Created on 1/1/06
PATIENT REGISTRATION
Created on 1/1/06
Patient Information:
Person to contact in case of emergency:
Created on 1/1/06
Name______
(last) (first) (middle)
Mailing Address:______
City/State/Zip:______
Social Security Number:______
Date of Birth:______
Home Phone: ______
Cell Phone:______
Would you prefer Appointment reminders by text? __Y __N
Employer:______
WorkPhone: ______
Spouse's name:______
Person responsible for bill (if different from above):
Name______
(last)(first)(middle)
Address:______
City/State/Zip:______
Social Security Number:______
Date of Birth:______
Guarantor Phone:______
Guarantor Employer:______
Primary Insurance: ______
Subscriber's Name: ______
Subscriber's SS #: ______
Subscriber's Date of Birth:______
Group Number: ______
Medicare Number: ______
Secondary Insurance: ______
Subscriber's Name: ______
Subscriber's SS #: ______
Subscriber's Date of Birth:______
Group Number: ______
Name:______
Phone Number:______
Their relationship with you?______
Who referred you to see us?______
Do you have a Living will?______Our office can provide you with the form if you wish.
NOTICE OF PRIVACYPRACTICES-ACKNOWLEDGEMENTS
We keep a record of the health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your records to others unless you direct us to do so or unless the law authorizes or compels us to do so. For the complete copy of our privacy practices please contact our front desk personnel for a copy.
Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you may access your information.By my signature below I acknowledge receipt of the Notice of Privacy Practices.
______
Patient or legally authorized individual signature Date
______
Printed name if signed on behalf of the patient Date
RELEASE OF BENEFITS AND INFORMATION
I authorize payment of medical benefits to Dr. Harris for any services provided by him and/or his staff to myself or anyone covered under my policy. I am financially responsible for any balance due. 1% interest is accrued every 30 days on unpaid balances. I understand that protected health information may be used and disclosed for billing and collecting purposes. I authorize the doctor or insurance company to release any information required for my claims. Littlerock Family Medicine P.S. accepts Medicare assignment. In the event it should become necessary to place for collection an unpaid balance due for services rendered to me or my family, I agree to pay collection fees, and should legal action be filed, reasonable attorney fees, filing fees, and any other costs the court determines proper.
Signed: ______
Date: ______
CONSENT FOR TREATMENT: I give Littlerock Family Medicine P.S. consent for treatment of myself. If thepatient is a minor, authorization is hereby granted to provide medical care for the child.
Signed: ______
Date: ______