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7954 University Ave NE Gridley, MN 55432 Tel (763) 7803036 Fax (763) 7800784www.leecarlsoncenter.orgAUTHORIZATION/CONSENT FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION Name: Date of Birth: Client
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01
Take out the new intake packet from the envelope.
02
Start by filling out your personal information such as your name, address, and contact details.
03
Next, provide details about your medical history, including any pre-existing conditions or medications you are currently taking.
04
Make sure to accurately complete the sections regarding your insurance information, including policy numbers and coverage details.
05
If applicable, fill out the emergency contact section with the appropriate details.
06
Read through any additional sections or forms included in the packet and complete them as required.
07
Once all the necessary information is filled out, review the entire intake packet to ensure accuracy and completeness.
08
Finally, sign and date the necessary sections and place the completed intake packet back in the envelope.

Who needs new intake packet for?

01
Anyone who is a new patient or client of the organization or healthcare provider would need to fill out the new intake packet.
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The new intake packet is for gathering information about a new client or individual.
Any individual or client who is seeking services or assistance.
The new intake packet can be filled out by providing personal information and details about the reason for seeking services.
The purpose of the new intake packet is to collect necessary information to better assist the client or individual.
Details such as personal information, contact details, reason for seeking assistance, and any relevant background information.
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2017 carlson cfr fridley leecarlsoncenter discloses mn applicable orally acknowledgement pertains pursuant prohibit dependency incurred restrict healthcare notification tel criminally revoke disclosed phi org disclosure expressly coordination updated ave

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