FOR US TO DISCUSS YOUR MEDICAL CONDITIONS OR APPOINTMENT SCHEDULING. IF YOU DO NOT WISH TO LIST ANYONE PLEASE TYPE "NONE" IN THE FIELD ABOVE UNDER "EMERGENCY CONTACT"
Relationship to Patient
Emergency Contact Phone Number

Area CodePhone Number
HIPAA AGREEMENT FOR 2025
In this PDF format is the HIPAA and Privacy Policy update for you to review.
By typing your full name here, you acknowledge you approve of any updates to your medical record, emergency contact info, HIPAA agreement.
DateTime
May we continue to send TEXT messages to you even though we cannot guarantee that texting messaging is HIPAA secure?
You have access to Dr Uricks private email address, which integrates with your chart in our electronic records system. We cannot guarantee that email is a HIPAA secure way of communication.
WHEN YOU PRESS "SUBMIT" BELOW, IF YOU DID NOT COMPLETE FIELDS WITH A RED ASTERISK * , THE FORM WILL NOT GO THROUGH.

If you do not receive a pop-up message stating "THANK YOU FOR YOUR SUBMISSION" or a confirmation email, then it did not go through.
Should be Empty:

ANNUAL HIPAA RENEWAL FORM

HEALTH INSURANCE INFORMATION

Emergency Contact Information

HIPAA AGREEMENT FOR 2025