Patient Registration Form
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- Pamela Anthony
- 5 years ago
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1 Patient Registration Form Patient Information: Patient/Child First Name: MI: Last Name: Age: Date of Birth: Occupation: Ethnicity: Hispanic Not Hispanic Language: English Spanish Other Race: White Black Native American Asian Other Marital Status: Single Married Widow/Widower Divorced Soc. Sec. #: Mailing Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: address: Drivers License #: Previous Primary Care Provider: Referring Doctor: What pharmacy do you use for medication refills: Address: Parent/Guardian (REQUIRED IF PATIENT IS UNDER 21 YEARS): NOTE: Per NC Law, Both Parents can be held responsible for medical bills for minors, a medical practice is NOT bound by any separation agreement, divorce or child support order. Parent/Guardian: Birth Date: Address (if different from above): Social Security # (required): Employer: Preferred Phone #: In case of an emergency, who would you like to be contacted? Contact Name: Relationship to Patient: Home Phone #: Work Phone #: HIPAA CONSENT: Below, please list anyone you would like to be allowed to receive information regarding your medical care (leave blank if you would not like any additional individuals to have information regarding your care) By signing, you agree the information above is correct and give permission for Lamond Family Medicine to file claims on your behalf as well as share your medical care information with the above listed contacts. Without signed consent, we can NOT share information regarding your medical care (including family). Patient/Guardian Signature: Date: 317 N. King Street Hendersonville, NC Page 1
2 Financial Policy and Signature on File I authorize the release of any medical pertinent information to my consulting provider, if needed and as necessary to process insurance claims, insurance applications and prescriptions. I also authorize payment of benefits to LaMond Family Medicine. I understand that I am financially responsible for all services rendered including for the following reasons: 1) no proper referral at the time of service or referral is invalid/expired 2) incorrect/invalid insurance information given or failure to give new updated insurance information 3) Expenses not covered by insurance 4) deductible not met 5) services rendered are deemed medically unnecessary by insurance. Failure of insurance company to pay does not excuse patient s financial responsibility. It is patient s responsibility to know what is and is not covered by their insurance policy/plan (including Medicare beneficiaries). Payment is required for all services at the time they are rendered including co-payments and any outstanding balances. You may be balance billed per your insurance contract guidelines for any amount not collected or known at the time of service. Outstanding balances not addressed/ paid in a timely fashion may be forwarded to collections and may be reported to your credit. Returned Checks: In the event a check is returned for Non Sufficient Funds, we will assess a $25.00 charge in addition to your current balance to cover the bank charges incurred by our office due to Non Sufficient Funds. Your signature below signifies your understanding and willingness to comply with the policies of this office and your insurance plan. Prescriptions: Please bring a list of your current medications with you at the time of your appointment. We will NEVER call in ANY pain medications, antibiotics or narcotics to any drug store. If you need a prescription refill, please call your pharmacy and ask that they fax a refill request to our office. Our providers will review the request and refill the prescription by return fax or we may request you make a follow up appointment if necessary. Please allow 24 hrs for a response to refill requests. Samples are given at scheduled appointments ONLY and can ONLY be given by the doctor. Missed Appointments: We charge $50.00 for any no show appointment not cancelled within 24 hrs. This charge will be billed directly to you. Please help us to serve you better by keeping all scheduled appointments. If you no show to 3 appointments within 1 year, we have the right to dismiss you from our practice for non compliance. Patient/Guardian Signature for Financial and Office Policies: HIPAA COMPLIANCE STATEMENT - THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. At this practice, we are committed to protecting your privacy. We comply with all federal, state, and local laws. This notice describes how we use your health information. It