Adult Annual Update Form

Patient Demographics

Thank you for choosing our office! In order to serve you properly, we need the following information. All information will remain confiential.

First Name*

Last Name*

Date of Birth*

SSN*

Gender*

Male
Female

Physical Address*

Street Address Address Line 2 City State ZIP Code

Is your mailing address different from your physical address?*

Yes
No

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Cell Phone (if different)

Email Address*

We will NOT use your email address for solicitation. It is for communication purposes via our patient portal only.

Preferred method of contact

Cell Phone
Home Phone
Text
Email
Mail

Marital Status

Are you a minor?*

Yes
No

Minor Information

Please list name of parent / guardian*

Parent / Guarantor Date of Birth

Parent / Guardian's phone (if different)*

In Case of Emergency

Patient or Parent's Employer*

Work Phone*

Emergency Contact Name*

Emergency Contact Home Phone*

People who can call and receive patient medical information: (for confidentiality purposes)*

Name	Relationship	Phone

Please select your primary medical provider in this office?

Primary Insurance*

Name of Insured*

Birth Date of Insured*

Relationship to Patient*

SSN of Insured*

ID Number*

Group Number*

Deductible / Co-Pay Amount

Deductible	Co-Pay

Do you have secondary insurance information you can submit?*

Yes
No

Secondary Insurance*

Name of Insured*

Birth Date of Insured*

Relationship to Patient*

SSN of Insured*

ID Number*

Group Number*

Deductible / Co-Pay Amount

Deductible	Co-Pay

I request that payment of authorized Commercial Insurance/Medicaid/Medicare/Medicare supplement benefits be made either to me, or on my behalf to Minidoka Medical Center/Rural Health Clinic for any services furnished me by that physician/supplier. I authorize any holder of medical information about me to release to my insurance, or Centers for Medicare and Medicaid Services, and its agents any information needed to determine these benefits or the benefits payable for related services.

Consent to Treat*

I authorize the release of any information concerning my (or my child’s) health care, advice, and treatment provided for the purpose of evaluating and administering claims for insurance benefits.

Patient Rights and Responsibilities

WHEN YOU ARE SEEN BY AN EMPLOYEE OR CONTRACTOR OF THE CLINIC, YOU HAVE THE RESPONSIBILITY TO:

Treat the staff with consideration, respect and dignity.
Understand that your life-style does affect your health.
Take an active part in your health care.
Follow the agreed upon treatment plan. If you choose or are unable to follow the treatment plan, it is your responsibility to inform the Medical Provider.
Observe facility rules and regulations that are for the safety and consideration of all patients and staff.
Provide accurate and complete information about present complaints, past illnesses, hospitalizations, medications, advance directives (living wills or durable power of attorney), and other matters relating to your healthcare.
Report whether you understand a contemplated course of action and what is expected of you.

WHEN YOU ARE SEEN BY AN EMPLOYEE OR CONTRACTOR OF THE CLINIC, YOU HAVE THE RIGHT TO:

Be treated with consideration, respect and dignity;
Have the confidentiality of your medical information protected, to have privacy act regulations enforced, and to have these areas of confidentiality explained to you in language you can understand;
Have privacy during case discussion, counseling & treatment;
Review your records in the presence of a healthcare professional;
Know the name and qualifications of staff providing your care;
Know your diagnosis, health problems, test results, the potential advantages and risks of treatment or procedures in language you can understand;
Expect that all services, treatment and counseling techniques will take place with your informed consent;
Participate in referral planning;
Have access to the patient comment procedure;
Refuse to participate in research.
Have another individual present in the exam room with you, if you so desire.

I have read the copy of Patients Rights and Responsibilities*

I agree

Release of information, treatment, privacy rights, and messages

Consent for Photograph*

I consent to allow photography of myself for identification purposes, and for purposes of improving my medical care documentation (ie: wounds, lesions, etc)..

Authorization for Treatment*

I hereby authorize, Minidoka Medical Center, and any assistants or associates that may be designated, to perform medical and hospital care to the above named patient

Privacy Practices / Discrimination*

I have received/or declined copy of the Notice of Privacy Practices, and I have been provided an opportunity to review this entire document. Minidoka Memorial Hospital and Medical Center will not discriminate against a patient because of race, color, national origin, religion, ability to pay, or because a patient is covered by a program such as Medicaid or Medicare. If you feel you are a victim of discrimination you have the right to file written complaint to the Compliance Officer. Forms are available in the business office.

Consent to use of answering machine and/or voicemail messaging/email:*

I hereby consent to the use of my answering machine and/or voicemail for the purpose of relaying important information regarding my treatment or care, including, but no limited to confirmation of appointments, changes in medication, results of lab tests, special instructions for testing procedures. I also consent to members of my family receiving this information in my absence. This consent will remain in effect until I rescind the consent in writing.

Signature

Phone*

Today's Date*

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Patient Demographics

Minor Information

In Case of Emergency

Patient Rights and Responsibilities

Release of information, treatment, privacy rights, and messages

LATEST NEWS

OUR ADDRESS

1224 8th Street
Rupert, Idaho
83350

(208) 436-0481

Notice of Privacy Practice
Aviso de Prácticas de Privacidad
Price Transparency

LATEST NEWS

OUR ADDRESS

1224 8th Street
Rupert, Idaho
83350

(208) 434-8340

Notice of Privacy Practice
Aviso de Prácticas de Privacidad

OUR ADDRESS

1224 8th Street
Rupert, Idaho
83350

(208) 436-0481

Notice of Privacy Practice
Aviso de Prácticas de Privacidad