Patient Registration Form


The Practice:

(A) Is required by Federal law to maintain the privacy of your Private Health Information (PHI) and to provide you with this Privacy Notice detailing the Practice’s legal duties and privacy practices with respect to your PHI.

(B) Under the Privacy Rule, may be required by State law to grant greater access to maintain greater restrictions on the use or release of your PHI than that which is provided for under federal law.

(C) Is required to abide by the terms of this Privacy Notice.

(D) Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all your PHI that it maintains.

(E) Will distribute any revised Privacy Notice to you prior to implementation.(F) Will not retaliate against you for filing a complaint.

Please click here to review and print Rio Abajo Family Practice’s Notice of Privacy Practices.


This Notice is in effect as of 11-25-2013


By subscribing my name below, I acknowledge receipt of a copy of this Notice, and my understanding and my agreement to its terms.

Patient Registration Form

Patient Information

May we send you text or e-mail messages informing you of appointment statuses or other important information?
Marital Status:
Race & Ethnicity:

Responsible Party or Patient Information

Relationship to Patient:

Emergency Information

If necessary, is this person authorized to make health care decisions for you:
If necessary, are we authorized to disclose or discuss billing or account information with this person:

Primary Insurance Information

Additional Insurance Information

Authorizations and Release of Information

Security Measure
  • Rio Abajo Family Practice - 111 Sandoval Rd SW, Los Lunas, NM 87031 Phone: (505) 565-4355 Fax: (505) 565-4360

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