Patient Registration Form - Family Doctors

Document Sample
Patient Registration Form - Family Doctors Powered By Docstoc
					            CHART NUMBER




                                                DESOTO PRIMARY CARE CLINIC, PLLC
                                                          PATIENT REGISTRATION
 (This information is needed to properly file your insurance. Any inaccurate or incomplete information may result in your insurance
                              company denying payment for services and you being billed personally.)

                                                            PATIENT INFORMATION
                 DATE                                                                                            PATIENT'S SOCIAL SECURITY #
                                                       State / Driver License #


PATIENT:     LAST NAME                    FIRST NAME                M.I.                                     PREFERRED PREFIX            SEX
                                                                                                         MR.     MRS.     MS.        FEMALE MALE
                                                                                                         OTHER:_______________

                                     STREET ADDRESS                                                        BIRTHDATE                     AGE




                 CITY                        STATE       ZIP CODE          HOME TELEPHONE      MOBILE TELEPHONE             WORK TELEPHONE




       EMPLOYER                            EMPLOYER'S ADDRESS                                OCCUPATION                      MARITAL STATUS




                  EMAIL ADDRESS                        OTHER CONTACT: NAME                          RELATIONSHIP           TELEPHONE NUMBER



In case of emergency, contact who does not live with you:             Preferred pharmacy:
                  NAME                          TELEPHONE NUMBER                            NAME                           TELEPHONE NUMBER




                                                             RESPONSIBLE PARTY
                               (Complete this section if you are listed as a dependent on someone else's insurance)

                                                                                                          RESPONSIBLE PARTY'S SOCIAL SECURITY #
IS THIS THE RESPONSIBLE PARTY FOR:                       State / Driver License #
_____PRIMARY INSURANCE _____SECONDARY INSURANCE _____BOTH


RESPONSIBLE PARTY:        LAST NAME                    FIRST NAME                M.I.                        PREFERRED PREFIX            SEX
                                                                                                         MR.     MRS.     MS.        FEMALE MALE
                                                                                                         OTHER:_______________

                                     STREET ADDRESS                                                  BIRTHDATE          RELATIONSHIP TO PATIENT




                        CITY                              STATE               ZIP CODE             HOME TELEPHONE           WORK TELEPHONE




              EMPLOYER                                               EMPLOYER'S ADDRESS                                      MARITAL STATUS




                                             PLEASE ALSO COMPLETE THE REVERSE SIDE OF THIS FORM.
                                                                                                                 Patient Registration - Page 2
                                                            INSURANCE INFORMATION
                             Please provide our front desk with your insurance card so that it may be copied. Thank you.

                                                                 PRIMARY INSURANCE

         INSURANCE COMPANY                           INSURED                   POLICY #                   GROUP #             DEDUCTIBLE COPAY/COINS %




                   STREET ADDRESS FOR CLAIMS                                      CITY              STATE           ZIP           TELEPHONE NUMBER




IF APPLICABLE, PLEASE INDICATE YOUR INSURANCE COMPANY'S PREFERRED LAB                            REFERRALS AND PRECERTS REQUIRED FOR:




                                                                SECONDARY INSURANCE

                              INSURANCE COMPANY                                                                     INSURED




                POLICY #                             GROUP #                    PLAN #                  DEDUCTIBLE              COPAY/COINSURANCE %




                   STREET ADDRESS FOR CLAIMS                                      CITY              STATE           ZIP           TELEPHONE NUMBER




           IF YOUR INSURANCE IS AN HMO, PPO, MCO OR OTHER MANAGED CARE POLICY, PLEASE READ AND SIGN BELOW:

I understand that each insurance contract is personal to the insured and that it is my responsibility to know the terms of my plan. I have verified that I
  am authorized to get treatment from the providers in this office. If a referral is needed under my plan, I understand that it is my responsibility to get
the referral. I also agree to let this office know whenever a treatment is ordered for which my plan requires precertifications. If my plan limits the use
of physician labs or requires a specific outside lab, I have listed the requirements above. I further agree to keep this office updated of any changes in
 my insurance or changes in my plan. If I fail to get proper referrals, advise of precertifications or lab requirements, I agree to be liable for any unpaid
    charges. This statement does not apply to contractual adjustments of allowed charges under my plan. This statement remains in effect until I
                                                               specifically revoke it in writing.

      ______________________________________                   _______________________________________________________________________________
                         Date                                                               Patient/Responsible Party

                                                     MEDICAL RECORDS CONFIDENTIALITY
  My signature below indicates that I have been offered a copy of the office's Notice of Privacy Practices For Protected Health Information (Privacy
Policy). Unless I specifically list my disagreement below, I agree that my protected healh information may be used according to the practice's Privacy
  Policy. Without in any way limiting the scope of the Practice's Privacy Policy, I specifically agree that the office may release my records to other
  providers involved with my care, prescriptions may be faxed to my pharmacies, records may be released to any third party payor responsible for
 paying the servies rendered to me, billing information may be released to outside labs and to outside billing companies, messages concerning my
   care may be left on my home or cellular answering machine or with adults who answer my home or cell phone who identifie himself as an adult
   member of my immedite family. If it becomes necessary, information may be released to collection agencies or others contracted to collect any
                    unpaid balances on services rendered. This statement remains in effect until I specifically revoke it in writing.

      ______________________________________                   _______________________________________________________________________________
                         Date                                                               Patient/Responsible Party

My records may not be used according to the practice's privacy policies in the following ways:




How did you find out about us?




Is there any additional information we need to properly file your insurance?

				
DOCUMENT INFO