Apex Health - Publicforms

Available Forms

1. NEW PATIENT REGISTRATION FORM 2. NEW PATIENT Medical History 3. HIPAA Release and CONTACT Policy 4. CONTROLLED SUBSTANCE AGREEMENT 5. NEW PATIENT Opioid Dependence Scale 6. Clinic Rules Form 7. FOLLOW UP Opioid Dependence Progress Report

3. HIPAA Release and CONTACT Policy

Name: *

Date of Birth: *

I authorize the release of information including the diagnosis, records, examination rendered, and claims information to: (list names and relationship)

eg "Norm Stewart, father"

Others:

Use this if information is not to be released to anyone.

This RELEASE OF INFORMATION will remain in effect until terminated by me in writing.

METHODS OF CONTACT

My preferred contact phone number is: *

Enter your number

The above number is: *

If I don't answer the office may: *

Leave a detailed message

Only leave a message asking me to return a call

Text this number

The best time of day to reach me is: *

Also enter if there are 'better days' to reach you.<br/>

If you have a home answering machine, may we leave a message on it? *

I understand that email is NOT a secure method of communication. However, Apex Health utilizes UPDOX which allows us to send secure messages, reports, and forms to patients. *

Please provide your email address for UPDOX messages *

Enter "none" if you do not have access to email. Please update this form once you get an email address

BACKUP CONTACT

All patients MUST have at least one alternative way to be contacted. Please enter a 2nd phone number or person (and number) we can contact if we are unable to reach you: *

REMINDER: Patients MUST update this form whenever there is a change in phone numbers or people we can contact.

Please re-enter your name: *

Today's Date: *

* Required field