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Z Med Clinic

ZMed Clinic Providers, PA and Z Med Spa
d/b/a Z Med Clinic

(HIPAA) Health Insurance Portability and Accountability Act
Privacy Compliance Patient Questionnaire
Compliance Privacy Rules Notification

All patients have the right to have confidential care provided.  All information, medical or social, whether written, spoken, electronic, or computer generated, is to be held in strict confidence (please refer to the  Z Med Clinic Compliance Privacy Rules Notice).  Please fill out this information in order for Z Med Clinic to provide better service.

If your lab testing is normal, our office may send you a private card notice. If anything is abnormal, our office will notify you by telephone. If you are not notified, please do not assume everything is normal. Call our office if it has been over two or three weeks since your test and you have not been notified.

1.  Please list the family members or other persons, if any, whom we may inform about your general medical condition and your diagnosis.  Please list complete name and phone number.

Name:    Name:   
Phone Number:     Phone Number:   

2.  Please type the address of where you would like your billing statements and/or correspondence from our office to be sent if other than your home.

Address:    Address:   
City:    City:   
State:    State:   
Zip Code:    Zip Code:   

3.  Please type the telephone number, if any, where you want to receive calls about your appointments, lab and x-ray results, or other healthcare information if other than your home phone number.

Phone Number:   
  

4. Can confidential messages (including appointment reminders) be left on your home answering machine or voice mail?    
5.  If you do not have voice mail, can a message asking you to call us about results or to confirm your appointment be left at your place of employment?   
6.  Can confidential messages (including appointment reminders) be sent to you by text message to a phone number designated by you?
   If yes, please enter cell phone number:  (xxx-xxx-xxxx)
7. Are you moving in the next 30 days, or changing your home or work phone numbers?  If so, please notify our office as soon as you have your new information in order for us to contact you with any test results, or provide the information below:

New Address:   
City:   
State:   
Zip Code:   
Effective date:   
New Phone Number:   
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