Dr. Gerald B Harris, II

Available Forms

Consent/Release Form Contract for Long-Term Controlled Substances Therapy for Chronic Pain and/or Dependence/Addiction Financial Policy Insurance Information New Patient - Registration New Patient - System Review Referral Form Weekly Blood Pressure Log Well-Woman Exam New Patient - Health History Questionnaire New patient - Alcohol Screening Test New patient - Depression Screening Pain Assessment New patient - Drug Abuse Screening Test (DAST) Therapy Progress Report Well Man Exam

Insurance Information

You MUST fill out this part

Subscriber's Name *

<br/>

ID # *

Group #

Subscriber's Name *

Relationship to Patient *

Subscriber's DOB

Secondary Insurance:

ID #

<br/>

Group #

Subscriber's Name

Relationship to Patient:

Please provide front desk with ALL insurance and or prescription cards.

Notice of Privacy Practices (Abbreviated) THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Gerald B. Harris, LLC is dedicated to maintaining the privacy of your personal health information. Each time patient visits this office, a record is made that describes the treatments and services provided. Federal outlines specific privacy protections and individual rights related to the information we maintain that identifies you as a patient. Protected information includes demographic data and facts about your past, present, or future physical or mental health. Our office has put in place policies ans procedures to help protect your health information. We are required to provide this notice outlining our legal duties and responsibilities related to the use and disclosure of patient identifiable health information, Privacy Practices, and examples of how your information may be used or disclosed. In short, your records are released for treatment, payment and operations. Your insurance may request records to process claims, Imaging services may need records to authorize X-rays/CTs/ect., Pharmacies may need records for prescriptions authorization, and /or Specialists may need records to book your appointment. (These are not all the ways your records are used, but merely a short overview of the types of ways your records may be released.) Practice will abide by the terms of this notice. We may revise this notice at any time. Revisions to the notice will be effective for all healthcare information this office maintains, past, present, or future. A full copy of the Notice of Privacy Practices is available for your review. If you would like a copy of your personal records, please ask the front desk. I have had the opportunity to read a copy of this office's Notice of Privacy Practices that outlines how patient confidential information will be used, disclosed, and protected. I can obtain a copy by asking the front desk.

Patient/Guardian Signature: ______________

Date *

<br/>

***For office use only*** We attempted to obtain written acknowledgement of receipt of this notice of Privacy Practices but could not because:

Individual Refused to Sign

Communication Barrier

Care Provided was Emergent

Other

* Required field