LAKESIDE NORTH
IS TODAY’S VISIT
WORK RELATED?
IF YES: NOTIFY FRONT DESK
Patient Information: Name:______Date of Birth:______
Home Email:______Sex: Male or Female SSN______
Address:______City:______State:_____Zip:______
Home Phone #:______Cell #:______
EmployerName:______Phone #:______
Ok to Leave Message on answering machine or cell phone: YES NO
Emergency Contact: Name:______Phone #:______
DUE TO FEDERAL GOVERNMENT REQUIREMENTS PLEASE CIRCLE THE FOLLOWING FOR THE PATIENT: ETHNICITY: Hispanic or Latino Not Hispanic or Latino
RACE: Caucasian African American Native American or Alaskan Asian Native Hawaiian or Pacific Islander
GUARANTOR INFORMATION: The person financially responsible for the patient.
{ } Check here if same as patient above; if not
Please complete the following.
Relationship: { } Spouse { } Parent { } Other
Name:______Date of Birth:______SSN:______
Address:______State:_____Zip:______
Home #:______Cell #:______Sex: Male or Female
READ CAREFULLY
CONSENT FOR TREATMENT: I, the undersigned, consent to the care and treatment of the attending physician, his/her associates or assistants.
ASSIGNMENT OF BENEFITS AND GUARANTEE OF ACCOUNT:
I acknowledge full financial responsibility for any services rendered and I understand that the payment of charges incurred in this office is due at the time of service. I also understand that the charges not covered by insurance remain my responsibility and assign insurance benefits to this office. In the event my account is turned over to a collection agency, I agree to pay ALL costs of collection fees and/or attorney’s fees and all court costs if any.
Signature______Date:______
LAKESIDE NORTH
PERMISSION TO RELEASE INFORMATION
I, the undersigned patient and/or responsible party hereby authorize Lakeside North, it’s physicians, agents, employees or representatives to discuss or release any or all patient information about me including but not limited to past and current medical information, billing information, appointment scheduling, prescriptions, etc to the person or persons names below:
Spouse / Name:Parents / Name(s)
Children / Name(s)
Other / Name(s)
PLEASE NOTE THAT CHECKING ANY BOX BELOW MAY RESULT IN THE STAFF OF LAKESIDE NORTH LEAVING YOUR PROTECTED HEALTH INFORMATION ON AN ANSWERING MACHINE AT THE NUMBER REQUESTED BY YOU.
Yes No
{ } { } The physicians/staff of Lakeside North may confirm appointments to my answering
machine at the number provided on my Patient Information Sheet.
{ } { } The physicians/staff of Lakeside North may leave lab results or results of other
Diagnostic studies (e.g., MRI, CT, bone scan, etc) on my answering machine.
{ } { } The physicians/staff of Lakeside North may release information to my pharmacy
without prior authorizations in order to allow call-in of a prescription.
Signature______Date:______
LAKESIDE NORTH
7938 AL Hwy. 69, Suite 130
Guntersville, AL 35976
(256) 571-8460 Fax (256) 571-8464
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
Patient’s Name: ______Date of Birth: ______
Address: ______
City: ______State: ______Zip: ______
SS#: ______Patient’s Phone #: ______
Date of Request: ______Date Needed: ______
I authorize LSN to releaseI authorize LSN to obtain
Information to:information from:
______
Name of Provider or Facility Name of Provider or Facility
______
AddressAddress
______
City, State, ZipCity, State, Zip
______
Phone/Fax NumberPhone/Fax Number
PURPOSE OF REQUEST: Healthcare Insurance Coverage Personal Other
Date of Service for Records Requested: ______
Type of Records Requested: ______
I HEREBY AUTHORIZE THE RELEASE OF ANY AND ALL MEDICAL INFORMATION (TO INCLUDE ALL PHYSICIAN’S NOTES, LABS RESULTS, X-RAY AND DIAGNOSTIC RESULTS AND ANY HIV RELATED INFORMATION, MENTAL OR SUBSTANCE ABUSE RECORDS) INCLUDING DIAGNOSIS, TREATMENT, PROGNOSIS, ETC., OF THE INJURIES AND/OR ILLNESSES RECEIVED BY THE ABOVE NAME PERSON ON AND SUBSEQUENT TO THE DATE OF THE INJURIES AND/OR ILLNESS. AUTHORIZATION IS KEPT ON FILE UNLESS REVOKED IN WRITING.
______
SIGNATURE OF PATIENT OR LEGAL GUARDIAN DATE
______
WITNESS DATE