Patient Information And Assignment Of Benefits Form.pdf

Susan Forster and Judith Forster at 114 Stanhope Street, Princeton, NJ 08854.

Patient Details:
- Name: [Patient Name]
- Date of Birth: [Date of Birth]
- Contact:
- Home Phone: [Home Phone]
- Mobile Phone: [Mobile Phone]
- Email: [Email Address]
- Occupation: [Occupation]
- Marital Status: [Marital Status, e.g., Single, Married, etc.]
- Insurance:
- Primary Insurance: [Primary Insurance Details]
- Card Holder (if different): [Name & Date of Birth], Relationship to Patient: [Partner/Spouse/Parent, etc.]
- Preferred Pharmacy: [Name, Address, Phone Number]

Emergency Contact:
[Emergency Contact Information with Name, Phone Number, and Relationship]

Assignment of Benefits:
The patient assigns all medical and surgical benefits to Women's Health First, understanding they are financially responsible for all charges.

Health Communication Preferences:
Patients can choose how they prefer to be contacted regarding appointments, test results, and follow-up care (Home Phone, Mobile Phone, Email, Voicemail, Email Reminders, Text Messages).

Authorization to Release Information:
Patients can authorize the release of medical information to specific individuals. A written revocation is required to cancel this permission.

HIPAA Privacy Policy:
In compliance with HIPAA, Women's Health First outlines:
- Permissible uses and disclosures of health information for treatment, payment, healthcare operations, and other legitimate purposes.
- Unusual situations allowing disclosure without patient consent, such as court orders or national security.
- Patient rights to access, request amendments, receive an accounting of disclosures, and file complaints.
- The practice's right to change the privacy policy and post revisions.