Eduard Docu, MD “Your Health, My Care”
4849 Paulsen St. Suite 314
Savannah, GA 31405-4426
Phone: 912-354-3363
Fax:912-354-3332
PATIENT REGISTRATION FORM
Patient’s Last Name: First: Middle: / □ Mr. □ Mrs. □ Ms. / Former Name: / Sex:□ M □ F
Marital Status (circle one)
Single / Mar / Div / Sep / Wid / Birthday: / Social Security No.:
Mailing Address: / Primary Phone No.: / Additional Phone No.:
City: / State: / Zip: / Email Address:
Employment Status:
□ Full-time □ Part-time □ Other______/ Employer:
Employer Phone No.: / Employer Address:
Spouse Name: / Phone No.: / How did you hear about us?
IN CASE OF EMERGENCY (Someone NOT living with you) / Name & Relationship: / Contact No.:
Is the patient under the age 18? □ YES □ NO / If so, name of the responsible party:
Responsible party’s phone no.: / Relationship:
INSURANCE INFORMATION
Please present insurance cards to the receptionist.
Name of Primary Insurance Company:
Patient’s relationship to the policy holder: □ Self □ Spouse □ Child □ Other______
Policy Holder’s Name: / Policy Holder’s SS#:
Policy Holder’s Address: / Policy Holder’s DOB:
Policy Holder’s Employer & Address:
ID/Policy #: / Group#
Name of Secondary Insurance Company:
Patient’s relationship to the policy holder: □ Self □ Spouse □ Child □ Other______
Policy Holder’s Name: / Policy Holder’s SS#:
Policy Holder’s Address: / Policy Holder’s DOB:
Policy Holder’s Employer & Address:
ID/Policy #: / Group#
The above information is true to the best of my knowledge.
Parent/ Guardian Signature: Date:
DOCU FAMILY MEDICINE CENTER /
Eduard Docu, MD “Your Health, My Care”
4849 Paulsen St. Suite 314
Savannah, GA 31405-4426
Phone: 912-354-3363
Fax:912-354-3332
Patients Name: ______DOB: ______
Medical Information/HIPAA Release Form
[ ] I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. The information may be released to:
[ ] Spouse______
[ ] Child(ren)______
[ ] Other______
[ ] Information is NOT to be release to anyone.
This Release of Information will remain in effect until terminated by me in writing.
Patient’s Preferred Pharmacy
Pharmacy Name: ______
Pharmacy Address/Location: ______
Patient’s Insurance Preferred Services
Many insurance companies specify which commercial laboratories, hospitals, and radiology services you must use for services. It is your responsibility as the patient to be aware of this information. For instance, if your lab work is sent to a non-preferred lab you will be responsible for payment.
Our in-office lab can perform only limited testing in all cases, and when appropriate, we will perform what we can in-house. All other specimens must be sent to a reference lab.
VERY IMPORTANT:Incomplete forms will result in tests being sent to our preferred facility St. Joseph’s/Candler. If your insurance does not cover this facility you will be responsible for payment.
Please initial preferred lab below:
St. Joseph’s/ Candler Hospital ______LabCorp______
Quest Diagnostics ______Other ______
By signing this document, I hereby acknowledge that I understand and agree to its content. I understand that Docu Family Medicine Center is not responsible for any incurred charges for using out-of-network facilities.
Patient’s Signature: ______Date:______
Patient History Form
Please answer all questions to the best of your knowledge.
Today’s Date: ______Date of Last Physical Exam: ______
Chief Complaint: What is the main reason for your visit today? (Describe your problem in detail) ______
______
Physicians you have seen in the past: ______
______
List personal past Illnesses/Surgeries Date List all current medications and dosage ______
______
______
______
______
______
______
______
□ NO PAST MEDICAL ILLNESS/SURGERIES □ NOT CURRENTLY TAKING ANY MEDICATION
Are you allergic to any medications or food? Yes No If yes, please explain ______
Have you ever had a blood transfusion? Yes No If yes, please explain ______
Do you have an advance directive? Yes No If yes, please have a copy sent to our office at your earliest convenience.
List all serious illnesses in your immediate family. Examples include Diabetes, Tuberculosis, Heart Disease, Breast Cancer, etc.
