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- Afghanistan
- Albania
- Algeria
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- Angola
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Care Preferences
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- Yes
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- A long time ago
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- Yes
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Insurance
Accident
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Health History & Lifestyle
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HIPAA Release of Information (Contacts)
Records Request
Photo/Video Consent & Cancellation Policy
Privacy Notice, HIPAA Acknowledgment & Patients Rights Agreement
Your information will be used by Full Swing Healthcare for treatment, billing and healthcare operations only. We safeguard your personal health information in accordance in HIPPA and will not share it without your authorization unless required by law.
By completing this form, you acknowledge that you have received or will receive our Notice of Privacy Practices and authorize us to use your information for its intended purpose. You understand you may request access to your health information, request amendments, and receive an accounting of disclosures as described under HIPAA regulations.
By typing my full name below, I understand and agree that my typed name shall be treated as my legal signature. I consent to the use of electronic signatures for this document and confirm that the information provided is true and accurate to the best of my knowledge.