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Includes structured selections for race, ethnicity, marital status, student status, veteran status, and preferred pharmacy. Adds HIPAA consent language authorizing communication with family or chosen contacts, emergency contact handling, and appointment reminder follow-ups via phone, email, text, or secure patient portal, including options to decline or revoke consent.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/new-patient-paperwork-patient-information-hipaa-consent-form/563356/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/new-patient-paperwork-patient-information-hipaa-consent-form/563356.png","ImageObject",442,249,{"name":88,"@type":89},"Fans","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-19","2026-10-12",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What patient details are collected in this new-patient paperwork?","Question",{"text":108,"@type":109},"The form collects name, date of birth, sex, address, phone numbers, email, emergency contact information, preferred pharmacy, and several demographic selections such as race, ethnicity, marital status, and veteran status.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How does the document request HIPAA consent for sharing medical information?",{"text":113,"@type":109},"It explains that medical information may be discussed with listed contacts and that leaving spaces blank indicates a “No Information” choice, limiting releases to others.",{"name":115,"@type":106,"acceptedAnswer":116},"Can a patient refuse or revoke consent for appointment reminders and follow-ups?",{"text":117,"@type":109},"Yes. Patients may refuse use of telephone number and/or email address for reminders and treatment alternatives, and may revoke consent in writing at any time. 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This will also be used for consent to leave you detailed telephone messages at the phone numbers listed below, mail your lab results to your home and also send secure email results to your personal email address once enrolled in MyChart. We are legally not allowed to release medical information to patient family members without the patient’s written consent. The purpose of this document is to protect your privacy.  \nCommunication to Family Members, Spouses or Other:  \nI authorize MMG and medical staff to discuss my healthcare information (which may include history, diagnosis, labs, test results, treatment and other health information) with the contacts listed below. I understand that by leaving spaces blank I am indicating my choice to be a “No Information” and I do not want any information released to anyone else.  \nName:  Relation: Phone:   \nName:  Relation: Phone:   \nEmergency Contact Only: Name:  Relation: Phone:   \nCommunication for Appointment Reminders and Appointment Follow-Ups:  \nMethodist Medical Group (MMG) may need to use your name, phone number, email address (“Contact Information”), and your clinical records to contact you with appointment reminders and information about treatment alternatives, If this communication is made by phone and you are not available, a message will be left on your voice mail or with the","cbCair2Ro5hgm994","https://ap.wps.com/l/cbCair2Ro5hgm994","pdf",1744287,7,"English","# Patient Information\n## Responsible Party/Guarantor Information\n## Primary Insurance\n## Secondary Insurance\n## Primary Care Provider and Referring Provider\n# HIPAA Consent for Communication\n## Communication to Family Members, Spouses or Other\n## Emergency Contact Only\n## Appointment Reminders and Follow-Ups\n## Communication Options and Consent Management","[{\"question\":\"What patient details are collected in this new-patient paperwork?\",\"answer\":\"The form collects name, date of birth, sex, address, phone numbers, email, emergency contact information, preferred pharmacy, and several demographic selections such as race, ethnicity, marital status, and veteran status.\"},{\"question\":\"How does the document request HIPAA consent for sharing medical information?\",\"answer\":\"It explains that medical information may be discussed with listed contacts and that leaving spaces blank indicates a “No Information” choice, limiting releases to others.\"},{\"question\":\"Can a patient refuse or revoke consent for appointment reminders and follow-ups?\",\"answer\":\"Yes. Patients may refuse use of telephone number and/or email address for reminders and treatment alternatives, and may revoke consent in writing at any time. If refused or revoked, it does not affect the treatment provided.\"}]","New Patient Paperwork - Patient Information & HIPAA Consent Form | PDF",1791830158]