New Patient Registration & Hipaa Release

Patient Name

Are You: Male Female

Check if same as patient’s address

American Indian or Alaska Native Asian Native Hawaiian Black or African American White Other Pacific Islander Prefer not to answer

Hispanic/Latino Non-Hispanic/Latino Prefer not to answer

English Spanish French Indian (includes Hindu & Tamil) Other

Policy holder information, if not same as patient:

Check if same as patient’s address

Patient Name

Do you have a Living Will?: Yes No

Do you have an Advance Directive?: Yes No

If you answered yes to either, please provide us a copy.

Emergency Contact:

I authorize Medical Associates of Brevard LLC to discuss my healthcare information with the below:

Home Phone Cell Cell Text Work Phone Mail Mail None With the person(s) authorized above

I authorize Medical Associates of Brevard LLC to leave a detailed message which may contain personal health information via:

Home Phone Cell Cell Text Work Phone Mail Email None With the person(s) authorized above

Note that authorization to contact via phone includes authorization for us to leave a message on your voicemail or answering machine.

Your HIPAA contact information will be recorded as you have indicated here. You will be asked to electronically sign to confirm this information.

I agree and acknowledge, that I will be coming 30 minutes prior to my scheduled appointment.

I agree, that I may have to fill in & submit other document/s related to my new patient application (Dr. Mitra staff will be providing those).

Patient Resources