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HIPAA & Compliance California

Personal Information

Full Name

Preferred Name

Phone

E-mail

Birth Date (DD/MM/YYYY)*

Address

Gender

Male Female

Emergency Contact

Name + Relationship

Phone Number

Insurance Information

Primary insurance company

Policy/Subscriber ID

Group number

Policyholder name (if different)

Secondary insurance (if applicable)

Front of insurance card

Back of insurance card

Consent & Notices

I acknowledge receipt of the Notice of Privacy Practices

eSignature: Patient (or guardian) signature + date