Patient Demographic Information and Financial Release

 
Patient Information
* = required fields
Marital Status



Address Type


Preferred Contact


Language


Race





Ethnicity


Insurance Information
Do you have healthcare insurance?

Emergency Contact Information
I hereby authorize the release of any medical and billing information necessary to process payment for claims and request benefits to be mailed directly to the physician until I revoke said authorization in writing. I understand that I (and spouse if married, or parent if minor) assume responsibility for payments of amounts due for services rendered and above the amount covered by insurance or the total amount, if I do not have applicable insurance coverage. My signature below guarantees my assumption of responsibility to the amount owed pursuant to this agreement.

Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature(s).
 
Authorization for Release of Information
Northland Women’s Health Care, P.C. is authorized to release protected health information about the below named patient in the following manner and to identified persons.
May we leave a voice mail for you that includes sensitive information?


May we discuss your information with others such as a Spouse or Parent? *


May we send you information via text message? *


May we send you information via email? *

Patient Rights
  • I have the right to revoke this authorization at any time.
  • I may inspect or copy the protected health information to be disclosed as described in this document.
  • Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
  • Information used or disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.
  • I have the right to refuse to sign this authorization and my treatment will not be conditioned on signing.
This authorization will remain in effect until revoked by the patient in writing.
Patient or Personal Representative Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
LuxSci helps ensure HIPAA-compliance for email and web services.