New Patient Forms Packet

Step 1 of 5

Pharmacy & Medication Information

Pharmacy

Phone

Fax

Address

Street Address City State ZIP Code

Mail Order Pharmacy

Phone

Fax

Address

Street Address City State ZIP Code

Name of Prescription Insurance

Is this a Medicare Part D Plan?

Yes

Member Service Phone

ID #

RxPCN

Rx Group

RxBin

Exact Name on the Prescription Card

List all prescription, medications, including aspirin, laxatives, cough medications, birth control, etc.

Name

Dose

Frequency

Last Dose

To add new list please click the "+" plus icon on the right side.

Do you have any allergies?

Yes

List all Allergies

Patient or Authorized Signature

Relation to Patient

Date

AUTHORIZATION FOR ACCESS OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

If you would like Nephrology Specialists of Oklahoma to be able to talk in person or on the phone to anyone including your spouse or family members regarding your appointments, medical results, or provide any medical information, you will need to list them below.

I hereby authorize the use or disclosure of the Protected Health Information described below to be provided to or obtained by the following:

Name of Individual/Facility/Company to receive Protected Health Information

Name(Required)

First Last

Name

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Relationship(Required)

Relationship

Information authorized for use or disclosure, or to be obtained:(Required)

All medical information concerning this patient.

Medical information of this patient compiled between specific dates.

From Date(Required)

To Date(Required)

I understand that I may revoke this authorization at any time, in writing, except revocation will not apply to information already used or diclosed to this authorization. I may revoke this document by presenting my written revocation as provided in the Notice of Privacy Practices.

NOTICE OF PRIVACY PRACTICES

CONSENT OF DISCLOSURE OF IN INFORMATION: Patient medical records and billing information are created and retained by Nephrology Specialists of Oklahoma and are accessible to its personnel and medical staff for use in your care. Nephrology Specialists of Oklahoma and physicians may use and disclose medical information for its business operations and to any other physician or health care personnel involved in providing care. Safeguards are in place to dicourage improper access. Nephrology Specialists of Oklahoma is authorized to disclose all or part of my medical record to any insurance carrier, worker's conpensation carrier, or administrator of a self-insured employer group which is responsible for any part of Nephrology Specialists of Oklahoma's charges and to any health care provider who is or is expected to become involved with a patient's care. These disclosures are for treatment or payment purposes. The information authorized for release may include records which may indicate the presence of a communicable or non communicable disease. You understand that your medical information may indicate that you have or have been treated for psychological or psychiatric conditions or substance abuse. By signing this agreement, you are consenting to such disclosure. You may revoke this consent in writing, addressed to Nephrology Specialists of Oklahoma, except to the extent er have already acted in reliance on it.

A complete description of how your medical information will be used and disclosed by Nephrology Specialists of Oklahoma is in our NOTICE OF PRIVACY, which can be given to you by Nephrology Specialists of Oklahoma at your request.

Patient or Authorized Signature(Required)

Relation to Patient(Required)

Date(Required)

Comments

This field is for validation purposes and should be left unchanged.

New Patient Forms Packet

Basic Information & Patient Consent

Spouse's Information

Insurance Information

Secondary Insurance

Section Break

Insurance Authorization and Assignment of Benefits

Pharmacy & Medication Information

Pre-Visit Questionnaire

History

Previous Diagnoses & Surgical Procedures

AUTHORIZATION FOR ACCESS OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

NOTICE OF PRIVACY PRACTICES

Our philosophy is a patient centric approach. We take care of the whole patient and their kidney disease.

Yale Office

Utica Office

Muskogee Office