HIPAA

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Hilltop Medical Clinic West ♦ 2123 Eureka Way ♦ Redding, Ca  96001 ♦ (530)246-4629 I understand that under the Health Insurance Portability and Accountability Act of 1996, (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used for the following: ● To conduct, plan, and direct my treatment and follow-up among multiple healthcare providers who may be involved in that...

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Returning Patients

First Name Last Name Birth Date Phone Number Reason for Visit Has your address changed since last visit? Yes No If a balance is owed at either clinic, you will be notified when you arrive and will be expected to pay before you are seen. Deductibles and co-pays are due at time of treatment.

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Registration

ATTENTION PLEASE:      YOU CANNOT SIGN IN  ONLINE BEFORE 8AM OR AFTER 4PM WEEKDAYS, OR BEFORE 9AM OR AFTER 4 PM ON WEEKENDS! Last Name First Name MI SEX Mailing Address Street APT# City State ZIP Birthdate: - Month - January Febuary March April May June July August September October November December - Day - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26...

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PROCESSING