Office of Dr. Kyoko Okamura, MD, MPH
Patient Name: ______Date of Birth: ______/______/ ______mo date year
Address: ______Social Security #: ______
______
Home Phone: ______[ ]
Work Phone: ______[ ]
Cell Phone: ______[ ]
* I prefer to be contacted regarding my results by:
[ ] Letter to the address above [ ] Phone as noted above [ ] Email ______
* I give permission to talk to the following person(s) regarding details about my health care.
Please note, information will be given to no oneelse.
[ ] Name: ______Relationship: ______Phone: ______
[ ] Name: ______Relationship: ______Phone: ______
[ ] Name: ______Relationship: ______Phone: ______
Please designate your Emergency Contact Person by placing a check next to his or her name.
Pharmacy Name: ______Phone: ______
Pharmacy Address: ______
Primary Care Physician: ______Phone: ______
Insurance #1:______Policy #: ______
Subscriber Name (if not patient): ______
Subscriber’s Social Security #: ______Subscriber Date of Birth: ______
Subscriber’s Address: ______[ ] Same as patient
Insurance #2:______Policy #: ______
Subscriber Name (if not patient): ______
Subscriber’s Social Security #: ______Subscriber Date of Birth: ______
Subscriber’s Address: ______[ ] Same as patient
* Please check the appropriate box(es):
Race: [ ] Declined[ ] American Indian or Alaskan native[ ] Asian[ ] Black or African American
[ ] Hispanic[ ] Native Hawaiian/Other Pacific Islander [ ] White[ ] Other ______
Ethnicity: [ ] Declined[ ] Hispanic[ ] Non Hispanic
Language: [ ] Declined[ ] English[ ] Other ______
I hereby give my permission for diagnostic evaluation, and any necessary treatment, and consultation for myself. I understand that confidential information in my record will remain confidential, as prescribed by state and federal regulations. Furthermore, I hereby request and authorize the doctor designated above to disclose any and all medical or other information about myself needed to process insurance claims from this doctor’s office. I hereby authorize all payments made directly to the doctor designated above and I agree to accept final responsibility for any patient balance.
HIPAA Notice of Patient Privacy Practices
I acknowledge receipt of Dr. Kyoko Okamura’spractice privacy notice. I may request an additional copy of the privacy notice at any time.
Patient Signature: ______Date: ______
Consent for RX Hub Inquiry
I hereby provide my consent for the Practice of Dr. Kyoko Okamura MD, PC to obtain my Rx History using the SureScripts-RxHub network. I understand that this inquiry will provide my physician with an accounting of my medication history reported by Pharmacy Benefit Managers and retail pharmacies. I also understand that SureScripts-Rx Hub has certified that Rx History Capture follows strict security protocols to align with HIPAA requirements and respect patient privacy. All queries and responses are made automatically through secure system-to-system communications.
Patient Signature: ______Date: ______