Patient Intake Form
ARYYN PLLC - Primary Care Dominic Keya DNP- FNP-C
510 E Main Ave, Suite D, Puyallup, WA 98372
Ph:253-325-1121 Fax: 425-536-8707
Email: [email protected]
Medical History/Patient Demographics
Home Address:
Allergies & Medications
Social History
Care Team
I authorize the following individuals to inquire and speak on my behalf for ALL healthcare, insurance,and billing issues**
REVIEWS OF SYSTEMS
PAST MEDICAL HISTORY
PAST SURGICAL HISTORY
GYNECOLOGICAL / REPRODUCTIVE HISTORY (FEMALE PATIENTS ONLY)
PREVENTIVE CARE
Immunization
HIGH RISK BEHAVIORS: ALCOHOL, TOBACCO & DRUG USE
SEXUAL ISSUES
NEEDS ASSESSMENT
MENTAL HEALTH –PHQ2 DEPRESSION SCREENING
NCCN DISTRESS SCREENING
FOR CLINICAL USE ONLY
Health Topic
CONSENT FOR RELEASE OF MEDICAL RECORDS to ARYYN PLLC
PLEASE FAX RECORDS TO ARYYN PLLC- (BELOW ADDRESS AND NUMBER)
ARYYN PLLC-510 E Main Ave Puyallup WA 98372 OFFICE FAX: 253-449-8032
PATIENT AUTHORIZATION FOR RELEASE OF INFORMATION
OTHER RELEASE OF INFORMATION
This authorization is valid for (1) one year from the date of signature. I understand that, as a patient I have the right to access my health records at any time. Copies of the records will be obtained with reasonable notice and payment of copying and postage cost. A photocopy or exact reproduction of this signed authorization shall have the same force and effect as the original. I understand that, as a patient I have the right to revoke this authorization at any time via verbal or written request to ARYYN PLLC.
HIPPA NOTICE OF PRIVACY PRACTICES
YOUR PRIVACY RIGHTS
To get an electronic or paper copy of your medical record and ask us to make corrections.
To request confidential communications and state a preferred method of contact (home or office phone, text message, mail or email).
To ask us to limit what we use or share. We will say “yes” unless a law requires us to share that information or if it would affect your care.
To get a list of those with whom we’ve shared information.
To get a copy of this privacy notice.
To choose someone to act for you.
To file a complaint if you feel your rights are violated
OUR USES AND DISCLOSURES
To treat you. We may share it with other professionals who are treating you.
To improve you care, manage your treatment and services.
To your health insurance plan so it will pay for the services provided to you.
To contribute to public health, safety issues and health research.
To comply with State and Federal Laws, including Department of Health and Human Services.
To respond to organ and tissue donation requests.
To collaborate with a coroner, medical examiner, or funeral director.
To respond to lawsuits and legal actions (in response to a court or administrative order, or a subpoena)
OUR RESPONSIBILITIES
To maintain the privacy and security of your Protected Health Information (PHI).
To inform you promptly if a breach occurs that may have compromised the privacy or security of your information.
To follow the duties and privacy practices described in this notice and give you a copy of it.
To not use or share your information other than as described here unless you tell us we can in writing.
WE MAY CHANGE THE TERMS OF THIS NOTICE, AND THE CHANGES WILL APPLY TO ALL INFORMATION WE HAVE ABOUT YOU. THE NEW NOTICE WILL BE AVAILABLE UPON REQUEST, IN OUR OFFICE, AND ON OUR WEB SITE. BY SIGNING THIS FORM YOU ACKNOWLEDGE RECEIPT OF ARYYN PLLC NOTICE OF PRIVACY PRACTICES
ARYYN PLLC - Primary Care Dominic Keya DNP-FNP-C
510 E Main Ave, Suite D, Puyallup, WA 98372
Ph:253-325-1121 Fax: 425-536-8707
Email: [email protected]
CONSENT TO TREAT PATIENT
CONSENT - PERMISSION TO TREAT PATIENT
CONSENT - TO COMMUNICATE WITH MEDICAL PROFESSIONALS/FACILITIES FOR TREATMENT PURPOSES through electronic and digital exchange.
GENERAL RELEASE OF INFORMATION
I acknowledge that records concerning the patient are the property of ARYYN PLLC and are maintained for the use and benefit of ARYYN PLLC and its staff in providing care and treatment to the patient.
