FORMS | Perpetual Help Medic

Patient Forms

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New Patient Form

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a. Fill up patient demographic information including insurance

b. Health Insurance Portability and Accountability Act (HIPAA) protects a patient's personal health information from being disclosed to third parties without their authorization or as required by law.

c. Office Policies that patient's need to abide.

d. Health Information Exchange (HIE) This consent form allows your health information to be shared securely through the Health Information Exchange (HIE) system. The HIE helps healthcare providers such as hospitals, specialists, and labs access your medical records more quickly and coordinate your care better.

Advance Health Care Directive

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An "advance health care directive" lets your physician, family and friends know your health care preferences, including the types of special treatment you want or don't want at the end of life, your desire for diagnostic testing, surgical procedures, cardiopulmonary resuscitation and organ donation.