For New Patient

Step 1 of 5

Patient Registration Information
Employment Information
Pharmacy Information
Emergency Contact
Meaningful Use Required by the Government

Step 2 of 5

HIPAA CONTACT INFORMATION
In order to assist you in receiving your health information from Brevard Health Center, please complete this form. Initial one:
Brevard Health Center is permitted to share any and all medical information with the individuals listed below, including test results, sensitive information as stipulated by the State of Florida, and information disclosed during office visits.
Brevard Health Center is permitted to share any medical information with the individuals listed below, including test results, sensitive information as stipulated by the State of Florida, and information disclosed during office visits except
Persons authorized to receive my medial information
(full name, relationship, and phone number):
You may notify me with test results, appointment reminders and other information regarding my health information as follows:
I understand and direct that this authorization will remain in effect until it is revoked by me in writing

(OR)
This authorization is not valid for the request of printed copies of your medical records. You and only you (or your legal personal representative) must sign a Health Information Release Form to obtain copies of your medical records.

Step 3 of 5

Brevard Health Center
Past Medical History
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Family History
Social History
Cigarettes
Pipe / Cigar
Chewing
Alcohol / Consumption

Step 4 of 5

Step 5 of 5

Authorization for Release of Protected Health Information
I hereby authorize - The Following Physician to release/disclose my Protected Health Information to Brevard Health Center

Include any federal and state protected information under Florida statue 394.d59(9) psychiatric information, Florida statute 397.053 and Florida statute 396.112, drug and/or alcohol abuse information and Florida statute 38160999 (2) human Immunodeficiency virus test results (aids and related conditions).


I understand that authorizing the disclosure of this protected health information is voluntary. I understand that I may expect copy of this information to used, disclosed, as provided in CPR 164.524. Understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of protected health information, I may contact Brevard Health Center.


I understand and direct that this authorization remains in effect for 6 months or until I revoke it in writing. I here-by release Brevard Health Center and its employees from any and all liability that may arise from the release of this protected health information as I have directed.



(OR)