Vickery Family Medicine

VICKERY FAMILY MEDICINE

Patient Registration Form (page 1 of 8)

PATIENT INFORMATIONGUARANTOR INFORMATION(Person responsible for bill)

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Full Legal NameFull Legal Name:

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Date of Birth:Date of Birth:

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Social Security Number:Social Security Number:

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Home AddressHome Address

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EmployerEmployer

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Employer AddressEmployer Address

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Home PhoneHome Phone

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Work Phone:Work Phone:

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Cell Phone:Cell Phone:

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EmailRelationship to Patient

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Emergency Contact NameIs guarantor a patient with us?

______Yes No

Relationship to Patient

Ethniticity:: Non-Hispanic Hispanic

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Emergency Contact NumberRace: ______

Language: ______Do you have special hearing / vision needs? ______

Vickery Family Medicine 15 Yorkshire Street Suite 201 Asheville, NC 28803

Phone: (828) 274-1600 Fax: (828) 274-1603

VICKERY FAMILY MEDICINE

Patient Registration Form (page 2 of 8)

PRIMARY INFORMATIONSECONDARY INSURANCE

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Insurance Company Name:Insurance Company Name:

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Insurance Company Phone NumberInsurance Company Phone Number

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Policy Number:Policy Number:

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Group Number:Group Number:

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Policy Holder:Policy Holder:

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Policy Holder Social Security #Policy Holder Social Security #

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Policy Holder Date of Birth:Policy Holder Date of Birth

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Relationship to PatientRelationship to Patient

HOW DID YOU FIND OUT ABOUT US?

___ Friend or Family Recommendation___ Co-Worker or Employer___ Radio

___ Newspaper or Magazine___ Physician Referral (please specify)___ Internet

___ Other (Please specify)

I ACKNOWLEDGE EVERYTHING ABOVE IS ACCURATE.

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Patient SignaturePrinted NameDate

I ACKNOWLEDGE I HAVE SEEN OR BEEN OFFERED A COPY OF THE “NOTICE OF PRIVACY PRACTICES”

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Patient SignaturePrinted NameDate

Vickery Family Medicine 15 Yorkshire Street Suite 201 Asheville, NC 28803

Phone: (828) 274-1600 Fax: (828) 274-1603

VICKERY FAMILY MEDICINE

Patient Privacy Directive (page 3 of 8)

In our efforts to comply with the Health Insurance Portability and Accountability Act (HIPAA), we need to be certain that we guard your privacy according to your wishes when it comes to your family, friends, and co-workers.

I hereby authorize one or all of the designated parties below to request and received the release of any protected health information regarding my treatment, payment, billing, appointments or administrative operations related to treatment and payment. I understand that the identities of each designated party must be verified before the release of any information.

My Rights: I understand that I do not have to sign this authorization form in order to receive health care treatment. I may revoke this authorization by writing a letter to Vickery Family Medicine, PLLC. I realize that revocation will not affect any actions already taken based upon this authorization and that revocation may not be possible if the purpose of authorization was to obtain insurance. Once protected health information is disclosed, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.

**Please provide phone number(s) that we may leave an automated service message regarding appointments:

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NamePhone number

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Name Phone number

**Please provide phone number(s) that we may leave an automated service message regarding treatments:

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NamePhone number

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Name Phone number

**Please provide phone number(s) that we may talk to regarding appointments:

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NamePhone number

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Name Phone number

**Please provide phone number(s) that we may talk to regarding medical treatments:

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NamePhone number

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Name Phone number

** You must inform us IN WRITING of any changes in your directives.

Vickery Family Medicine 15 Yorkshire Street Suite 201 Asheville, NC 28803

Phone: (828) 274-1600 Fax: (828) 274-1603

VICKERY FAMILY MEDICINE

Disclosures and Consents (page 4 of 8)

Patient Name:______Date of Birth: ______

ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize direct payment of my insurance benefits to Medical Edge HealthCare Group, PA or the physician individually for services rendered to my dependents, or me, by the physician or those under his/her supervision. I understand that it is my responsibility to know my insurance benefits and whether or not the services I am to receive are a covered benefit. I understand and agree that I will be responsible for any co-pay or balance due that MedicalEdge Healthcare Group, PA is unable to collect from my insurance carrier for whatever reason.

