NMPHC Patient Registration and Authorization Form 2020
Name:
Mailing Address:
Homeless:
Contact Information:
Voice Call Text Message
E-Mail Do Not Contact
Other Information
Sexual Orientation: Lesbian, Gay, or Homosexual Straight or Heterosexual Bisexual Something Else Don't know
Choose not to disclose
Gender Identity: Male Gender Queer Female Other Transgender Male Transgender Female Choose not to Disclose
Marital Status: Single Married Divorced Widowed
How did you hear about us? Family/Friends Advertisement Website Social Media Pharmacy
Staff Member Health Care Provider Other
More Info:
Race: Check All That Apply Native Hawaiian Black/African-American American Indian/Alaska Native
White/Caucasian Pacific Islander Asia
Ethnicity: Choose One Hispanic or Latino All others
Are you a Veteran? Yes No
Do you live in public housing? Yes No
If Patient is a Minor
Responsible Party Information for Payment of Services
My Emergency Contact Person - (NO RELEASE of Health Information - just Emergency Contact Only)
Who can we contact about your health for assistance? (Blank means no one -not even a spouse-)

1. I have read and acknowledge the NMPHC Privacy Policy regarding my Protected Health Information (PHI) under HIPAA law and understand my contact person above can be contacted as necessary to assist me. I agree with the terms of the policy. I understand that I may retain a copy of the policy by asking for one and I have the right to amend or revoke my PHI.

2. I hereby authorize payment of services including the information necessary to process claims. I have submitted all the appropriate cards to be copied for my file (e.g. Medicare, Medicaid, and Insurance).

3. I hereby authorize and give permission to NMPHC and its employees to provide such medical, dental and/or behavioral treatment as may be deemed necessary for the patient named above.