describes some of your rights and some of our responsibilities. UNDERSTANDING YOUR HEALTH RECORD/INFORMATION - Each time you visit our offices, we record your symptoms, physical examination, test results, diagnosis, and treatment. This information enables us to plan for your care, communicate with others who care for you, report to your insurance carrier, bill for our work, and improve the quality of our care to you. YOUR RIGHTS - Although your medical chart belongs to our practice, the information contained in the chart is yours. You have the right to inspect your records, obtain a copy of your chart for a small fee, correct your records, and tell us not to release your information to certain parties. OUR RESPONSIBILITIES - We are required to maintain the privacy of your health information, send needed health information to other medical providers, and release information to insurance companies, certain government agencies, and others. We may be required to release some information, even without your permission. EXAMPLES OF HOW YOUR INFORMATION IS USED - Your health information will be recorded and used to plan your treatment. Reports may be sent to other doctors to help them plan your treatment. Claims will be sent to your insurance company. The information in the claims will include confidential information such as your name, address, diagnosis, and treatment. In providing your care, we may communicate with other individuals or businesses. Examples include other physicians and/or laboratories. To protect your privacy, we ask our business associates to safeguard your information. OTHER NOTICES - We may leave a message at your home, at your business, on your answering machine or on your voic . We may mail you a postcard or other written notices. We may need to disclose your information to your family members or other people helping with your care. In doing so, we will use our best judgment. We may disclose information to others as required by law or if subpoenaed. If you were injured on the job, we will need to disclose your health information to your workers compensation insurance company. We may, from time to time, update these policies. FOR MORE INFORMATION, QUESTIONS OR TO REPORT A PROBLEM - If you have concerns or would like additional information, you may contact the Office Manager. Signature: (HIPAA Policy) Date: 317 N. King Street Hendersonville, NC Page 2
3 Health History All questions contained in this questionnaire are strictly confidential and will become part of your medical record. List your prescribed drugs, over the counter medications and supplements Name of Drug: Strength: Frequency Taken: Personal Health History: List any medical problems that other doctors have diagnosed: Year: Medical Problem: Treatment/Medication(s):(if prescribed) Allergies to medications: Name of Drug: Reaction: Surgeries: Year: Type of Surgery: Surgery Reason: 317 N. King Street Hendersonville, NC Page 3
4 Health History (Continued) Hospitalizations: Year: Reason: Family Health History: (Please comment on general, weight and psychiatric history) All questions contained in this questionnaire are optional and will be kept strictly confidential. Father Mother Other Other Paternal Grandfather Other Paternal Grandmother Other Maternal Grandfather Other Maternal Grandmother Other 317 N. King Street Hendersonville, NC Page 4
5 Health History (Continued) Siblings Brothers Enter Qty. Other Sisters Enter Qty. Other Children Son Enter Qty. Other Daughter Enter Qty. Other Health Habits Exercise: (check your selection) Sedentary (no exercise) Lightly active (1-3 days per week) Moderately Active (3-5 days per week) Very Active (6-7 days per week) Caffeine Coffee Tea Cola None # of cups/cans per day? Do you drink alcohol? Yes No If yes, what kind? How many drinks per week? Are you concerned about the amount you drink Yes No Do you Use Tobacco? Yes No Cigarettes (packs/day): Chew (#/day): Pipe (#/day): Cigars (#/day): # of years: Year quit: 317 N. King Street Hendersonville, NC Page 5