Father: / □ Diabetes / □ Hypertension / □ Stroke / □ Cancer of ______Mother: / □ Diabetes / □ Hypertension / □ Stroke / □ Cancer of ______
Sister: / □ Diabetes / □ Hypertension / □ Stroke / □ Cancer of ______
Brother: / □ Diabetes / □ Hypertension / □ Stroke / □ Cancer of ______
IMMUNIZATIONS & LABS:
Tetanus Boster: Last Done: / PNEUMONIA SHOT: Last Done:Flu Shot: Last Done: / Urinalysis & MicroAlbumin: Last Done:
Hgb A1C: Last Done: / Lipids: Last Done:
PSA: Last Done: / TSH: Last Done: / AST: Last Done:
ROUTINE EXAMS: Please list the date of the last exam and the location in each box.
Sigmoidoscopy: / Eye Exam:Dental Exam: / Podiatry Exam:
Diabetic Education: / Colonoscopy:
FEMALE SPECIFIC EXAMS: Please list the date of the last exam and the location in each box.
Mammogram: / PAP:SOCIAL HISTORY:
Are you a current or past smoker? Yes No How many years? / Do you drink alcohol? Yes NoHow much? _____days per week
Occupation: / Marital Status:
DOCU FAMILY MEDICINE CENTER /
Eduard Docu, MD “Your Health, My Care”
4849 Paulsen St. Suite 314
Savannah, GA 31405-4426
Phone: 912-354-3363
Fax:912-354-3332
PRACTICE POLICIES
Please carefully read over ALL of our practice policies below, sign and date the bottom of this practice policy document. If there are any questions or concerns about these policies, please feel free to ask any of our staff.
Appointment Cancellation Policy:
Docu Family Medicine Center requires at least a 24-hour notice of rescheduling or cancelling an appointment. The patient will be considered a no-show if 24- hour notice is not given to the practice and will be charged a fee of $25 for office visits and $100 for imaging studies. Before being seen again, all no-show fees must be paid in full. After THREE no-show appointments, patient will be discharged from our practice. NO EXCEPTIONS!
Late Appointment Policy:
Patients are required to be on time for their scheduled appointments. If the patient shows up 15 minutes after their scheduled appointment time, they will not be seen and will be asked to rescheduled to another date and time.
Prescription Refill Policy:
All prescription refill requests must be called in to the patient’s preferred pharmacy. Your pharmacy will then contact our office if authorization is needed. Refill requests will be handled by the practice within 48 business hours of receiving the pharmacy's request.For any refills on controlled substances, patient MUST schedule an appointment to be seen by one of our providers. NO EXCEPTIONS.
Any prescription requiring a prior authorization from the patient’s insurance may take up to 5 business days. Once we receive correspondence regarding the outcome of the request from the insurance company, we will notify the patient as well as the pharmacy.
*For any prescription issues/request, after the patient has verified our practice has received all of the proper information to process the request, (i.e. refill or prior authorization request) please refrain from making multiple calls to our practice as this will prolong the process of the patient’s request.
Controlled Substances Policy:
IF THE PATIENT IS HERE TO SEEK PAIN MANAGEMENT BY REQUESTING PRESCRIPTIONS FOR ANY CONTROLLED SUBSTANCES FOR LONG TERM PAIN MANAGEMENT – PLEASE BE ADVISED, DR. DOCU WILL NOT PRESCRIBE THESE MEDICATIONS BUT WILL BE HAPPY TO REFER THE PATIENT TO A PAIN MANAGEMENT PHYSICIAN. IF THE PATIENT MISREPRESENTS THEIR MEDICAL VISIT PURPOSE, DR. DOCU WILL ASK THE PATIENT TO LEAVE AND CONCLUDE THE OFFICE VISIT IMMEDIATELY. IN THE EVENT THAT THE PATIENT IS ASKED TO LEAVE DUE TO THESE CIRCUMSTANCES, NO REIMBUREMENT FOR COPAYS/OFFICE VISITS WILL BE REFUNDED.
Insurance Policy:
Docu Family Medicine Center ask the patients to present their insurance card to our receptionist at EVERY visit along with their co-pay, if the patient’s insurance holds them responsible for one.If the patient fails to provide our practice with the correct insurance information at each visit, the patient will be held responsible for payment of all services provided.
