L o a d i n g

Easier Workflow with

Online Forms

Use intake forms to make your workflow easier. Have the form ready when the patient arrives so that they only need to sign or you can use an online signature technology. It will help prevent patients from having to arrive early and reduce wait times in your office. This works in combination with our appointment reminder system, so AutoRemind will also remind the patient about the form.

Below is a sample. In this case, your office will receive a secure PDF file that can be unlocked with a password only your office knows and the paperwork is ready for the patients.

Patient Registration Information

1. Patient Information

2. Patient Contact Information

*By listing my confidential email address, I am giving NYHC permission to send a patient portal request electronically to the email on file in addition to newsletters and invoices.


*Please check the appropriate box if New York Health Clinic has permission to leave results or health information on your phone.

3. Insurance

4. Doctor and Pharmacy Contacts


5. Other Information

6. Privacy

HIPAA PRIVACY NOTICE ACKNOWLEDGEMENT AND DISCLOSURE RELEASE

This document acknowledges that I have seen the HIPAA Notice of Privacy Practices posted in this office and have had an opportunity to read it and obtain a copy of it.

DO YOU WANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM THE PROVIDER MAY DISCUSS YOUR MEDICAL CONDITION? IF YES, WHOM?

I give permission for my Protected Health Information to be disclosed for purposes of communicating results, findings and care decisions to the family members and others listed below: