Patient Forms

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PATIENT REGISTRATION FORM

PATIENT INFORMATION: PLEASE FILL OUT COMPLETELY

LAST NAME

FIRST NAME

MIDDLE NAME

DATE OF BIRTH

SEX M (Male)F (Female)

Patient Social Security No.

ADDRESS INFORMATION

STREET ADDRESS

P.O. BOX ADDRESS

CITY

STATE

ZIP CODE

CONTACT INFORMATION

HOME PHONE

EVENING PHONE

CELL PHONE

DEMOGRAPHIC INFORMATION

ETHNICITY HispanicNon-Hispanic

RACE

GUARDIAN INFORMATION

NAME OF LEGAL GUARDIAN(S)

ADDRESS OF LEGAL GUARDIAN(S)

ACCOUNT RESPONSIBILITY

PERSON RESPONSIBLE FOR PATIENT ACCOUNT

PHONE NUMBER

IN CASE OF EMERGENCY

FIRST TO BE NOTIFIED - NAME

PHONE NUMBER

MEDICATION CONSENTS

PHARMACY NAME

PHARMACY PHONE NUMBER

EMPLOYER/INSURANCE INFORMATION

PRIMARY INSURANCE

Insurance Subscriber's Name

Social Security No.

Subscriber's Date of Birth

Employer's Name

Relationship to Patient

SECONDARY INSURANCE (If Applicable)

Secondary Insurance Subscriber's Name

Social Security No.

Subscriber's Date of Birth

Employer's Name

Relationship to Patient

REFERRAL INFORMATION

PATIENT REFERRED BY

Health Information Release Authorization

Communication between behavioral health providers and your primary care physician (PCP) is important to ensure that you receive comprehensive and quality health care. This form will allow Harsha Outpatient Services, LLC to share protected health information (PHI) with your Primary Care Physician (PCP). This information will not be released without your signed authorization.

This PHI may include, but is not limited to, diagnosis, treatment plan, progress notes and medication prescribed.

Patient Name (please print)

Patient Date of Birth

PCP Phone

PCP Name

PCP Address

City

State

ZIP Code

Patient Rights

You can end this authorization (permission to use or disclose information) at any time by filling out a new authorization form or by contacting the Practice Manager at (812) 234-4899. If you make a request to end this authorization, it will not include information that has already been used or disclosed based on your previous permission. For more information about this and other rights, please see the applicable Notice of Privacy Practices. You cannot be required to sign this form as a condition of treatment, payment, enrollment or eligibility for benefits. Information that is disclosed as a result of this Authorization Form may be re-disclosed by the recipient and no longer protected by law. You do not have to agree to this request to use or disclose your information.

Patient Authorization

I understand that I may revoke this consent at any time except to the extent that action has been taken in reliance upon it and that in any event this consent shall expire at the termination of treatment or I have read and understand the above information and hereby identify my Date of Expiration wishes regarding my protected health information:

Date of Expiration (Optional)

If left blank, authorization expires at termination of treatment

PLEASE CHECK ONE OF THE FOLLOWING:

YES, I authorize Harsha Outpatient Services, LLC to release any applicable mental health/substance abuse information to my primary care physician whose name and address appear above.

NO, I DO NOT give my authorization to release any information to my primary care physician.

Digital Signature

Digital Signature * Please sign in the box below using your mouse or touchscreen

Or type your name as signature (if digital signature doesn't work):

No signature yet. Please sign above.

By signing above, you acknowledge that this is your legal electronic signature. Your signature will be saved as a digital image.

Relationship to patient (if applicable)

e.g., Parent, Guardian

Date Signed

Notice to recipient of information:

This information has been disclosed to you from records whose confidentiality may be protected by federal or state law. If these records are protected under federal regulations on confidentiality of alcohol and drug abuse patient records, the federal law (42 U.S.C. 290dd-2) and regulations (42 C.F.R. Part 2) prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.