Follow the steps to complete the form accurately

1. Press the ‘Get Form’ button to access the document. This will allow you to open the form in the appropriate editing tool.
2. Begin by entering your full name in the 'Patient Name' field. This should be the name that matches the identification documents you possess.
3. Fill in your 'Date of Birth' in the specified format. This information helps to verify your identity and maintains accurate medical records.
4. Include your 'Chart Number' in the designated area. This number is internally used by Piedmont HealthCare to track your medical history and treatment.
5. If available, enter your 'Account Number'. This field is optional, but it can assist with administrative processes if applicable.
6. In the 'Physician' field, write the name of the healthcare provider you are seeing. This connects the document directly to your specific treatment.
7. Sign the document in the space provided, indicating that you have received a copy of the 'Patient Privacy Rights Notice'. Your signature serves as acknowledgment of understanding your rights.
8. Record the 'Date' and 'Time' of signing the form to establish a timeline for your acknowledgment.
9. If you are completing this form on behalf of the patient, please include your 'Relationship to patient' so that it is clear who authorized the signature.
10. To authorize information release, fill in the physician's name and the names of individuals to whom information can be disclosed. Each name should be completed separately along with the date.
11. Review the information provided for accuracy, and ensure all necessary sections are filled out completely.
12. After verifying all details, save your changes, and you can choose to download, print, or share the completed form as needed.

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