Transcription of NEW PATIENT PACKET
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Example: bachelor of science
NEW PATIENT PACKET
NEW PATIENT PACKET PATIENT s Name: _____ Last Middle First Address: _____ City: _____ State: _____ Zip: _____ Home Phone: _____ Cell Phone: _____ Primary Contact: Home Phone Cell Phone Email Address: _____ Driver s License #: _____ DOB: _____ Gender: Male Female Social Security #: _____ Employer: _____ Work Phone: _____ Race: White Hispanic Black or African American Asian Decline to Report Other: _____ Ethnicity: Hispanic or Latino/a Not Hispanic or Latino/a Decline to Report Other: _____ Whom may we call in Case of Emergency?
My “Protected Health Information” means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care ... patient confidentiality and privacy of healthcare information. As a new patient, you will be asked to ...
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