Patient Information

Responsible Party

Insurance Information

Additional Information

Preferred Pharmacy:  
Address:  
Primary Care Provider:

Marital Status:  Single  Married
Widowed  Divorced  Separated

Language:  English  Spanish 

Other: 

Race:  
Ethnicity:

I authorize my provider to review my medication fill history.

I authorize Telehealth visits with my provider.

How would you prefer your reminders? 
 Text     Voice


Assignment of Benefits - Release of Information - Financial Responsibility:

I hereby assign all medical benefits to which I am entitled to Rapid City Medical Center, LLP (RCMC). I further authorize assignee to obtain my plan provisions under ERISA and to act as an authorized representative on my behalf on insurance claims. This order will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information, including medical record copies, necessary to secure payment and to complete disability forms presented to me. In response to any reasonable request for cooperation, I agree to cooperate with RCMC in any attempts by RCMC to pursue such claim, chose in action or right against my insurers and/or employee health care plan. Certain physicians (e.g. pathologists and radiologists) may interpret your test results. These physicians may not be employees or agents of Rapid City Medical Center, LLP and you may, therefore, receive a separate bill from these physicians for their services. A $40 plus tax service charge will be assessed against all non-sufficient funds/closed account checks. I have read and fully understand this agreement.

Patient's Name:
Date:

Signature of Patient or Parent/Guardian of Minor Child:

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Authorization of the Use and Disclosure of Protected Health Information:

As required by the Health Insurance Portability and Accountability Act of 1996, Rapid City Medical Center, LLP may not use or disclose your health information except as provided in our Notice of Privacy Practice without your authorization. Your signature on this form indicates that you are giving permission for the uses and disclosure described herein. You may revoke this authorization in writing at any time by signing and dating a revocation form and returning it to this office.

I, , authorize and request the following persons to receive these disclosures of my health information and elect not to provide a statement of purpose for the use of disclosure for the following persons:

Name:
Relationship:
Phone:
All Health Information  Progress Notes 
Lab Reports  Image Reports  Medications 
Other: 

Name:
Relationship:
Phone:
All Health Information  Progress Notes 
 Lab Reports  Image Reports  Medications 
Other: 

Name:
Relationship:
Phone:
All Health Information  Progress Notes 
Lab Reports  Image Reports  Medications 
Other: 

I understand the I am authorizing Rapid City Medical Center, LLP to make the above disclosure of my health information.

I understand that information disclosed pursuant to this authorization may be re-disclosed to additional parties and no longer be protected. I understand that this authorization will automatically expire one year from the date this form is signed, but that I may revoke this authorization at any time by signing the revocation section of the Use and Disclosure form and returning it to Rapid City Medical Center, LLP. I further understand that any such revocation does not apply to the extent that persons authorized to use or disclose my health information have already acted in reliance on this authorization. I understand that I am under no obligation to sign this authorization. I further understand that my ability to obtain treatment will not depend in any way on whether I sign this authorization or not.

I have received a copy of Rapid City Medical Center, LLP's Privacy Notice.

Patient's Name:
Date:      

Signature of Patient or Parent/Guardian of Minor Child:

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Minor Consent Form:

Children under the age of 14 must be accompanied by an adult for any appointment.

As the Parent/Guardian of a minor, I am authorizing the following:

I authorize to be seen at any Rapid City Medical Center facility without a parent or guardian present.

I authorize a minor, to be seen and/or treated at any Rapid City Medical Center facility when accompanied only by one of the following adults listed:

Name:

Relationship:
 

Name:

Relationship:

I further understand this authorizes the Rapid City Medical Center, LLP to provide medical and/or billing information to various laboratories, radiology or other medical facilities for a test that may become necessary for treatment. I accept responsibility for all physician charges, laboratory fees. This authorization will remain in effect until revoked by me or the minor becomes 18.

Parent/Guardian Name:  
Date:      

Signature of Parent/Guardian of Minor Child:

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