1.

Patient first name*

Patient last name*

Patient DOB*

2.

Patient first name

Patient last name

Patient DOB

3.

Patient first name

Patient last name

Patient DOB

Ethnicity

Unknown

Hispanic or Latino

Not Hispanic or Latino

Declined to specify

Race

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Who does patient(s) live with?:

Mom

Dad

Legal Guardian

Other

Other, who?

Mom's information

Name

DOB

Phone

Address

Email

Dad’s Information:

Dad Name

DOB

Phone

Address

Email

OR Legal guardian Information (if applicable) *please provide custody paperwork and photo ID*

Name

DOB

Phone

Address

Email

May we leave a message on voicemail with results?

Yes

No

May we send you a text messages?

Yes

No

Insurance Information

Primary insurance name

Primary insured

Primary insured DOB

Primary Members ID

Primary Group Number

Secondary insurance information

Secondary Insured Name

Secondary Insured

Secondary Insured DOB

Member ID

Group Number

Our Notice of Privacy Practices provides information about how we may use ancl disclose protected health information (PHI) about you. We provide this form to comply with the Health Insurance Portability and Accountability Act (HIPAA). Please review the Notice of Privacy Practices thoroughly before signing this acknowleclgement form. lfterms of our Notice change, a revised copy will be made available to you.

By signing this form, you acknowledge that our practice may use and disclose PHI about you for treatment, payment and healthcare operations. You have the right to request that we restrict how PHI about you is used or disclosed for treatment, payment or healthcare operations.

Date

Printed Name of Patient

legal Relationship to the Patient (If required)

We cannot discuss your health information with anyone other than yourself unless you authorize us to do so. Please list belcw names of the individuals you authorize our office to discuss care with.

I give you permission to share my health information with:

1.

Name

Relationship

Phone

2.

Name

Relationship

Phone

Consent to email or text for appointment reminders and other healthcare communication.

If you approve, we may contact you via email and/or text messaging to remind you of an appointment or provide general health reminders or information. I understand that once I have consented to receive communications via text or email, I still have the right to revoke the consent at any time.

The cell phone number I authorize lo receive text messages for appointment reminders and general health information is:

Phone:

Please initial

The email address that I authorize to receive email messages for appointment reminders and general health information is

Email

Please initial

Or

I decline to receive communications via text

I decline to receive communications via emaii

Revocation

I hereby revoke my request to receive future appointment reminders or healthcare updates via text.

I hereby revoke my request to receive future appointment reminders or healthcare updates via email.

Patient Name

Date requested

CONSENT FOR USE / DISCLOSURE OF HEALTH INFORMATION

Patients Name:

Patient's Date of Birth*

Patient's SS Number

Notice to Patient:
By signing this form, you grant us consent to use and disclose your protected health care information for the purposes of treatment, various activities associated with payment and health care operations. Our Notice of Privacy Practices provides more details on our treatment, payment activities and health care operations. If there is not a copy of the Notice accompanying this Consent form, please ask for one. We encourage you to read it since it provides details on how information about you may be used and/or disclosed and describes certain rights you have regarding your health care information. As stated in our Notice of Privacy Practices, we reserve the right to change our privacy practices. If we should do so, we will issue a revised Notice. Since revisions may apply to your health care information, you have a right to receive a copy by contacting our Privacy Officer.

You have the right to revoke your Consent by giving written notice to our Privacy Officer. The revocation will not affect actions that were already taken in reliance upon this Consent. You should also understand that if you revoke this Consent we may decline to treat you.

You are entitled to a copy of this Consent Form after you have signed it.

(To Be Completed by Patient or Patient’s Representative)

Patient Name:

I have read the contents of this Consent Form and the Notice of Privacy Practices. I understand that I am giving you my consent to use and disclose my health care information to carry out treatment, payment activities and health care operations.

Date

Printed Name of Patient’s Representative

Relationship to Patient

Our Privacy Officer can be contacted as follows:
Name:Gabby Terrell
Phone:(940) 566-5437
Email:gterrell@nubypediatrics.com

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

TO REQUEST RELEASE OF MEDICAL INFORMATION PLEASE COMPLETE AND SIGN BELOW

I hereby voluntarily authorize the disclosure of information from my health record.