I hereby authorize ARYYN PLLC to disclose and receive all or any part of my patient records to physicians, consulting physician(s), or hospital-based physicians for the purpose of treatment through digital electronic exchange.
I further authorize ARYYN PLLC and providing physicians to disclose all or any part of my patient record to any person or corporation which is or may be liable under contract to ARYYN PLLC to me or a family member of mine, for all or part of the clinic charges, including but not limited to, medical service companies, insurance companies, Worker's Compensation carriers, welfare agencies, or my employer, provided such release of information shall be in accordance with state and federal laws and regulations.
CONSENT TO TREAT PATIENT AND RECEIVE MEDICAL CARE FROM ARYYN PLLC.
I recognize that a condition exist requiring medical care and I voluntarily consent to such medical care and Treatment.
I hereby authorize my provider, as provided by law to furnish medical treatment within the scope of his license. I understand that I may be referred to an emergency room or urgent care services if the provider deems this is necessary.
I am aware that the practice of medicine, and the administration of medical care, are not exact sciences and I acknowledge that no guarantees have been made to me as to the result of treatment, examinations or care undertaken with ARYYN PLLC.
Any questions which I have asked have been answered to my satisfaction. I certify that I understand the contents of this form.
ARYYN PLLC - Primary Care Dominic Keya DNP-FNP-C
510 E Main Ave, Suite D, Puyallup, WA 98372
Ph:253-325-1121 Fax: 425-536-8707
Email: [email protected]
CONSENT FOR ACCESSING MEDICATION
HISTORY ELECTRONICALLY AND ARYYN
PLLC TO FILL PRESCRIPTIONS(S)
CONSENT FOR ACCESSING MEDICATION HISTORY ELECTRONICALLY
We have started to use electronic prescriptions and ask for you to grant us permission to access your medication history electronically.
Electronically accessing your medication history allows us to receive critically important information on your current and past prescriptions and to become better informed about potential medication issues. We can use this information to improve safety and quality.
By signing below I give my consent for ARYYN PLLC to access my medication history electronically.
CONSENT FOR ARYYN PLLC TO FILL PRESCRIPTION(S)
ARYYN PLLC - Primary Care Dominic Keya DNP-FNP-C
510 E Main Ave, Suite D, Puyallup, WA 98372
Ph:253-325-1121 Fax: 425-536-8707
Email: [email protected]
ASSIGNEMENT OF BENEFITS / FINANCIAL AGREEMENT
We continually strive to contain costs, while maintaining our commitment to provide you the highest quality of care. The following is a statement of ARYYN PLLC Financial Policy which requires you to read and sign prior to any treatment.
We will bill your insurance company to agreements with your insurance carrier however, you will need to provide complete billing information at the time of your visit(s) including a valid insurance card and valid personal identification. It is your responsibility to notify our office of any changes to your insurance PRIOR to services being rendered.
I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits.
Co-Payments & Insurance Collection
We are required by law, and your health plan, to collect co-payments at the time of service. Patients are financially responsible for services provided and therefore expected to pay at the time of service. We accept Cash, Debit or any of the following credit cards: VISA, MASTER CARD, AMERICAN EXPRESS, DISCOVER and CHECK PAYABLE TO EPIC CARE.
Attorney Fees and Collection Costs
If any legal action is necessary to enforce or interpret the terms of these billing policies, the prevailing party shall be entitled to reasonable attorneys’ fees, costs and necessary disbursements in addition to any other relief to which that party may be entitled. You agree by your signature below to pay all collection costs, including attorneys’ fee on all delinquent payments.
Access the Compassionate, Convenient Care You Deserve
With flexible scheduling, virtual options, and a team that meets you where you are, getting help has never been easier.
Let’s Get You Scheduled
Call, click, or visit — we’re here to make getting care feel simple and stress-free.
510 E Main Ave Suite D
Puyallup, WA 98372
Our Promise to You
To show up with heart, skill, and respect — every time you walk through our doors. You’re not just another patient. You’re a person with a story, and we’re here to support your health, your goals, and your life.
We’re here to serve this community with integrity, compassion, and a commitment to real connection — not just checklists.
_____________________________________
© 2025 Aryyn Integrated Care | Accessibility | Terms & Conditions | Privacy Policy | Powered by DoctoGrow
