Active Life, Inc.

Patient Registration

At Active Life we strive to provide the highest level of quality care and service for your orthotic or prosthetic needs. Active Life's motto of Humanity Through Technology and its promise to be a green company prove themselves once more with the introduction of this online Patient Information form. New advancements in technology allow our facilities to upload all of your supplied information to our network, eliminating the need for countless form and papers.

Prior to filling out this new online form, we invite you to read Active Life's provided HIPAA Notice regarding the privacy of your medical information. Should you have any questions or need assistance, please contact our office at (505) 266 - 1700.

Consent for the Use and Disclosure of
Protected Health Information

By signing below, you give consent to the use and disclosure of your protected health information by Active Life, Inc. and its staff and associates for treatment, payment and healthcare operations and purposes. For further details regarding the privacy of your medical information, please review Active Life's provided HIPAA Notice of Privacy Practices. By signing below you also acknowledge your receiving of this HIPAA Notice on this date. You have the right to review our HIPAA Notice prior to signing this consent agreement.

The terms of this HIPAA Notice may change. If the terms do change, you may obtain a revised copy by contacting our office at (505) 266 - 1700. You have the right to request that Active Life restrict its uses or disclosures of your protected health information that we are otherwise permitted to make for treatment, payment and healthcare operations, although we are not required to agree to these restrictions. However, if Active Life agrees to further restrictions, they are binding on us. Finally you have the right to revoke consent in writing, except to the extent that we have taken action in reliance on it.

Please sign by entering your name and date of birth below. Your Name:       Your Date of Birth: //

 
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