Patient Intake Form Template for United States

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Key Requirements PROMPT example:

Patient Intake Form

"Need a Patient Intake Form for my new dental practice opening in March 2025, focusing on pediatric patients and ensuring comprehensive collection of guardian information and dental history, while maintaining HIPAA compliance."

Document background

The Patient Intake Form serves as the primary document for gathering crucial patient information in U.S. healthcare settings. This document is typically used during a patient's first visit or when updating records, collecting comprehensive information about the patient's demographics, medical history, insurance details, and emergency contacts. The form must comply with federal regulations including HIPAA, ADA, and state-specific healthcare laws. It provides the foundation for creating the patient's medical record and ensures the healthcare provider has necessary information for proper care delivery and legal compliance.

Suggested Sections

1. Patient Demographics: Basic patient information including name, DOB, address, contact details

2. Emergency Contact Information: Primary and secondary emergency contacts

3. Insurance Information: Primary and secondary insurance details

4. Medical History: Past medical conditions, surgeries, medications

5. HIPAA Acknowledgment: Patient acknowledgment of privacy practices

6. Consent for Treatment: General consent for medical treatment

Optional Sections

1. Language Preference: Required for facilities serving diverse populations - captures patient's preferred language for communication

2. Advanced Directives: Optional for adult patients, especially in primary care settings - documents patient's medical care preferences

3. Research Participation: For use in academic medical centers or research facilities - contains consent for research participation

Suggested Schedules

1. Notice of Privacy Practices: Detailed HIPAA privacy information

2. Financial Policy: Payment terms and insurance processing information

3. Patient Rights and Responsibilities: Outline of patient rights and responsibilities under care

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare
Mental Health
Dental
Allied Health

Relevant Teams

Front Office
Medical Records
Compliance
Legal
Information Technology

Relevant Roles

Medical Office Manager
Healthcare Administrator
Compliance Officer
Front Desk Coordinator
Medical Records Manager

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Electronic Intake Forms

Legal framework for electronic intake forms compliant with US federal and state regulations, governing digital information collection and processing.

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Authors

Alex Denne

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