logo color FormHeader NewPatientPackage
* = required fields
First Name *MILast Name *Account No.
Preferred Name (if different) Date of Birth *Marital Status  
Street AddressApt.CityStateZip
Address Type – Home    Relative    Other 
Home PhoneCell PhoneWork PhonePreferred Contact Phone  
Email AddressSocial Security No.
Language  English  Spanish  Other Race American Indian/Alaska Native Asian
Black or African-American Native Hawaiian White Refused to report/unreported  
Ethnicity Hispanic or Latino Non-Hispanic or Latino Refused to report/unreported
Employed byHow did you hear about us?
INSURANCE INFORMATION

Primary Insurance Company
Subscriber NameDate of BirthSocial Security No.
Relationship to PatientEmployer Name

Secondary Insurance Company
Subscriber NameDate of BirthSocial Security No.
Relationship to PatientEmployer Name
EMERGENCY CONTACT INFORMATION

NamePhoneRelationship
I hereby authorize the release of any medical and billing information necessary to process payment for claims and request benefits to be mailed directly to the physician until I revoke said authorization in writing. I understand that I (and spouse if married, or parent if minor) assume responsibility for payments of amounts due for services rendered and above the amount covered by insurance or the total amount, if I do not have applicable insurance coverage. My signature below guarantees my assumption of responsibility to the amount owed pursuant to this agreement.
Patient Signature – Draw your signature below using a tablet, mouse or smartphone.
By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature(s).
Date

logo color FormHeader PHI Release

Northland Women’s Health Care, P.C. is authorized to release protected health information about the below named patient in the following manner and to identified persons.
Name of PatientDate of BirthPatient ID No.
Preferred Contact PhoneMay we leave a voice mail for you that includes sensitive information?Yes   No
May we discuss your information with others such as a Spouse or Parent?Yes   No
NAME
RELATIONSHIP
PHONE
 
Financial  Medical
Financial  Medical
Financial  Medical
May we send you information via text message?* Yes   No   When I mark YES, I understand that if information is not sent in an encrypted manner there is a risk it could be accessed inappropriately, and I still elect to receive text communications.
If yes, please select applicable box(es)Appointment ReminderOther   
May we send you information via email?* Yes   No   When I mark YES, I understand that if information is not sent in an encrypted manner there is a risk it could be accessed inappropriately, and I still elect to receive email communications.
If yes, please enter email address and select applicable box(es) below
Financial  MedicalAppointment ReminderBreach Notification
Patient Rights:
  • I have the right to revoke this authorization at any time.
  • I may inspect or copy the protected health information to be disclosed as described in this document.
  • Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
  • Information used or disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.
  • I have the right to refuse to sign this authorization and my treatment will not be conditioned on signing.
This authorization will remain in effect until revoked by the patient in writing.
Patient or Personal Representative Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
*Description of Personal Representative’s Authority