NMPHC Patient Registration and Authorization Form 2020


Name:











Mailing Address:












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:


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)
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.