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

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

Patient Information

Patient Name(Required)

First Last

Sex

Age

Date of Birth(Required)

Race

Social Security Number

Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone Number(Required)

Secondary Phone Number

Emergency Contact Outside the Home

Name

First Last

Phone

Responsible Party/Parents

Mother (Stepmother/Guardian) Name(Required)

First Last

Date of Birth(Required)

Phone Number(Required)

Social Security Number

Employer

Email

Father (Stepfather/Guardian) Name(Required)

First Last

Date of Birth(Required)

Phone Number(Required)

Social Security Number

Employer

Email

Insurance Information

Primary Insurance Company

Contract Number

Copay

Insured's Name

First Last

Date of Birth

Secondary Insurance Company

Contract Number

Copay

Please Upload a Picture of the Front of Your Insurance Card

Max. file size: 50 MB.

Please Upload a Picture of the Back of Your Insurance Card

Max. file size: 50 MB.

Patient Authorization

I give authorization to the following person(s) listed below to discuss medical records, obtain medical advice & consent to medical treatment for the child referenced in this authorization.

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

Patient's Name(Required)

First Last

Patient's Date of Birth(Required)

Name of the Responsible Party Completing This Form(Required)

First Last

Today's Date(Required)

HIPAA Forms Children

Patient Information

Emergency Contact Outside the Home

Responsible Party/Parents

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