There are several ways to register as a patient of the Other Medical Clinic.
1. Come into the clinic and fill out papers or take papers home to finish. 2. Have a friend or relative pick up registration forms for you. 3. Call and say you want to register as a patient over the phone.
If your medical problem is urgent, we can sign you in and start your medical chart using only your Name and Sex.
Try that somewhere else!
Ours
Theirs
MEDICAL RELEASE FORM
PRINT COMPLETE Mail or Fax to your previous physican or other provider.
This way we can have your records available for review when you come for your appointment.
Authorization to Use or Disclose Health Care Information.
Patient Name:_______________ Date of Birth: _______________ Address:________________ ____________
I authorize my health care information may be disclosed to Alda L Knight, MD FACP the Other Medical Clinic, PLC 410 East Robinson, Ste B-2, Knoxville, Iowa 50138
Phone (641)842-3700. Fax (641)-842-3363
From _________________________________________________________
FAX or Phone of prior Provider _________________________________
CHOICES: I restrict disclosure as follows: [check all that apply]
__ Send ONLY myhealth care information relating to the following treatment(s) or condition(s):
________________________________________
OR __________________________________________
□I AM allowing transfer of sensitive information related to □ Infectious or Sexually transmitted diseases past or present. YES NO (circle one)
□ I AM allowing transfer of sensitive information related to Psychiatric illness past or present. YES NO (circle one)
AND
□My health care information ONLY for the following date(s) or amount of time:
OR
□All my health care may be disclosed and used for ongoing care by the Other Medical Clinic, PLC.
□This health care information may be ALSO disclosed to: (relative or another clinic for example)(____________________________________________________________________________________________________________
□ I understand that I have the RIGHT NOT TO SIGN this authorization. My refusal to sign will NOT affect my ability to get treatment.
□I understand that my records can and may be sent to my insurance company as part of the billing process and health care information collection without my specific request.
□I understand that my records can and may be sent to other doctors who are caring for me, including sub-specialists, for continuing medical care without my specific consent.
□ I understand that I may revoke this authorization by writing a letter to the physician and/or hospital stating that I want to revoke, cancel or withdraw this authorization.
□I understand that this letter will not affect any actions already taken by (the above physician and/or hospital) based on this authorization before it was revoked.
□I understand that I may not be able to revoke this authorization if its purpose was to obtain insurance.
□I understand that the physician and/or hospital have no control over the information. The person or organization that I authorize to receive the information might re-disclose it. It may no longer be protected by privacy laws.
This authorization is valid for ___6 months ___1 year____ until (date) The purpose(s) of this disclosure and use are:
Patient request ___ Doctor’s request ___ Continued Medical Care ____other Research_____ Insurance, as for eligibility ___Legal matters _____
Signature of patient or authorized representative
___________________________________
Print Name _________________________
Date: _________________
Relationship to patient:_______________