6 HIPAA I understand that I have the following rights and privileges: The right to review the notice prior to signing this consent, The right to object to the use of my health information for directory purposes, and The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations. I,, understand that as part of my health care, LaMond Family Medicine originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information serves as: A basis for planning my care and treatment, A means of communication among the many health professionals who contribute to my care, A source of information for applying my diagnosis and surgical information to my bill, A means by which a third-party-payer can verify that services billed were actually provided A tool for routine health care operations such as assessing quality and reviewing the competence of health care professionals. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section of the Code of Federal Regulations. Patient s Signature (authorized representative signing for the patient): Signature: Date: By signing this document, I confirm that I fully understand and accept the terms of this consent. FOR OFFICE USE ONLY: Consent received by: Date: I further understand that LaMond Family Medicine reserves the right to change their notice and practices and prior to implementation, in accordance with Section of the Code of Federal Regulations. Should the physicians at LaMond Family Medicine change their notice, they will send a copy of any revised notice to the address I ve provided (whether U.S. Mail or, if I agree, ). I wish to have the following restrictions to the use or disclosure of my health information: I understand that as part of this organization s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax. 317 N. King Street Hendersonville, NC Page 6
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Namaste Health Care Bridget P. Early, M.D. Kate Branham, F.N.P. New Patient Registration Packet Patient Name Date of Birth Age Sex M F Date: Social Security # Mailing Address Marital Status Single Married
Keri. Connections Family Therapy, LLC. Keri L Christensen LISW 1310 Tower Lane NE, Cedar Rapids, IA 52402
Thank you for choosing Connections Family Therapy! Please complete the forms below. If the paperwork is not completed before the first session, you will be asked to stay after the intake session to complete
Mailing Address City State Zip Code. Employer City State Zip Code. How did you hear about us? Circle one
PATIENT REGISTRATION PATIENT Name (Last, First, MI) Sex M F Birthdate Social Security Number Marital Status- M S W Mailing Address City State Zip Code Employer City State Zip Code Home Phone Cell Phone
New Patient Registration Form
New Patient Registration Form PATIENT INFORMATION Last Name (Legal): First Name (Legal): MI: Preferred Name: Date of Birth: Social Security #: Marital Status: Sex Assigned at Birth: Single Married Widowed
Social Security No: Home Phone: _. Employer: Work Phone: _. Employer Address: Occupation: _. Spouse/Parent Name: Phone No: _
THE NATIONAL RETINA INSTITUTE LEADERS IN THE TREATMENT OF RETINAL DISEASES Patient Information Form Patient Name: Date of Birth: -,--I _----'--/ Age: Social Security No: Home Phone: _ Street Address: --------------------------------------
Please be aware that this office does not do pain management and will not prescribe narcotics to new patients, nor on an ongoing basis.
Patient Information Sheet Last Name: First Name: Middle Initial: Patient Is: Policy Holder Responsible Party RESPONSIBLE PARTY Last Name: First Name: Middle Initial: Address: City, State, Zip: Home Phone:
PEDIATRIC PATIENT REGISTRATION GALEN MEDICAL GROUP, PC
PEDIATRIC PATIENT REGISTRATION GALEN MEDICAL GROUP, PC Your Child: Name Your Child s Full Name: Child Goes By: Gender: Male Female DOB: Age: SS#: Child s Home Address: City: State: Zip: Phone: Primary
REGISTRATION FORM. Physician (PCP): PATIENT INFORMATION. Last Name: First Name: MI: Billing Address: City: ST Zip Code:
: REGISTRATION FORM Physician (PCP): PATIENT INFORMATION Last Name: First Name: MI: Social Security #: DOB: Sex: M F Billing Address: City: ST Zip Code: Home Phone#:( ) Cell Phone#:( ) Work Phone#:( )
Patient Information. Employer's Name. Health Insurance Information HMO. Co-pay Amount. Cross Streets
Registration/Update Form Today's : Patient Information Patient's Name: Last First MI Male Female Age Race: American Indian Black or African American Native Hawaiian White Other Ethnicity: Hispanic or Latino
Patient Registration WELCOME TO OUR OFFICE
Patient Registration WELCOME TO OUR OFFICE Date of Birth: Home Address: Apt / Unit: City: State: Zip: SSN: Telephone: Home: Cell: Work: Email: Marital Status: Name of Spouse / Partner: Preferred method
South Lake Pain Institute
Welcome to South Lake Pain Institute We are honored that you have chosen us as your health care provider. Our goal is to provide the highest quality care for all of our patients in a timely and respectful
Who to call for an emergency: Name: Address: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Relationship:
Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one) Married/Single/Divorced/Widow Address: Zip Code: Home Phone: ( ) - E-mail Address: Cell Phone:
ELYSE S. RAFAL, F.A.A.D.
