2022 Client Update

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First and Last Name

Has your contact information changed in the last 12 months? If so please update your information below:

Yes

Address (optional)

City (optional)

State (optional)

Zip Code (optional)

Email Address (optional)

Phone Number (optional)

Has your Credit Card / Debit Card/ HSA Card changed in the last 12 months? If so please update your information below:

Yes

Credit Card Number (optional)

Expiration Date (optional)

CV Code (optional)

Has your insurancechanged in the last 12 months? If so please update your information below:

Yes

Contract Number (optional)

Group Number (optional)

Date of Birth of Client / Patient (optional)

PRIVACY POLICY I acknowledge having been offered Bevill and Associates "Notice of Privacy Policies"and their "Client Rights Statement". My rights include the right to see and copy my record, to limit disclosure of my health information, and to request an amendment to my record.These are explained in the Policy. My right to make a complaint and file a grievance has also been explained. I understand that I may revoke in writing my consent for release of my health care information except to the extent Bevill and Associates has already made disclosure with my prior consent. Privacy Policy- https://bevillandassociates.com/privacy/ CONSENT FOR TREATMENT I hereby consent to the treatment provided by Bevill and Associates and its employees or designees. I authorize the services deemed necessary or advisable by my caregivers to address my needs. PLEASE E-SIGN BELOW TO INDICATE THAT YOU HAVE READ AND UNDERSTAND THE ABOVE NOTIFICATIONS AND THAT YOU ARE CONSENTING TO RECEIVE TREATMENT BY Bevill and Associates LLC. Type your First and Last name (E-signature)

I agree that my typed name below will be as valid as a handwritten signature to the extent allowed by local law