HIPAA Update Form

HIPAA Update Form
This form will be valid until the patient listed turns 18. If there are any changes that need to be made a new form will need to be filled out. When patients turn 18 they will need to complete a new form themselves.
Patient's Name*

First NameLast Name
Patient's Cell*

Area CodePhone Number
Patient's DOB*

MonthDayYear
Date
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact (parent/guardian/self):
Name*

First NameLast Name
Relationship To Patient*
DOB*

MonthDayYear
Date
Cell Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Contact (parent/guardian/self):
Name

First NameLast Name
Relationship to Patient
DOB

MonthDayYear
Date
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact (optional)
Name

First NameLast Name
Relationship To Patient
DOB

MonthDayYear
Date
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you have any privacy preferences about any of these individuals please list them in the lines below:·*
Would you like to receive appointment reminders and medical information via calls or texts?

If so, please list the name and phone number of the person that will be receiving these (only one person can be listed):
Name

First NameLast Name
Relationship To Patient
Phone Number for Calls

Area CodePhone Number
Cell Number for Texts

Area CodePhone Number
Decline automated reminder callsDecline text appointment reminders
I attest that all the information I provided above is true and accurate to the best of my knowledge. I have received and am agreeable to the terms of Medical Health Associates of Western New York's privacy practices.
Signature*

Clear
Printed Name*

First NameLast Name
Date*

MonthDayYear
Date
Email*
example@example.com
Should be Empty:

Primary Contact (parent/guardian/self):

Secondary Contact (parent/guardian/self):

Emergency Contact (optional)