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NEW PATIENT AUTHORIZATION TO RELEASE AND DISCLOSE PROTECTED HEALTH INFORMATION (PHI) 1) PATIENT NAME: PRINT name of patient (Last, First, MI) Date of Birth 2) CURRENT ADDRESS AND TELEPHONE: Street

How to fill out new patient authorization to

How to fill out new patient authorization:

1. Start by filling in your personal information. This includes your full name, date of birth, address, and contact information. Make sure to provide accurate and up-to-date information.
2. Next, provide information about your insurance. If applicable, include your insurance provider, policy number, and any other relevant details. This information is necessary for billing purposes and to determine coverage.
3. Specify your primary care physician or referring physician. If you were referred to the healthcare provider by another doctor, provide their name and contact information. This assists in maintaining accurate medical records and facilitates communication between healthcare providers.
4. Indicate any special requests or limitations. If you have specific preferences or restrictions regarding your medical care, such as not receiving certain treatments or disclosing your medical information to specific individuals, make sure to clearly communicate these in the authorization form.
5. Sign and date the form. By signing the authorization, you are acknowledging that you understand and agree to the terms stated in the document. Ensure that your signature is legible and matches the name provided.

Who needs new patient authorization:

1. New patients: Anyone who is visiting a healthcare provider for the first time typically needs to fill out a new patient authorization form. This allows the healthcare provider to obtain necessary medical information, consent for treatment, and billing details.
2. Minors: In the case of minors, a parent or legal guardian usually needs to complete the new patient authorization form on their behalf. This ensures that the responsible adult has authorized medical treatment and provides consent on behalf of the minor.
3. Patients seeking specialized care: If you are being referred to a specialist or a different healthcare facility for specialized treatment, you may be required to complete a new patient authorization form. This helps in transferring your medical records and ensures continuity of care.

In conclusion, filling out a new patient authorization form involves providing personal and insurance information, specifying the referring physician if applicable, indicating any special requests, and signing the form. New patients, minors, and those seeking specialized care typically need to complete this form.

For pdfFiller’s FAQs

What is new patient authorization to?

New patient authorization is a form that allows a healthcare provider to release patient information to a new healthcare provider or facility.

Who is required to file new patient authorization to?

The current healthcare provider or facility is required to file new patient authorization to release patient information.

How to fill out new patient authorization to?

To fill out new patient authorization, the healthcare provider must include patient information, reason for release, and recipient information.

What is the purpose of new patient authorization to?

The purpose of new patient authorization is to ensure that patient information is securely transferred between healthcare providers.

What information must be reported on new patient authorization to?

The new patient authorization must include patient name, date of birth, medical record number, reason for release, and recipient information.

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