Membership Inquiry Membership Inquiry Date* Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone - Cell*Phone - HomeEmail* Would you like someone from Preferred Family Medicine to contact you? Yes, please contact me. No, I'm comfortable submitting my information online. What is your preferred method of communication? email Cell Phone Home Phone Postal Mail Were you a former patient of Dr. Bearfield/Dr. Highley? Yes No Do you give us permission to obtain records from your past/current provider? Yes, I give permission to obtain records No Who is your current doctor and where are they located?Please provide Doctor's name, address, and phone (if you know it)Do you give Preferred Family Medicine permission to obtain your medical records from the above mentioned doctor? YES, please request records NO Section Break Medical Records Request --- I give Preferred Family Medicine permission to request copies of my medical records as allowed by the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services regulations. I request copies of all health records related to my treatment. [Note: HIPAA also allows you to request a summary of your medical records. If you prefer a summary, you should agree to a fee beforehand.] I understand I may be charged a reasonable fee for copying the records, but I will not charged for time spent locating the records. Please mail the requested records to the patient at the above address or directly to Preferred Family Medicine 9120 Double Diamond Pkwy, Reno, NV 89521. . I understand that I may be charged for postage. I look forward to receiving the above records within 30 days as specified under HIPAA. If my request cannot be honored within 30 days, please inform me of this by letter as well as the date I might expect to receive my records*. Sincerely, *Under HIPAA you can be charged a reasonable fee for copying records. You may also be charged for postage if you ask that records be mailed to you. HIPAA allows 30 days for a provider to respond to your request for records, with one 30-day extension for good reason. SignatureWould you like to schedule a Meet & Greet? Yes, take me to the online scheduler. Yes, I'd rather have someone call me to schedule an appointment. No, I don't need a Meet & Greet appointment. Meet & Greets are no-charge casual visits to get acquainted with the practice. No medical advice, consultation, referrals, prescriptions, or orders will be provided at the meet and greet appointment. Would you like to download and/or print the Medical Records Request form? Yes, I'm comfortable downloading / printing the form No, I'd rather you send me the form No, I'll fill out the form in person at the office Δ
