ATIGA FAMILY PRACTICE Jefferson Ave Ste. 204 Temecula Ca, Patient Registration

Transcription

1 ATIGA FAMILY PRACTICE Jefferson Ave Ste. 204 Temecula Ca, Patient Registration Patient Information Name: Date of Birth: Social Security Number: Gender Address: Preferred language: Do you need Language assistance : Home Phone: Cell Phone: Work Phone: Marital Status: Address: Insurance Information Primary Insurance: Subscriber Name: Date of Birth : Subscriber ID: Secondary Insurance: Subscriber Name: Date of Birth: Subscriber ID: Emergency Contact Emergency Contact Name: Phone Number: Relationship to patient: Pharmacy Information Pharmacy Name: Phone Number: Address: Rx History Consent: (initials) My initial here is to hereby authorize the practice to obtain my external prescription/medication history through external sources. The above information is complete and correct. I hereby authorize release of information necessary to file a claim with my insurance company. I assign benefits otherwise payable to me to the practice. I understand that I am financially responsible for charges for medical services rendered regardless of insurance coverage. I also understand that I am responsible for any office visit copayment due at time of service and/or deductibles that may apply. If this account is assigned to an attorney for collection and/or suit, a copy of the signature is valid as the original. ** Also note, Effective January 01, 2012 we will be charging for NO show visits of $ Please call 24 hours in advance of your appointment.** Signature: Date:

2 ROLANDO A. ATIGA ATIGA FAMILY PRACTICE OFFICE FINANCIAL POLICY We are committed to providing all our patients with the best possible medical care. If you have medical insurance, we are anxious to help you receive your maximum allowable benefit. In order to achieve these goals, we need your assistance and your understanding of our payment policy. ALL PATIENTS: The patient is responsible for all services rendered regardless of insurance coverage. The full responsibility of payments rest with YOU. CASH PATIENTS: All services are rendered on a cash basis and must be paid in full at the time of service. Financing and financial assistance is available. PRIVATE INSURANCE: We must have a fully completed and signed insurance form at the time of service. If you can not supply us with all the necessary billing information your account will be handled the same as a cash patient. Deductible and copays are due at the time of service. PPO: We must have a copy of both sides of your insurance card on file. All co-payments are due at the time of service. HMO: ALL HMO patients must be assigned to Dr. Rolando Atiga or Dr. John Feeney under the medical group Vantage or Primecare at the time of the visit. If you are not assigned to Dr. Rolando Atiga or Dr. John Feeney at the time of visit you will be responsible for the charges should your insurance deny payment. Co-payment must be made at time of service. TRICARE: ALL TRICARE PATIENTS MUST BE ASSIGNED UNDER DR. ROLANDO ATIGA. Amounts which are over 60 days past due by an insurance company are immediately due from the patient. Amounts which are over 90 days past due are subject to collection procedures which could include small claims court or a 1-12 % service charge per month on the unpaid balance. Account sent to a collection agency will include an additional $10.00 transferring fee. If at any time you should experience financial hardship, please make this office aware of the situation. We are willing to make special arrangements for those patients who need extra help. If you need to make arrangements, please ask to speak to the office manager, I have read and understand all of the above. Print name: Patient or responsible party signature: Date:

3 Physician-Patient Arbitration Agreement Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute in a court of law before a jury, and instead are accepting the use of arbitration. Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term patient herein shall mean both the mother and the mother s expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician s partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for the loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counseling fees or witness fees, or other expenses incurred by a party for such party s own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, nor supplant, any other applicable statutory or common law. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity, which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of California law applicable to health care providers shall apply to disputed with this arbitration, including, but not limited to, Code of Civil Procedure Section and and Civil Code Sections and Any party may bring before the arbitrators a motion for summary judgement or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section ; however, depositions may be taken without prior approval of the neutral arbitrator. Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration. Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition. Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below: Effective as of the date of first medical services. If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. Physician s or Authorized Representative s Signature Date Patient/Representative s Signature Date Atiga Family Practice Jefferson Avenue, Suite 204 Temecula, Ca Print Patient s Name

