Patient Registration Form

Patient Registration Form 2017-08-31T12:55:42-07:00

Patient Registration Form

  • Date Format: MM slash DD slash YYYY
  • Our Notice of Health Information Practices and Privacy (HIPPA) provides information about the privacy rights of our patients and how we may use and disclose protected information (PHI) about our patients. Federal regulation requires that we give patients or their authorized representative the opportunity to review our Notice of HIPPA before signing this acknowledgment, a copy will be made available to you at your request. By signing this form you acknowledge only that we have provided you with immediate access to our HIPPA Notice.
  • Date Format: MM slash DD slash YYYY