New COVID-19 Hours ! Mon-Fri 8:00am - 6:00pm Sat & Sun CLOSED

New Patient Form

Demographics


James E. Lynch MD, Heather Headrick APRN-CNP,
Traci Lambert APRN-CNP, Gary Seymore APRN-CNP


200 W. Britton Rd  |  Oklahoma City, OK 73114  |  PO Box 14740  |  Oklahoma City, OK 73113
Telephone: 405-755-8000  |  Facsimile: 405-755-8001 |  www.charterclinic.com


PATIENT INFORMATION

Sex:
Address *
Address
City
State/Province
Zip/Postal
Preferred form of contact? *
May we text you? *
May we leave a voicemail? *
Race *
Ethnicity: *
Marital Status? *
Children: *

EMERGENCY

Phone # Type

HEALTH INSURANCE

What type of Insurance do you have?

PAST MEDICAL HISTORY

Family History:

Food Allergies: *
Stroke: *
Heart Attack: *
Migraines: *
Diabetes: *
Seizures: *
Cancer: *
Bleeding Problems: *
Have you had any recent preventative care? *
Are you or could you be pregnant? *
Do you have any dietary issues? *
Do you have any developmental issues? *
Do you smoke? *
Do you drink alcohol? *
Do you use recreational drugs? *
Do you have any advanced directives? *
Are you currently taking any medications? *

MEDICATION LIST:

ALLERGIES

Do you have any Drug Allergies? *
Do you have any Food Allergies? *
Do you have any Environmental Allergies? *

MINOR AUTHORIZATION

attest that I am the custodial parent or legal guardian of the above- referenced minor and hereby authorize The Charter Clinic to administer treatment as it so deems necessary to the minor.

AUTHORIZATION TO RELEASE INFORMATION TO FAMILY/FRIENDS OR OTHERS

I authorize The Charter Clinic to release any information regarding my treatment; including lab results, x-rays, and medical records, to the following individuals/entities (The Charter Clinic may not release information or records to individuals/entities unless you identify them here):

Repeater

The Charter Clinic will use my home phone and primary address supplied during registration to contact me regarding my treatment; including lab results, x-rays, and medical records. I will ensure this information is up to date at every visit.

This digital signature(e-signature) will serve as your signed signature.
We are permitted and/ or required by law to make certain other uses and disclosures of your personal health information without your consent or authorization for the following:

  • Any purpose required by law;
  • Public health activities, such as required reporting of disease, injury, birth and death, or required public health investigation;
  • If we suspect child abuse or neglect; if we believe you to be a victim of abuse, neglect, or domestic violence;
  • To the Food and Drug Administration to report adverse events, product defects, or to participate in product recalls;
  • To your employer when we have provided health care to you at the request of your employer;
  • To a government oversight agency conducting audits, investigations, or civil or criminal proceedings;
  • Court of administrative ordered subpoena or discovery request;
  • To law enforcement officials as required by law to report wounds and injuries and crimes;
  • To coroners and/or funeral directors consistent with law;
  • If necessary to arrange an organ or tissue donation from you or a transplant for you;
  • If you are a member of the military, we may also release your personal health information for national security or intelligence activities; and
  • To workers’ compensation agencies for workers’ compensation benefit determination.

RIGHTS THAT YOU HAVE REGARDING YOUR PERSONAL HEALTH INFORMATION:

    • Access to Your Personal Health Information: You have the right to copy and/or inspect much of the personal health information that we retain on
      your behalf. All requests for access must be made in writing and signed by you or your legal representative. You may obtain a “Patient Access to
      Health Information Form” from the front office person. You are entitled to one free copy of your personal health information. If you request additional
      copies you may be charged a nominal fee for copying and postage.
    • Amendments to Your Personal Health Information: You have the right to request in writing that personal health information that we maintain
      about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. All
      amendment requests, must be in writing, signed by you or your legal representative, and must state the reason for the amendment/correction
      request. If an amendment or correction request is made, we may notify others who work with us if we believe that such notification is necessary. You
      may obtain an “Amendment Request Form” from the front office person or individual responsible for medical records.
    • Accounting for Disclosures of Your Personal Health Information: You have the right to receive an accounting of certain disclosures, made by
      us, of your personal health information after April 14, 2003. Requests must be made in writing and signed by you or your legal representative.
      “Accounting Request Forms” are available from the front office person or individual responsible for medical records. The first accounting in any 12-
      month period is free; you will be charged a fee for subsequent accounting you request within the same 12-month period. You will be notified of the
      fee at the time of your request.
    • Restrictions on Use and Disclosure of Your Personal Health Information: You have the right to request restrictions on uses and disclosures of
      your personal health information for treatment, payment, or health care operations. We are not required to agree to your restriction request, but will
      attempt to accommodate reasonable requests when appropriate. We retain the right to terminate an agree-to restriction if we believe the termination
      is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing or orally, any
      agreed-to restriction by sending such termination notice to the individual responsible for medical records.
      Complaints: If you believe your privacy rights have been violated, you can file a complaint in writing with the Clinic Director/Privacy Officer at The Charter Clinic
      at 200 W. Britton Ave, Oklahoma City, OK 73114. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services in
      Washington D.C. in writing within 180 days of a violation of your rights. There will be no retaliation for filing a complaint.

AUTHORIZATIONS:

    1. Authorization to release medical information
      I hereby authorize the release of medical and medication information pertinent to my care to the Doctors, Nurse Practitioners, Physician Associates,
      Medical Assistants, and Office Staff at The Charter Clinic.
    2. Privacy notice Acknowledgment
      With my signature below, I acknowledge that I have read and received a copy of The Charter Clinic Notice of Privacy Practices.
    3. Informed Consent
      I have been informed that I have the right to refuse any form of treatment. I understand the nature of treatment, and have been informed of the risks
      and possible consequences involved with this treatment.
    4. Financial Responsibility
      I understand that I am fully responsible to The Charter Clinic for all charges I incur in this office, including deductible, co-pays, co-insurance, and all
      charges not covered by insurance, as detailed in The Charter Clinic’s Financial Policy, available upon request.
    5. Consent to Treat
      I understand that by signing the authorization below I am allowing for the Doctors, Nurse Practitioners, Physician Associates, Medical Assistants,
      and Office Staff to treat me and discuss the details of my treatment with me as well as with each other. I also understand that the staff of The Charter
      Clinic may utilize the Prescription Monitoring Program service to help decide the best steps of care for me.
      I agree to the authorizations listed above and I certify that all the information contained in this booklet is complete and true to the best of my knowledge.
This digital signature(e-signature) will serve as your signed signature.