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.Format: (000) 000-0000.
If I don't answer the phone:
Cell number
Please enter a valid phone number.Format: (000) 000-0000.
If I don't answer the phone:
Text
Do you want to add an additional contact to your records?
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.Format: (000) 000-0000.
Cell #
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact:
Health Info:
Payment Info:
Add another contact?
Contact Name

First NameLast Name
Relation to patient
Home #
Please enter a valid phone number.Format: (000) 000-0000.
Cell #
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact:
Health Info:
Payment Info:
Add another contact?
Contact Name

First NameLast Name
Relation to patient
Home #
Please enter a valid phone number.Format: (000) 000-0000.
Cell #
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact:
Health Info:
Payment Info:

PATIENT CONTACT INFORMATION

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