Woodland Park Medical Clinic I understand that I have certain rights to privacy regarding my protected Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent, I authorize you to use and disclose my protected health information to carry out: Treatment (including direct or indirect treatment by other healthcare providers involved in my Treatment). Obtaining payment from third party payers (I.E, my insurance company). The day to day healthcare operation of your practice. I have also been informed of and given the right to review and source a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected. * Assignments & Authorizations * = Required Field Client's Medical/Family History * = Required Field Instructions: Please fill out a Patient Intake Form using one of the two methods below: Click Here to then fill out form then scan it or fax it or email it or bring it to our office. Manually PRINT PDF
Fill out the ONLINE PATIENT INTAKE FORMS on this page (all 3 of them) and when completed click the "Submit" button . for each of the 3 forms Please provide Patient Intake Form prior to setting your appointment. Thank you! Richard Y. Harris, M.D. 381 Rampart Range Road
Woodland Park, Colorado, 80863
Email: firstname.lastname@example.org Fax: 719.687.0940 Call 719-687-6088 if you have any questions.