QPC New Patient - Page 7

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Quick Primary Care

Caring, Kind, Professional, Compassionate, Trustworthy

New Patient Info (Continued)

Today's Date *

Email *

Complaints / Authorization for release

NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES

I have received a copy of Quick Primary Care's Notice of Privacy Practices and understand my rights as a patient. I also authorize Quick Primary Care to release and obtain medical information for the purpose of treatment, payment, and healthcare operations.

I understand that I have the right to revoke this authorization at any time by providing written notice to Quick Primary Care. I also understand that any information released prior to the revocation will not be affected.

Please list below any individual(s) that you authorize Quick Primary Care to discuss your medical information with (e.g., spouse, parent, child, etc.).

I authorize Quick Primary Care to discuss my medical information with the following individuals:

Authorized individual 1

Authorized individual 2

Authorized individual 3

Patient signature

Patient signature *

Patient Name *

Signed Date *

Witness signature

Witness Name