Patient Intake Form
Please Complete & Submit The Following Form
HIPAA Privacy Rule of Patient Authorization Agreement
Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))
I understand that as part of my healthcare, this Practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:
a basis for planning my care and treatment;
a means of communication among the health professionals who may contribute to my health care;
a source of information for applying my diagnosis and surgical information to my bill;
a means by which a third-party payer can verify that services billed were actually provided;
a tool for routine health care operations such as assessing quality and reviewing the competence of health care professionals.
I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures.
I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this Practice’s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.
Privacy Rule of Patient Consent Agreement
Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))
I understand that:
I have the right to review this Practice’s Notice of Information practices prior to signing this consent;
that this Practice reserves the right to change the notice and practices and that prior to implementation will mail a copy of any notice to the address I’ve provided, if requested;
I have the right to object to the use of my health information for directory purposes;
I have the right to request restrictions as to how my Protected Health Information may be used or disclosed to carry out treatment, payment, or healthcare operations, and that this Practice is not required by law to agree to the restrictions requested;
I may revoke this consent in writing at any time, except to the extent that this Practice has already taken action in reliance thereon.
Consent to Obtain Patient Medication History
Patient medication history is a list of prescriptions that healthcare providers have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history.
The collected information is stored in the practice electronic medical record system and becomes part of your personal medical record. Medication history is very important in helping providers treat your symptoms and/or illness properly and avoid potentially dangerous drug interactions.
It is very important that you and your provider discuss all your medications in order to ensure that your recorded medication history is 100% accurate. Some pharmacies do not make prescription history information available, and your medication history might not include drugs purchased without using your health insurance.
Also over‐the‐counter drugs, supplements, or herbal remedies that you take on your own may not be included.
I give my permission to allow my healthcare provider to obtain my medication history from
my pharmacy, my health plans, and my other healthcare providers.
By signing this consent form you are giving your healthcare provider permission to collect and share your pharmacy and your health insurer information about your prescriptions that have been filled at any pharmacy or covered by any health insurance plan. This includes prescription medicines to treat AIDS/HIV and medicines used to treat mental health issues such as depression.
Aryyn Integrated Care
253-325-1121
Patient Consent for Use and Disclosure
of Protected Health Information
I hereby give my consent for Aryyn Integrated Care (the Practice) to use and disclose my protected health information (PHI) to perform treatment, payment and health care operations (TPO).
With this consent, the Practice may call me or email me to my home or other alternative location and leave a message by voice, email or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and anything pertaining to my clinical care, including laboratory test results.
With this consent, the Practice may mail to my home or other alternative location any items that assist the practice in performing TPO, such as appointment reminder cards, patient statements and anything pertaining to my clinical care as long as they are marked “Personal and Confidential.”
By signing this form, I am consenting to allow the Practice to use and disclose my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the Practice has already made disclosures upon my prior consent. If I do not sign this consent, or later revoke it, the Practice may decline to provide treatment to me.
Insurnance Card
Medical History
Family History
Social History
If Married...
Females, Only
Review of Systems
Do you know or have you had any problems related to the following systems?
Constitutional
Genitourinary
Eyes
Musculoskeletal
Ear/Nose/Throat
Integumentary (Skin)
Cardiovascular
Neurological
Psychological
Respiratory
Endocrine
Gastrointestinal
Hematologic/Lympatic
Sexual History
Allergic/Immunologic
Health Screenings
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510 E Main Ave Suite D
Puyallup, WA 98372
Our Promise to You
To show up with heart, skill, and respect — every time you walk through our doors. You’re not just another patient. You’re a person with a story, and we’re here to support your health, your goals, and your life.
We’re here to serve this community with integrity, compassion, and a commitment to real connection — not just checklists.
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