4 PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims. ATIGA FAMILY PRACTICE Jefferson Avenue Suite 204 Temecula, CA Phone: Fax: Date: The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE. Please print name of Patient Legal Representative / Guardian Please sign for Patient / Guardian of Patient Relationship of Legal Representative / Guardian Your comments regarding Acknowledgements or Consents: HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM THE RECEPTION AREA: First Name Only Proper Surname Other PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION: (This includes step parents, grandparents and any care takers who can have access to this patient s records): Name: Relationship: Name: Relationship: I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA: Cell Phone Confirmation Home Phone Confirmation Work Phone Confirmation Text Message to my Cell Phone Confirmation Any of the Above I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA: Cell Phone Confirmation Home Phone Confirmation Work Phone Confirmation Text Message to my Cell Phone Confirmation Any of the Above I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS or NEW HEALTH INFO on behalf of this Healthcare Facility via: Phone Message Any of the Above Text Message None of the above (opt out) In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent Office Use Only As Privacy Officer, I attempted to obtain the patient s (or representatives) signature on this Acknowledgement but did not because: It was emergency treatment I could not communicate with the patient The patient refused to sign The patient was unable to sign because Other (please describe) Signature of Privacy Officer

5 CONFIDENTIALITY FORM ROLANDO A. ATIGA M.D/ JOHN R. FEENEY D.O/ JHERMIE SALAS N.P. ATIGA FAMILY PRACTICE JEFFERSON AVE. SUITE 204 TEMECULA, CA I medical information to allow Atiga Family Practice to disclose any of my (MY SPOUSE/CHILDREN/PARENTS/OTHER). If you circled other please specify person by name (Please Print Name) Atiga Family Practice will not release information pertaining to: DRUGS/ALCOHOL/SUBSTANCE ABUSE/PSYCHIATRIC/MENTAL HEALTH/TESTS FOR ANTIBODIES TO HIV/HIV DIADNOSIS/TREATMENT Patient signature Date

6 PEDIATRIC TB RISK ASSESSMENT QUESTIONAIRE CUESTIONARIO PARA DETERMINAR RIESGO DE TUBERCULOSIS Name of Child/Nombre Del Paciente: Date of Birth/Fecha de Nacimiento: Date/Fecha _/_/ /_/ /_/ /_/_ 1. Was your child born in a high risk region? (Nacio su hijo/hija en una region o pais de alto riesgo) 2. Has your child ever travelled to a high risk country for more than one week? (Alguna vez ha viajado su hijo/hija a un pais de alto riesgo por mas de una semana?) 3. Has a family member or contact has tuberculosis disease? (Ha tenido un pariente o familiar con tuberculosis?) 4. Has a family member or close contact had a positive Tuberculin skin test? (Alguien en su familia ha tenido una prueba de tuberculosis con resultado positive?) High Risk Regions Include/Una region de alto region de alto riesgo incluye cualquier pais en: Africa, Asia, Central America, South America or Eastern Europe Name: Date:

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10 AUTHORIZATION FOR USE AND DISCLOSURE OF MEDICAL RECORDS This authorization allows the healthcare provider(s) named below to release confidential medical information and records. Note: Information and records regarding treatment of minors, HIV, psychiatric/mental health conditions, or alcohol/substance abuse have special rules that require specific authorization. AUTHORIZATION I hereby authorize: / Physician/Healthcare Facility Phone Number To release information regarding my medical history, illness or injury, consultation, prescriptions, treatment, diagnosis or prognosis, including x-rays, correspondence and/or medical records by means of mail, fax or other electronic methods to: Atiga Family Practice Dr. Rolando Atiga, Phone: , Fax: Jefferson Ave Suite#204, Temecula, Ca The medical information/records will be used for the following purpose: This authorization is: ( ) Unlimited (all records, excluding Substance Abuse, Mental Health, HIV Diagnosis/Treatment) ( ) Limited to the following medical information: I also consent to the specific release of the following records: Drug/Alcohol/Substance Abuse (initial) Test for Antibodies to HIV (initial) Psychiatric/Mental Health (initial) HIV Diagnosis/Treatment (initial) DURATION: This authorization shall be effective immediately and remain in effect until Date RESTRICTIONS: Permissions for future use or disclosure of this medical information is not granted unless another authorization is obtained from me or unless such a disclosure is specifically required or permitted by law. A photocopy of this facsimile of this authorization shall be considered as effective and valid as the original. I have been advised of my right to receive a copy of this authorization. Signature of Patient or legal/personal representative Relationship if other than patient Patients Name (PRINT) Date Patient s Social Security Number Patient s Date of Birth Witness Name Witness Signature