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Betty H Yao, MD APC
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Acknowledgement Of Receipt Of Notice Of Privacy Practices
Agreement to pay, records release & privacy policy
New Patient Information
Records request form
Updated Patient Information(for existing patients only)
Well Check/Preventative Care
Updated Patient Information(for existing patients only)
New Patient Enrollment
Please fill out all starred items
Full Name
*
Date of Birth
*
Address
*
Home phone:
Cell Phone:
*
Work Phone:
Martial Status
*
Email
*
Primary Insurance
*
Relationship to Suscriber
*
Suscriber Date of Birth
*
Suscriber Social Security Number
*
Member ID Number
*
Group Number
*
Secondary Insurance
Relationship to Suscriber
Suscriber Date of Birth
Suscriber Social Security Number
Member ID Number
Group ID
Emergency Contact-Relationship, Name and Phone Number
*
Signature
*
please type your name
Today's Date
*
Race/Ethnicity:
*
-- Please Select --
Hispanic/Latino
Chinese
African American
Caucasian
Japanese
Asian
Other
* Required field
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