Established Patient Update Form (July 2025)
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  • General Information

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  • Notice to see a minor child: Anyone under the age of 18 years of age cannot be seen without a parent or guardian present, unless they are an emancipated minor. In the case that the parent or legal guardian cannot attend the appointment for the child, the parent or legal guardian must provide us with a signed and dated document that permits the minor child to be seen with another representative of the parents or guardian before the patient's scheduled appointment. Photo identification will be required for the representative.

    Documentation and be provided on the form below.

  • I/We         and/or          the parent(s) of          , a minor, do consent to and authorize Oliverio Medical Corporation and its healthcare providers to administer all diagnostic and treatments that may be considered, advisable, and/or necessary in their judgment.

    I/We hereby authorize Oliverio Medical Corporation to release any information acquired in the course of the examination and treatment to the accompanying adult in my/our absence. We also hereby authorize payment directly to Oliverio Medical Corporation of any insurance benefits otherwise payable to me.

    During our absence, I/We hereby consent to have         
    the minor's         to bring him or her, my child, a minor, to Oliverio Medical Corporation for medical treatment by their healthcare providers.

       

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  • Emergency Contacts

  • Permission to Disclose Relevant Health Information

  • Under federal law (HIPAA), I understand that my health information is protected and may not be disclosed without my permission. Law enforcement and court orders are two exceptions to this requirement. At your initial visit, you will receive a PATIENT PRIVACY, RIGHTS, AND RESPONSIBILITIES NOTICE. If you would like a new copy, please let us know. The Privacy Notice Acknowledgement can be requested physically or will be on the next page of this online form for your review.

     

    PLEASE NOTE: Relevant medical information will only be released to you (the patient) unless permission is given to a listed person, regardless of the relationship between you and that person; this includes spouses, children, or other family members.

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  • Please fill out if you said YES to the above.

    I give permission for Oliverio Medical Corporation to release my relevant medical information to the following individuals on my behalf:

  • Terms and Conditions

    Please review and acknowledge the documentation below.
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