Patient Information Update Form Signature: Type or Draw × Type Mode On. Draw Mode On. Type It Draw It Clear CONFIDENTIAL PATIENT INFORMATION SHEET PATIENT INFORMATION LAST NAME:FIRST NAME:MI:RESPONSIBLE PARTY (IF A MINOR):ADDRESS:APT. #:CITY:STATE:ZIP:HOME PHONE#:WORK PHONE #:DATE OF BIRTH:SEX: M F SOCIAL SECURITY #: SINGLE MARRIED WIDOW SEPARATED DIVORCED OTHER PRIMARY INSURANCE INSURANCE COMPANY:ADDRESS:POLICY#:PHONE #:POLICY HOLDER:DATE OF BIRTH: RELATIONSHIP TO INSURED: SELF SPOUSE CHILD OTHER EMERGENCY CONTACT:RELATIONSHIP:ADDRESS:CITY, STATE, ZIP:PHONE #: H W C ALTERNATE #: H W C Release of Information This authorization will permit South Atlanta Neurology and Spine Clinic to release any and all information pertaining to my health and well-being. I hereby authorize South Atlanta Neurology and Spine Clinic to release my information to any insurance company for the purpose of determining eligibility or for payment of benefits. I authorize South Atlanta Neurology and Spine Clinic to disclose protected health information (PHI) about me to the following person/people: Name:Relationship:Name:Relationship: This authorization will expire on:(There must be a date of expiration, ex. 10-100 years, divorce, death, etc.) I understand that when my PHI is used or disclosed pursuant to this authorization, it may be subject to disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to: South Atlanta Neurology and Spine Clinic, 518 Eagles Landing Parkway, Stockbridge, GA 30281. Patient Signature:Date