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NEW PATIENT INTERNAL MEDICINE AUTHORIZATION TO OBTAIN RECORDS I, authorize Thunderbird Internal Medicine to obtain my medical records which may include information concerning communicable diseases
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How to fill out new patient authorization to
How to fill out new patient authorization to
01
Read the instructions on the new patient authorization form carefully.
02
Fill in your personal information such as name, address, date of birth, and contact details.
03
Provide your insurance information, including policy number and group number.
04
If applicable, indicate the primary care physician and any referring physician.
05
Sign and date the form at the designated places.
06
Make a copy of the completed authorization form for your records.
07
Submit the filled-out new patient authorization to the healthcare provider or facility.
Who needs new patient authorization to?
01
New patients who wish to receive medical services from a healthcare provider or facility.
02
Individuals who have not previously been registered as patients at a particular healthcare facility.
03
People who have changed their insurance provider and need to update their patient information.
04
Patients who have undergone a change in their primary care physician or referring physician.
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