Patient Name

Patient DOB

Information requested

Purpose of release:

Transfer of care

Other

From:

Phone number:

Fax number:

The information is to be provided to:

Name of person/organization/facility:

Address:

Phone number:

Fax number:

1. I understand that this authorization will expire on (one year from today’s date)

Todays date:

2. I understand that I may revoke this authorization (except to the extent that action was already taken in reliance on this signed authorization) at any time by notifying NUBY PEDIATRICS in writing.
3. I understand that I can refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment, payment, or my eligibility of benefits (if applicable)
4. I may inspect or copy any information used or disclosed under this agreement.
I understand that if the person or organization that receives the information is not a health care provider or plan covered by the federal privacy law and regulations, the information described above may be redisclosed and would no longer be protected by these regulations.

Printed name of Patient’s representative

Relationship to patient

You have a right to receive a copy of this form!

Email concent

VERY IMPORTANT! PLEASE READ!

• HIP AA stands for the Health Insurance Portability and Accountability Act
• HIPAA was passed by the U.S. government in 1996 ln order to establish privacy and security protections for health information
• Information stored on our computers is encrypted
• Most popular email services (ex. Hotmail, Gmail, Yahoo) do not utilize encrypted email
• When we send you an email, or you send us an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is transmitted over the Internet. In addition, once the email is received by you, someone may be able to access your email account and read it.
• Email is a very popular and convenient way to communicate for a lot of people, so in their latest modification to the HIPAA act, the federal government provided guidance on email and HIPAA
• The information is available in a pdf (page 5634) on the U.S. Department of Health and Human Services website
• The guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email

OPTION 1-ALLOW UNENCRYPTED EMAIL
I understand the risks of unencrypted email and do hereby give permission to the Nuby Pediatrics to send me personal health information via unencrypted email

Allow date

Printed name

Please print email address

OPTION 2 - DO NOT ALLOW UN ENCRYPTED EMAIL
I do not wish to receive personal health information via email

Date

Printed name

Patient Portal Consent

Nuby Pediatrics is now offering a secure HIPAA compliant communication tool as a courtesy to our patients.
It is an optional service, and we reserve the right to suspend or terminate it at any time. We will alert you to any changes as promptly as possible.
This form is intended to inform you of the facts and risks surrounding the use of the web portal.
By signing below, you confirm that you have read, understand and agree to comply with our procedures and guidelines for using the patient portal.
You also agree not to hold Nuby Pediatrics or any of the staff liable for network infractions beyond their control.
Privacy and security the web portal or webpage has secure connection with our clinic that uses encryption to keep unauthorized persons from being able to access and read your health information or your communication to us.
To help ensure that it remains secure, we need to have your password secure so only you or someone authorized by you can gain access to patient information.
If you think someone has learned your password, immediately go to your portal account and change it. Your email is confidential and protected information.
With our best effort, we will protect this Information with any third-party. All access to our internal network and our electronic medical records are password protected.
Our staff are Instructed to log off their workstations when not physically present. Like phone communications, messages may be read and addressed by different Nuby Pediatrics staff members.

Confidential Email*

Your Portal login vill go to this address

DOB*

Patient's Printed Name*

DOB*

Name of guardian/parent requesting access*

THE FOLLOWING LISTED HAVE CONSENT TO BRING MY CHILD TO NUBY PEDIATRICS TO DISCUSS CARE AND TREATMENT.

Name

Relationship

Phone #

Name

Relationship

Phone #

E-Signature

Please sign electronically below.

Patient Update

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES/ USE AND DISCLOSURE FORM

Or

Revocation

CONSENT FOR USE / DISCLOSURE OF HEALTH INFORMATION

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Email concent

Patient Portal Consent

THE FOLLOWING LISTED HAVE CONSENT TO BRING MY CHILD TO NUBY PEDIATRICS TO DISCUSS CARE AND TREATMENT.

E-Signature