HIPAA Authorization Adults | Internal Medicine and Pediatrics of Cullman, P.C.

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Patient Information

Patient Name(Required)

First Last

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Sex

Date of Birth(Required)

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Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone Number(Required)

Secondary Phone Number

Social Security Number

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Employer

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Emergency Contact Outside the Home

Name

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Identity Verification

Driver's License Upload(Required)

Max. file size: 50 MB.

To verify your identity, please upload a picture of the front of your driver’s license for review.

Spouse Information (If Applicable)

Spouse Name

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Insurance Information

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Copay

Insured's Name

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Copay

Please Upload a Picture of the Front of Your Insurance Card

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Please Upload a Picture of the Back of Your Insurance Card

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Patient Authorization

You may communicate confidential information to me, or the following individuals:

Please provide the names and phone numbers of any individuals listed here.

Patient's Name(Required)

First Last

Date of Birth(Required)

Today's Date(Required)

HIPAA Forms Adult

Patient Information

Emergency Contact Outside the Home

Identity Verification

Spouse Information (If Applicable)

Insurance Information

Patient Authorization

INTERNAL MEDICINE & PEDIATRICS OF CULLMAN, P.C.

CONSENT FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR PAYMENT, TREATMENT AND HEALTH CARE OPERATIONS

CONSENT FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
FOR PAYMENT, TREATMENT AND HEALTH CARE OPERATIONS