2021 Client Information Update and HIPAA Acceptance Form Leave this field blank First and Last Name Has your contact information changed in the last 12 months? If so please update your information below: Yes No Address (optional) Get location 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 No Credit Card Number (optional) Expiration Date (optional) Month January February March April May June July August September October November December Nothing found 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 27 28 29 30 31 Nothing found Year 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 Nothing found CV Code (optional) Has your insurancechanged in the last 12 months? If so please update your information below: Yes No Contract Number (optional) Group Number (optional) Date of Birth of Client / Patient (optional) Month January February March April May June July August September October November December Nothing found 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 27 28 29 30 31 Nothing found Year 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 Nothing found 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
