Platte County Health Department
 
 
 
Patient Registration Form
 

*
 
*
 
*
 
*
 
*
 
Patient's Gender *



 
*
 
Max 1000 Characters
*
Max 1000 Characters
 
*
 
*
 
*
 
Citizen of United States? *

 
Race *














 
Ethnicity *





 
Are you enrolled in WIC (supplemental nutrition program for women, infants, and children)? *

 
Marital Status *





 
*
 
*
 
*
 
Patient Insurance *


 
If Patient is insured, does the insurance cover (Check all that apply)? *





 
*
 
*
 
*
 
I hereby authorize treatment deemed necessary by the Platte County Health Department Provider. I also authorize the release of my medical records to any Insurance Company with whom I have insurance coverage, or to any company to which I have applied for coverage.
Authorization Granted? *

 
I understand that I am responsible for any amount not covered by insurance, if applicable. *
 
Max 1000 Characters
Platte County Health Department has offered me a copy of its "Notice of Privacy Practices". *

 
I hereby grant permission to the Platte County Health Department to obtain laboratory specimens ordered by the Provider or by the Nursing Staff operating under standing orders. *

 
Please Note: The patient or patient's guardian is responsible for contacting Platte County Health Department for all test results if the results are not received within two weeks. All positive STD test results will be reported to the Missouri Department of Health and Senior Services, and if HIV positive or TB positive, the patient will be offered management services. No prescriptions (refills or new) will be called in after business hours.
All services are confidential. However, in the event that we need to contact you regarding a lab result, may we identify ourselves as the Platte County Health Department?
May we identify ourselves? *

 
*
Max 1000 Characters
 
*
Max 1000 Characters
 

 



Platte County Health Department
Parkville Location: 1201 East Street - Parkville, MO 64152 - Phone: 816.587.5998 - Fax: 816.587.6028
Platte City Location: 212 Marshall Road - Platte City, MO 64079 - Phone: 816.858.2412 - Fax: 816.858.2087
Contact Us |  Powered by MunicipalCMS
E-notify RSS Feeds Twitter Facebook 
 
0