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City: State: Zip Code: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Date of Birth: / / Sex: !Male !Female Email: Social Security Number: - - Marital Status: !Single !Married !Other Employment Status: !Employed !Full Time Student !Part Ti.

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Examples of PHI: Billing information from your doctor. Email to your doctor's office about a medication or prescription you need. Appointment scheduling note with your doctor's office. An MRI scan. Blood test results. Phone records.

Here are specific examples of both physical and electronic PHI that cannot be shared under HIPAA. Healthcare claims. Documentation of doctor's visits. Payment and remittance information. Coordination of healthcare benefits. Claim status. Health claims attachments. Enrollment information in a health plan.

With limited exceptions, the HIPAA Privacy Rule (the Privacy Rule) provides individuals with a legal, enforceable right to see and receive copies upon request of the information in their medical and other health records maintained by their health care providers and health plans.

More Definitions of Patient Information For example, it can include your name, address, phone number, birthdate, and medical record number.

Patient data may include information relating to their past and current health or illness, their treatment history, lifestyle choices and genetic data. It may also include biometric data, which is any measurable physical characteristic that can be checked by machine/computer.

demographic – name, address, contact details and NHS number. administrative – details of appointments, or whether they are waiting for a place in a health and care setting such as a care home or hospital ward. medical – information such as symptoms, diagnosis, weight, medicines, treatments and allergies.

Information Included in Medical Records Patient identification, contact information, and date of birth. Billing and health insurance details. List of current and chronic ailments and diagnoses. Current medications list with dosage.

Patient information forms are documents used by healthcare providers to collect patient information such as contact information, medical history, and insurance information.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232