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Telemedicine Services

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Patient Registration

Demographics
INSURANCE INFORMATION/ RESPONSIBLE PARTY INFORMATION
ADDITIONAL INSURANCE INFORMATION
Assignment and Release

I the undersigned certify that I or my dependent have insurance coverage with and assign directly to DR , under my insurance benefits: if any, otherwise payable to me for service rendered. I understand that i am financially responsible for all charge whether or not paid by my insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on file for insurance submissions.

Please list the name of medication you are currently taking.

Please provide details regarding any allergies to medications you may have
Use pharmacy info as a separate page. Pharmacy phone number and address are needed.
Assignment and Release

Please indicate whether you give permission for any staff member of Atlantic to act on your behalf, and if so, please list the individuals to whom we may disclose your PHI (Protected Health Information).

Practice Requirements

The Practice:

  1. Is required by federal law to maintain the privacy of you PHI and to provide you with this Privacy Notice detailing the practice's legal duties and privacy practices with respect to your PHI.
  2. Under the Privacy Rule, may be required by State law to grant greater access or maintain greater restrictions on the use or release of your PHI than that which is provided for under federal law.
  3. You have the right to be treated with dignity and respect
  4. You have the right to appropriate services in the least restrictive settings available that meets your needs
  5. Is required to abide by the terms of this Privacy Notice
  6. Reserves the right to change the term of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains.
  7. Will distribute any revised Privacy Notice to your prior implementation.
  8. Will not retaliate against you for filing a complaint
Patient Acknowledgement

By subscibing my (missing) below, I acknowledge receipt of a copy of a this Notice, and my understanding and my understanding and my agreement to its terms.

(Guardian’s Signature if Patient is under 18)