BNG New Patient Registration Form (July 2025)

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.
Do you permit Oliverio Medical Corporation to release relevant medical information?*

NO: I do not permit for Oliverio Medical Corporation to disclose relevant medical information.YES: I do permit for Oliverio Medical Corporation to release relevant medical information on my behalf.
Signature (draw with mouse)*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
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:
Contact #1
Contact #2
Contact #3
Contact #4

	Marijuana	Cocaine	Opioids	Methamphetamines	PCP	Hallucinogens (i.e. LSD, mushrooms)
CURRENT USE
FORMER USE

General Information