MEDICARE/MEDICAID/CHAMPUS INSURANCE BENEFITS: I certify that the information given by me in applying for payment under these programs is correct. I authorize the release of any of my, or my dependent’s records that these programs may request. I hereby direct that payment of my, or my dependent’s authorized benefits be made directly to MedicalEdge Group, PA or the physician on my behalf.

AUTHORIZED TO RELEASE NON-PUBLIC PERSONAL INFORMATION: I certify that I have read and been offered a copy of the “HIPAA Notice of Privacy Practices”. I hereby authorize MedicalEdge Healthcare Group, PA or the physician individually to release any of my, or my dependent’s medical or incidental nonpublic personal information that may be necessary for medical evaluation, treatment, consultation, or the processing of insurance benefits.

AUTHORIZATION TO MAIL, CALL, TEXT OR E-MAIL: I certify that I understand the privacy risks of the mail, phone calls, texts and emails. I hereby authorize a MedicalEdge Healthcare Group, PA representative or my physician to mail, call, text or e-mail me with communications regarding my healthcare, including but not limited to such things as appointment reminders, referral arrangements and diagnostic test results. I understand that I have the right to rescind this authorization at any time by notifying MedicalEdge Healthcare Group, PA to that effect in writing.

LAB/X-RAY/DIAGNOSTIC SERVICES: I understand that I may receive a separate bill if my medical care includes lab, x-ray or other diagnostic services. I further understand that I am financially responsible for any co-pay or balances due for these services if they are not reimbursed by my insurance for whatever reason.

CONSENT TO TREATMENT: I hereby consent to evaluation, testing, and treatment as directed by my MedicalEdge Healthcare Group, PA, physician or those under his/her supervision.

PATIENT SIGNATURE: ______DATE: ______

GUARANTOR SIGNATURE: ______DATE: ______

(if different from patient)

GUARANTOR NAME (please print): ______

Vickery Family Medicine 15 Yorkshire Street Suite 201 Asheville, NC 28803

Phone: (828) 274-1600 Fax: (828) 274-1603

VICKERY FAMILY MEDICINE

Financial Responsibility Agreement (page 5 of 8)

Patient Name: ______Date of Birth: ______

Please Print

I understand and agree that I will be financially responsible for any and all charges for services not paid by my insurance for my visits. This includes any medical service or visit, Preventative exam or physical, lab testing, x-ray, EKG, and any other screening service or diagnostic testing ordered by the physician or the physician’s staff.

I understand and agree it is my responsibility and not the responsibility of the Physician or Office to know if my insurance will pay for my medical service or visit, preventative exam or physical, lab testing, x-ray, EKG, or any other screening service or diagnostic testing ordered by the physician or the physician’s staff.

I understand and agree it is my responsibility to know if my insurance has any deductible, co-payment, co-insurance, out-of-network amounts, usual and customary limit, or any other type of benefit limitation for the services I receive, and I agree to make full payment.

I understand and agree it is my responsibility to know if the physician or provider I am seeing is a contracted in-network provider recognized by my insurance company or plan. If the physician or provider I am seeing is not recognized by my insurance company or plan, it may result in claims being denied or higher out of pocket expense to me. I understand this and agree to be financially responsible and make full payment.

I understand and agree it is my responsibility to know if my PCP (primary care physician) choice has been processed by my insurance company or plan. If I have requested a PCP change that is not processed by my insurance company, it may result in claims being denied. I understand this and agree to be financially responsible and make full payment.

SIGNATURE: ______DATE: ______

(Please sign here – patient or responsible party)

RESPONSIBLE PARTY NAME: ______

(Please print name of Responsible Party if different from patient)

Vickery Family Medicine 15 Yorkshire Street Suite 201 Asheville, NC 28803

Phone: (828) 274-1600 Fax: (828) 274-1603

VICKERY FAMILY MEDICINE

Disclosure Regarding Ancillary Services / Research Programs (page 6 of 8)

ANCILLARY SERVICES

Your physician may refer you to one or more “Ancillary Services” in connection with your medical care. An “Ancillary Service” is a service relating to your medical care or treatment. The following types of services are Ancillary Services:

Magnetic Resonance Imaging (MRI)Bone Density Imaging

MammographyNuclear Imaging

UltrasoundLaboratory

Computer Tomography (CT)Durable Medical Equipment (DME)

Positron Emission Tomography (PET)Echo Cardiograph

X-RaySleep Therapy

Infusion TherapyAudiology

Your physician may have an economic interest in or a business relationship with the company or person who provides the Ancillary Services. You are not obligated to use the provider that your physician refers you to. You are free to use any provider you choose.

