Bradley M. Smith, MD
Member, Integrated Health Partners
6910 Douglas Blvd, Ste C
Granite Bay, CA 95746
Patient Registration Form
Last First MI
Street City Zip Code
Phone Number:________________ Birthday____/____/______
Social Security # ____/____/______ Drivers Lic. # ______________
Payment in full at the time of service is required. Acceptable payment includes cash, check,
or charge card. We do not bill insurance directly but can provide billing information to
submit to your insurance carrier for reimbursement upon request.
Delineation of Care
Due to limited office hours and availability, the scope of medical services will be limited to
patient initiated requests for evaluation of specific medical or wellness issues. Ongoing
Primary Care is not possible at this time, and Dr Smith’s current role is limited to
consultations only. Continued use of an established, pre-existing Primary Care provider is
Patient Consent for Use and Disclosure of Protected
I hereby give consent for Bradley Smith, MD to use and disclose protected health
information (PHI) about me to carry out treatment, payment, and health care operations
I have the right to review the Notice of Privacy Practices prior to signing this consent.
Bradley Smith, MD reserves the right to revise his Notice of Privacy Practices at any time.
With this consent Bradley Smith, MD may call my home or alternative location and leave a
message on voice mail or in person in reference to any items that assist the practice in
carrying out TPO, or pertaining to my clinical care.
With this consent, Bradley Smith, MD may mail to my home or other alternative location any
items that assist the practice in carrying out TPO, such as appointment reminder cards,
patient statements, or laboratory results.
By signing this form, I am consenting to allow Bradley Smith, MD 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 in reliance upon my prior consent. If I do not sign
this consent, or later revoke it, Bradley Smith, MD may decline to provide treatment to me.
Signed by:_____________________________________ Date__________________
Signature of Patient/Legal Guardian
Print Patient Name
Print Name of Legal Guardian, if applicable