ELYSE S. RAFAL, F.A.A.D. Welcome to our practice. Thank you for placing your trust in us. We look forward to serving you with quality and compassionate care. Patient Information Today s : First Name: M.I.
INSURANCE INFORMATION
PATIENT INFORMATION Last Name First Name M.I. Marital Status: Married Single Divorced Widowed Social Security No.: - - Birth Date: / / Sex: M F Place of Birth: Driver s License Number: Preferred Language:
Please review the checklist on the next page to ensure that your application is complete and ready for submission.
Program Overview How to Complete this Application: 1. Review the information on this page carefully and keep it for your records. 2. Complete pages 3, 4 and 5 of the application. 3. Gather the required
***PLEASE PRINT USING BLACK INK ONLY***
***PLEASE PRINT USING BLACK INK ONLY*** 100 Hospital Lane, Suite 220 Danville, IN 46122 HOME PHONE WORK PHONE CELL PHONE PHARMACY LOCATION PHONE # NAME SS# ADDRESS CITY STATE ZIP BIRTHDATE AGE HEIGHT WEIGHT
HOME ADDRESS APT. NO CITY STATE ZIP CODE S M D W PRIMARY INSURANCE INFORMATION SUBCRIBER S FIRST NAME LAST NAME RELATIONSHIP TO PATIENT DATE OF BIRTH
PATIENT REGISTRATION FORM PATIENT NAME LAST FIRST MIDDLE INITIAL PATIENT DATE OF BIRTH HOME ADDRESS APT. NO CITY STATE ZIP CODE OCCUPATION EMPLOYED RETIRED STUDENT SOCIAL SECURITY # MARITAL STATUS S M
Oliver Winston Behavioral Urgent Care, LLC
Presenting Symptoms: What physical or emotional symptoms brought you here today? Current Stressors: Are there significant changes in your life which may have contributed to the symptoms which brought you
PATIENT INFORMATION. PRIMARY INSURANCE Ins Co. Name: PRIMARY POLICYHOLDER PARENT/GUARDIAN INFORMATION (REQUIRED IF PATIENT UNDER 18 YEARS OF AGE)
PATIENT INFORMATION Name: Sex: of Birth: Social Security #: Address: Apt # City: State: Zip: Primary Phone: Primary Phone Type: Cell Home Work Secondary Phone: Secondary Phone Type: Cell Home Work Email:
CLIENT IV Vitamin /Nutrients
IV NUTRIENTS COMPANY CLIENT IV Vitamin /Nutrients INTAKE EVALUATION Name: Phone / - email: Street: City State Zip Emergency Contact: DOB / / Age Male Female Height Weight What Service are you here for?
PALMETTO PULMONARY MEDICINE, P.A.
Peter N Manos, MD FCCP Denise Mercier, PA-C Board Certified: Internal Medicine Pulmonary Disease Critical Care Medicine Sleep Medicine 989 Ribaut Road, Suite 340 Beaufort, SC 29902 (843)-521-8484 Fax (843)
Sierra Endocrine Associates Endocrinology, Diabetology & Metabolism
Patient Name: Consultation Date: Next 2 week Appointment: Provider: Arrival Time: Arrival Time: Thank you for choosing Sierra Endocrine Associates as your specialty endocrine provider. Enclosed is your
PATIENT APPLICATION FORM
PATIENT APPLICATION FORM WELCOME TO OUR CLINIC! We specialize in assisting our patients to achieve their highest level of health through our spinal and postural corrective programs. Our approach is very
Child s Name: Gender: M or F Last First MI. Date Of Birth: - - ADDRESS: CITY: STATE ZIP: REFERRING SOURCE. Physician Name Last First MI
PATIENT INFORMATION PATIENT INTAKE FORM DATE: PT/OT/ST Child s Name: Gender: M or F Last First MI Date Of Birth: - - SS# - - ADDRESS: CITY: STATE ZIP: REFERRING SOURCE Physician Name Last First MI Phone: