Please complete this form so our office has accurate registration, communication, and health information. You can review your answers before submitting.
Contact Information
Pharmacy & Emergency Contact
Preferred Pharmacy
Emergency Contact
Responsible Party & Insurance
Is someone other than you financially responsible for your medical care?
Primary Insurance
Do you have secondary insurance?
Past Medical History
Select all conditions you have now or have had in the past.
Select all that apply. Use Other if your condition is not listed.
Surgeries & Hospitalizations
Have you ever had surgery, a procedure, or been hospitalized?
Current Medications
Do you currently take prescription medications, over-the-counter medications, vitamins, supplements, or herbal products?
Allergies
Do you have any medication allergies?
Do you have any food allergies?
Do you have any environmental allergies?
Family History
Please enter significant health conditions in your biological family. “Unknown” is available.
Mother
Father
Siblings
Children
Social History
Tobacco / nicotine use
Alcohol use
Recreational drug use
Medical Care & Financial Responsibility
I voluntarily consent to evaluation, treatment, and routine medical services provided by Kyaw Lyn, MD, and authorized clinical staff. I understand that I may ask questions about my care and may refuse treatment.
I authorize release of information necessary for treatment, payment, and healthcare operations, including submission of claims to my health insurance plan. I understand that I am financially responsible for applicable copayments, deductibles, coinsurance, noncovered services, and balances not paid by my health insurance plan.
Signature
Please sign below. This signature can be reused for later consent sections if you choose.
Notice of Privacy Practices
Please review this privacy notice. It summarizes how the practice may use and share your health information and explains your privacy rights.
Your Information. Your Rights. Our Responsibilities.
This notice explains how medical information about you may be used and disclosed, how you can access that information, and how to exercise your privacy rights.
Your Rights
Inspect or obtain a paper or electronic copy of your medical record.
Ask us to correct health information you believe is incorrect or incomplete.
Ask us to contact you in a specific way or at a specific location for privacy reasons.
Ask us to limit certain uses or disclosures of your information. We will consider your request and will follow it when required by law.
Request an accounting of certain disclosures of your health information.
Receive a paper copy of this notice at any time.
Choose a legally authorized person to act on your behalf.
File a privacy complaint without retaliation.
How We May Use or Share Your Information
Treatment: to provide, coordinate, and manage your care and communicate with other health professionals involved in your treatment.
Payment: to bill health plans or other responsible parties and obtain payment for services.
Health care operations: to run the practice, improve quality, coordinate services, and contact you when necessary.
Other permitted or required uses: for public health and safety activities, health oversight, workers' compensation, certain law-enforcement or legal requirements, and other disclosures permitted or required by law.
Your Choices
For certain uses or disclosures, such as sharing information with family or friends involved in your care or for purposes that require your authorization, we will follow your instructions or obtain written permission when required.
Our Responsibilities
We are required by law to maintain the privacy and security of your protected health information.
We will notify you as required by law if a breach may have compromised the privacy or security of your information.
We must follow the privacy practices described in our current notice.
We will not use or share your information for purposes requiring authorization unless you give permission in writing. You may revoke that permission in writing as allowed by law.
Effective date: August 26, 2026
Privacy Practices Acknowledgment
Authorization to Discuss Health Information
Would you like to authorize us to discuss your health information with another person?
Information allowed
Authorization Signature
Communication Preferences & Authorization
Please indicate how this office may contact you regarding appointments, billing, prescription refills, test results, referrals, and routine healthcare matters.
Telephone call Yes
Voicemail Yes
Text / SMS Yes
Email Yes
Voicemail Preference
Text / Email Preference
Communication Authorization Signature
Telehealth Consent
Telehealth may include medical visits by secure video, telephone, or other electronic communication when you and the clinician are in different locations.
Telehealth may have limitations compared with an in-office visit, including the inability to perform a complete physical examination. A telehealth visit may not be appropriate for every health concern, and an in-person evaluation, urgent care, or emergency care may be recommended. Reasonable steps will be taken to protect the privacy and security of your information; however, electronic communication may carry privacy or technical risks. You may stop or decline telehealth services at any time and request an in-person visit when clinically appropriate.
Telehealth Consent Signature
AI Scribe Consent
Our office may use a HIPAA-compliant AI scribe to assist with documenting your visit. The AI scribe is used to help your provider create a draft medical note. This allows your provider to spend less time typing and more time focused on your care. The service is used in accordance with applicable privacy and security requirements for protected health information.
Your choice is voluntary. Signing this consent is not binding and you have the option to request that it not be used for any particular visit, or change your mind at any time. Declining AI Scribe will not affect your ability to receive medical care from this office.
AI Scribe Consent Signature
Medical Records Authorization
This authorization allows Kyaw Lyn, MD, Inc. to obtain or provide the medical records you select for the purpose you specify.
What would you like us to do?
Records Requested
Purpose
This authorization expires one year from the date signed unless you enter an earlier expiration date.
Medical Records Authorization Signature
Review Your Answers
Please review your information. Use Back to make changes.
Your completed answers will appear here before submission.
Patient attestation Moving forward to submit this questionnaire means you attest that the information you provided is true and complete to the best of your knowledge.
Final Certification Signature
✓
Intake & Consent Forms Completed
Your form is complete. Please return this iPad to the front desk staff.
Patient: DOB: Completed:
Front Desk Only
Save the PDF, verify the upload in Practice Fusion, then clear the form before handing the iPad to the next patient.
