CHEMED HIPAA Form

PATIENT CONTACT INFORMATION
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Please contact me in the following manner (Please fill out all that apply):
Home number
Please enter a valid phone number.
If I don't answer the phone:

Leave a detailed messageCall back ONLY
Cell number
Please enter a valid phone number.
If I don't answer the phone:

Leave a detailed messageCall back ONLY
Text

AppointmentsResults
I designate the following person(s) listed below as an emergency contact(s) and/or as a person(s) involved with my healthcare and/or payment (check as applicable), to whom the information checked "yes" below may be released:
Contact Name

First NameLast Name
Relation to patient
Home #
Please enter a valid phone number.
Cell #
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact:

YesNo
Health Info:

YesNo
Payment Info:

YesNo
Add another contact?

YesNo
Contact Name

First NameLast Name
Relation to patient
Home #
Please enter a valid phone number.
Cell #
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact:

YesNo
Health Info:

YesNo
Payment Info:

YesNo
Add another contact?

YesNo
Contact Name

First NameLast Name
Relation to patient
Home #
Please enter a valid phone number.
Cell #
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact:

YesNo
Health Info:

YesNo
Payment Info:

YesNo
Patient Name or Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date
Patient Signature or Guardian Signature*

Clear
Should be Empty:

PATIENT CONTACT INFORMATION

Please contact me in the following manner (Please fill out all that apply):