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    Patient Confidentiality Sign-In Sheet
    with Record Copy

    English / Spanish Available

    These are three of the best systems available
    Sample Available - Please call Customer Service

    The Health and Human Services Patient Privacy Act
    regarding patient health information (PHI) establishes
    requirements and guidelines for protection of patient
    records in the health care system.

    Information as it applies to
    "the Health and Human Services Patient Privacy Act"
    can be reviewed on the United States Department of
    Health and Human Services web site
    http://hhs.gov/ocr/hipaa/

    The use of a Patient Sign-in Sheet is still permissible.
    However the Privacy Act prohibits "Reason for Visit"
    Information to be available to public view.

    Is your office "hipaa" compliant?
    Link to "hipaa" privacy rules

    Landscape clipboard
    FREE CLIPBOARD with First Order
    (see below)

    The Micro Format Document Security Paper Division's PATIENT CONFIDENTIALITY SIGN IN LOG
    hides not only the "Reason for Visit" Information but the "PATIENT'S NAME" as well.

    PATIENT CONFIDENTIALITY
    SIGN-IN SHEETS - PSL20
    Shingled Set Version

    Twenty (20) shingled tickets printed on bond sheets are glued to a two-part carbonless set. Tickets are consecutively numbered on the body of the ticket and on a stub that is given to the patient. This allows the office staff to call the patient by either name or by number. Nothing transfers to the first part of the set, but does transfer to the second part - which is not visible to the patient. Information becomes a permanent record of patients who have visited the office that day.

    Shingled Set Patient Sign-In Form
    Each set includes 20 sign-in tickets.

    Shingled Tickets, numbered in two positions, record the patient's registration information. The ticket is filled out by the patient and detached from the booklet. The patient retains the numbered stub and gives the ticket to the receptionist. This allows the health care provider the option of calling in patients by their name OR by their number on the stub receipt.

    As the registration progresses, as patients sign in, they cannot view the names above theirs due to the block out of information on page one of the two part log sheets. The second journal page records each line entry of registration. The two journal sheets are spot glued on both sides to prohibit viewing of the logged information.

    This is a SECURE Document

    Unlike other forms, special security features built into the Micro Format Patient Confidentiality Sign-In Log give both the health care professionals and the patient privacy while transacting the medical information process during office visits.

    Item# PSL20
    Shingled Set Patient Sign-In Form
    Each "Sign-In Sheet" includes
    20 sign-in tickets

    PSL20
    50 sets ~ $125.00
    PSL20
    100 sets ~ $205.00
    PSL20
    200 sets ~ $390.00
    ($195.00 per 100)
    PSL20
    400 sets ~ $740.00
    ($185.00 per 100)
    PSL20
    600 sets ~ $876.00
    ($169.00 per 100)

    PATIENT CONFIDENTIALITY
    SIGN-IN SHEETS - CSL-20
    Label Version

    The label version is a two-part set with part one being label material. The second part is a bond sheet with a sheet of carbon paper in between. There are slits below each line that allow office staff to remove each entry as the patient signs in. The strip is then attached either to the patient's chart or to the sheet outlining the reason for the patient's visit. All of the information transfers to the second part of the form and becomes a permanent record of patients who have visited that day.

    Patient Sign-In Log

    Each set contains 20 numbered strips.

    Label strips, numbered in two positions. record the patient's registration information. The strip is filled out by the patient and removed from the top page. The patient retains the small numbered stub and gives the long strip to the receptionist. This allows the health care provider the option of calling in patients by their name OR by their number on the stub receipt.

    As the registration progresses, as patients sign in, they cannot view the names above theirs since the entire registration label has been removed from the top page. The second journal page records each line entry of registration. The label sheet and the journal sheet is glued on both sides to prohibit viewing of the logged information.

    This is a SECURE Document

    The Special security features are built into the Micro Format Confidential Sign-In Log give both the health care professionals and the patient privacy while transacting the medical information process during office visits.

    Item# CSL20
    Patient Sign-In Form
    Each "Sign-In Log" includes
    20 sign-in label strips

    CSL20
    200 sets ~ $165.00
    CSL20
    500 sets ~ $350.00
    CSL20
    1000 sets ~ $500.00

    Patient Sign-In Form with record copy
    Bi-Lingual PATIENT CONFIDENTIALITY SIGN-IN SHEETS
    (ENGLISH / SPANISH)
    Forma Confidencial de Registro

    Free Clipboard with FIRST order

    This Version is EXACTLY THE SAME as CSL-20 EXCEPT all headings are printed in both English and Spanish.
    This version is a two-part set with part one being label material. The second part is a bond sheet with a sheet of carbon paper in between. There are slits below each line that allow office staff to remove each entry as the patient signs in. The strip is then attached either to the patient's chart or to the sheet outlining the reason for the patient's visit. All of the information transfers to the second part of the form and becomes a permanent record of patients who have visited that day, exactly the same as English only CSL-20 version.

    Bi-Lingual English-Spanish Patient Sign-In Form

    Each set contains 20 numbered strips.

    Label strips, numbered in two positions. record the patient's registration information. The strip is filled out by the patient and removed from the top page. The patient retains the small numbered stub and gives the long strip to the receptionist. This allows the health care provider the option of calling in patients by their name OR by their number on the stub receipt.

    As the registration progresses, as patients sign in, they cannot view the names above theirs since the entire registration label has been removed from the top page. The second journal page records each line entry of registration. The label sheet and the journal sheet is glued on both sides to prohibit viewing of the logged information.

    This is a SECURE Document

    The Special security features are built into the Micro Format Confidential Sign-In Log give both the health care professionals and the patient privacy while transacting the medical information process during office visits.

    English/Spanish Version in stock
    Ready to Ship

    Item# CSL20-SP
    Spanish Patient Sign-In Form
    Each "Sign-In Log" includes
    20 sign-in label strips

    CSL20-SP
    200 sets ~ $165.00
    CSL20-SP
    500 sets ~ $350.00
    CSL20-SP
    1000 sets ~ $500.00
    Special Offer ...
    FREE LANDSCAPE CLIPBOARD
    with your FIRST BULK ORDER of
    200 or more sets CSL20-SP
    Bi-Lingual Patient Sign-In Forms

    Click to Add FREE CLIPBOARD
    to your order

    Patient Sign-In clipboard
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    Self Expiring Visitor Badge


    Micro Format Customer Service - (800)333-0549

    Copyright © 2003- Micro Format, Inc., All Rights Reserved
    830-3 Seton Court ~ Wheeling, IL 60090
    847/520-4699~In the USA call Toll Free 800-333-0549
    FAX 847/520-0197
    e-mail: support@microformat.net