RESEARCH PROGRAMS

Your physician may ask if you would like to participate in a clinical trial or other research program. These programs may be sponsored by a drug company or may be part of a governmental research program. Your physician may be compensated for services rendered in connection with these programs. You are not obligated to participate in any research program and your permission will be obtained prior to your participating in a program your physician believes may be appropriate for you.

Please feel free to ask your physician if you have any questions about a particular Ancillary Service or Research Program.

By Signing this form I am only stating that I was informed of the above and am aware of these services offered. I have no obligation, nor have I given permission for, any of the above services to be performed.

Printed Patient Name: ______

Patient Signature: ______

Date: ______

Vickery Family Medicine 15 Yorkshire Street Suite 201 Asheville, NC 28803

Phone: (828) 274-1600 Fax: (828) 274-1603

VICKERY FAMILY MEDICINE

Past Medical and Family History (page 7 of 8)

Current Prescription Medications: Please include any over-the-counter medications or vitamins / supplements

______mg – times per day______mg – times per day

Preferred Pharmacy: Local: ______Mail Order: ______

ALLERGIES to medications: [ ] No Known Drug Allergy

Medication:______Reaction: ______

Other Allergies: ______

Previous Surgeries:Year:Previous Surgeries:Year:

______

OTHER HOSPITALIZATION Year:OTHER HOSPITALIZATION Year:

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Please list other physicians and health care providers you see (specialists, therapists, counselors, chiropractic, eye doctor, etc):

Provider ______Reason ______

ADULT IMMUNIZATIONS:

Shingles vaccine: [ ] Yes [ ] No Date: ______Hepatitis B [ ] Yes [ ] No Date: ______

Influenza [ ] Yes [ ] No Date: ______HPV [ ] Yes [ ] No Date: ______

Pneumonia [ ] Yes [ ] No Date: ______Tetanus: [ ] Yes [ ] No Date: ______

Preventative screenings:

Last Annual Wellness Exam: ______or last physical ______

Colonoscopy: ______DEXA (bone density):______

Women: Pap: ______Mammogram: ______

When was your last Eye Exam? ______

Vickery Family Medicine 15 Yorkshire Street Suite 201 Asheville, NC 28803

Phone: (828) 274-1600 Fax: (828) 274-1603

VICKERY FAMILY MEDICINE

Past Medical and Family History (page 8 of 8)

Past Medical History: Please describe any condition that you have yourself:

ConditionDetails

Eye Disease or Cataracts ______

Lung Disease (describe) ______

Cancer (describe) ______

Heart Disease (describe) ______

Depression ______

Mood Disorder ______

Diabetes ______

Digestive/stomach/GERD ______

DVT or pulmonary embolus (blood clots) ______

High Blood Pressure ______

High Cholesterol ______

Kidney Disease______

Sleep Apnea______

Thyroid Disease______

Other: ______

______

Family Health History:

Mother’s Health Conditions: ______

Living? Y/N If no, age at death ______

Father’s Health Conditions: ______

Living? Y/N If no, age at death ______

Sibling’s Health Conditions: ______

Other: ______

Personal and Social History:

Do you smoke?: [ ] No, I have never smoked

[ ] Yes, I smoke _____ packs of cigarettes a day for years

[ ] No, I quit smoking _____ yrs ago. I smoked _ ____ packs a day for _____ yrs.

[ ] Yes, I smoke cigars or a pipe, _____ a day for _____ yrs

[ ] Yes, I use snuff _____ times a day

[ ] Yes, I chew tobacco _____ times a day

Foreign travel outside the U.S. in past year: ______

Safety: Do you have / use the following? Seat belts [ ] Yes [ ] No Smoke detectors in home [ ] Yes [ ] No

Do you have advanced Directives? (Living Will, Durable Power of Attorney for medical decisions) [ ] Yes [ ] No

Vickery Family Medicine 15 Yorkshire Street Suite 201 Asheville, NC 28803

Phone: (828) 274-1600 Fax: (828) 274-1603