It is the patient’s responsibility to contact their insurance company prior to their scheduled appointment to verify if our practice and practice providers are a preferred provider with their insurance company. If our practice is not contracted with the patient’s insurance plan, payment in full is expected at the time of service.
If the patient’s insurance company requires the patient to have a Primary Care Physician (PCP), Dr. Eduard Docu must be the PCP listed on their insurance card. Patient will be asked to call their insurance company before they are seen if their insurance card list a different physician. If possible, please contact the patient’s insurance company prior to the scheduled appointment and document the telephone.
Please be aware that some or all of the services rendered may be considered non-covered or not medically necessary by the patient’s insurer. In the event this occurs, the patient will be responsible to pay for these services in full.
Please remember that the patient’s insurance coverage is a contract between the patient and their insurance company, not between the patient and our practice. We make every effort to work with all of our patients and their insurance companies. However, if there is a dispute over what the patient’s insurance company paid and what was left to the patient’s responsibility, the patient’s insurance company will need to be contacted before calling our billing department.
Payment Policy:
Patients are expected to pay their copay along with any balance incurred with our office prior to being seen.
There will be a $37 insufficient funds fee applied to the patient’s account for any returned checks.
Docu Family Medicine Center makes every effort to work with our patients in regards to any balance they may have with our practice. However, if the patient fails to make payment arrangements with our office in a timely manner, their account is subject to being turned over to a collection agency. Balances over 120 days old will be sent to a collections agency with an added finance charge of 30%. Once a patient’s account is turned over to a collection agency, the patient will be discharged from our practice and will no longer be considered a patient.
I, ______, have read and understand the practice policies Docu Family Medicine Center has implemented. I understand that failure to comply with the terms of these policies may result in Dr. Docu no longer being my primary care physician as well as being discharged from the practice.
Patient’s/Guardian’s Signature: ______Date: ______
DOCU FAMILY MEDICINE CENTER /Eduard Docu, MD “Your Health, My Care”
4849 Paulsen St. Suite 314
Savannah, GA 31405-4426
Phone: 912-354-3363
Fax:912-354-3332
Authorization & Care/Release of Information & Assignment of Benefits
Consent to Treat
The term “health care provider(s)” in this document means Docu Family Medicine Center, its agent and employees, members of the medical staff, their agents and employees, and other health care practitioners who provide care to patients.
I understand that as part of my health care, this organization originates and maintains health records describing my health history, symptoms, examination, and test results, diagnoses, treatment, and any plan for care including future treatments. I understand that this information serves as:
1. Basic for planning my treatment and care.
2. Information used to file my claim with the insurance company (procedure and diagnosis).
3. Means by which a third-party payer can verify that billed services were actually provided.
4. A tool for routine health care operations including assessing quality and reviewing competency of your staff and/or other health care providers.
I understand that I have been provided with the Notice of Information Practices that provides more complete information of uses and disclosures. I understand that I have the right to review the notice before signing this consent. I understand that the organization reserves the right to change their notice and practices and before implementation will mail a copy of any revised notice to the address I have provided. I understand that I have the right to restrict how my health information may be used or disclosed to carry out payment, treatment, or health care operations and that the organization is not required to agree to the restrictions requested. I understand that I have the right to revoke this consent in writing, except to the extent that the organization has already taken action on my behalf.
Permission is hereby granted to all health care providers involved with my care to administer such examination, treatment, testing, and procedures as are deemed necessary in the course of my care.
Release of Information
Information about me necessary to substantiate my insurance claims may be released by the health care provider involved in my care.
Financial Responsibility/Assignment of Benefits
For those health care providers who accept assignment, I hereby authorize any insurance carrier with whom I have a policy to pay directly to that provider any benefits of any policies of insurance to those health care providers who have rendered services to me and who accept such assignment. I agree to pay all charges that are not paid in full by assigned insurance. If such amounts due to the health care providers are not paid after reasonable notice, that account shall be deemed delinquent and a service charge shall be added to the amount due. In the event that I default on payment of my account, I agree to be responsible for collection fees and interest due on amounts in default, including court costs and reasonable attorney’s fees. If the debt is assigned to a third party for collection, I agree to be responsible for collection fees and interest due on amounts in default.
Medicare Lifetime Beneficiary Claim Authorization and Release of Information