Anchor Medical Group - Publicforms

Available Forms

1. New Patient Registration 2. New Patient Medical History 3. HIPPA 4. Financial Responsibility Agreement 5. Annual Preventive Exam 6. Medicare Private Contract 7. Patient Health Questionnaire (PHQ-9) 8. ROI (Release of Information) To Anchor Medical Group 9. ROI (Release of Information) From Anchor Medical Group Notice of Privacy Practices (HIPAA, to read only) Out of Network Consent Form

3. HIPPA

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (HIPAA)

I acknowledge and agree that I am either the patient or the patient's personal representative. I have been offered, received, or viewed a copy of Notice of Privacy Practices. I understand that I may contact the person named in the Notice if I have questions about the content of the Notice. (A copy of the Notice can be found to the left, or at www.amgak.com)

Patient or patient's representative

Type your name

Signature

Patient Signature

BY TYPING MY NAME ABOVE, I CERTIFY THAT THIS REPRESENTS MY ELECTRONIC SIGNATURE

TODAY'S DATE

Parent or Guardian Signature

BY TYPING MY NAME ABOVE, I CERTIFY THAT THIS REPRESENTS MY ELECTRONIC SIGNATURE

* Required field