Patient Demographic Form

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1 Patient Demographic Form New Patient Returning Patient Primary Care Physician (PCP) Name: Patient Name: Last Name First Name MI Address: P.O. Box City: State: Zip: Cellular Number: Home Number: Work Number: Social Security Number: of Birth: Age: Sex: Marital Status (please circle): Married / Divorced / Separated / Widow Ethnicity (please circle): Caucasian / African American / Hispanic / Asian / Other Religious Preference: Patient Employer: Patient Employer Address: Employer Telephone Number: Guarantor Information Is the patient a minor? (Under 18) Yes / No (If Yes, please fill out the Guarantor information) Is Guarantor information same as above? Yes / No (If No, please fill out the Guarantor information) Guarantor Name: Last Name First Name MI Social Security Number : Relationship to patient:

2 Insurance Information CMMC Outpatient Clinics require that you have a PHOTO I.D. and INSURANCE CARDS at each visit. Is the patient covered by insurance? Yes / No If No, please see the self pay fee schedule. If Yes, please complete the following: Primary Insurance Company: Policy Number: Group Number: Secondary Insurance Company: Policy Number: Group Number: Do you have an advanced directive? Advanced Directive Information Yes / No Is your Advanced Directive on file at Chicot Memorial Medical Center? Yes / No Do you have a Living Will? Yes / No Is your Living Will on file at Chicot Memorial Medical Center? Yes / No Do you have a Power of Attorney? Yes / No Who has Power of Attorney? Contact Number: Are you a Healthcare Surrogate / Organ Donor? Yes / No Emergency Contact Information (1) Name: Relationship to patient: Address (City, State, Zip): Contact Number: (2) Name: Relationship to patient: Address (City, State, Zip): Contact Number: The above information is true to the best of my knowledge. I understand that I/Guarantor am financially responsible for any balance. I also authorize Chicot Memorial Medical Center to release my information required to process my claim. Patient / Guarantor Signature: : Chicot Memorial Medical Center Witness: :

3 Patient Information Sheet : 1. I, the of (Name) (relationship) (patient) hereby voluntarily consent to outpatient care encompassing routine diagnostic procedures, examination and medical treatment including, but not limited to routine laboratory work (such as blood, urine or other studies), taking x-ray, heart tracing and administration of medications prescribed by the physician. 2. I further consent to the performance of those diagnostic procedures, examinations and rendering of medical treatment by the medical staff, their assistants including nurses and aides as is necessary in the medical staff s judgment. 3. Release of information: (a) I authorize the clinic to release medical information to the third party insurance carriers for the purposes of filing insurance claims related to my (his/her) medical care. (b) I further authorize the release medical information about treatment here to my (his/her) doctor or any designated by me. (c ) I further authorize the ability to view prescriptive history from external sources. (d) I further authorize the release of medical information to federal and state governing entities for the purposes of required reporting. 4. I understand that this consent from will be valid and remain in effect as long as I (he/she) attend the clinic. 5. This form has been fully explained to me and I understand its contents. Signature of patient or authorized person to consent for patient Signature of person who explained the consent of this form If this patient is a minor or unable to consent complete the following: A. Patient is a minor of years of age. Father s Name Mother s Name B. Patient is unable to consent because. Pharmacy Preference For your convenience, please let us know your preferred pharmacy:.

4 About Our Notice of Privacy Practices We are committed to protecting your personal information in compliance with the law. The attached Notice of Privacy Practices states: Our obligations under the law with respect to your personal health information. How we may use and disclose the health information that we keep about you. Your rights relating to your personal health information. Our rights to change our Notice of Privacy Practices. How we file a complaint if you believe your privacy rights have been violated. The conditions that apply to uses and discloses not described in this notice. The person to contact for further information about our privacy practices. CMMC Notice of Privacy provides the above information regarding disclosures of protected health information. Your signature below indicates that you have been provided with a copy of the notice of privacy practices. I hereby acknowledge that I have received a copy of the Notice of Privacy Practices, Living Will, Advance Directive Information and Patient Rights. Signature of Patient Signature of Parent of Legal Representative if applicable Signature of CMMC Employee giving information CMMC respects the right of all patients to comment on and submit expressions of satisfaction and dissatisfaction about their healthcare experience at our facilities. In order to provide our patients or their representative with a mechanism to share their comments or concerns, a dedicated phone line is available twenty-four hours, seven days a week. The number is CMMC encourages patients and their representatives to provide feedback to help us better serve you.

5 Authorization For Release of Medical Information I authorize CMMC to: O Release information to: O Obtain information from: Individual/Agency Address I authorize CMMC to fax-copy this consent for release of information. This authorization will expire in 90 days from signature date. I understand that I may revoke this authorization at any time. Patient Signature Copied and released by This information is needed for: O Continuity of Care O Legal Reasons ODisability O Insurance O Other: s of Service: From: To: Release of Information Authorized To Share Protected Health Information As a patient of CMMC we are obligated to protect your health information. By law, we cannot discuss your health information with anyone but you unless we have written consent that authorized us to do so. If you have family and/or friends that you want us to share your personal health information with, please list them below. A child s (under age 18) health information may be discussed with their legal parent or guardian without a signed authorization. The following individuals MAY BE TOLD about my personal health information., illness or treatment. We must have secure means to make sure that we are speaking to the correct person. Please list the person s name, relationship, date of birth, and last 4 digits of their social security number. They will be asked this information before any information will be released to them. If there is no one that you wish to list, then please mark N/A. Name Relationship of Birth Last 4 of social security number

6 Patient Portal User Agreement CMMC provides a secure patient portal via the internet that is designed to enhance patient, physician, and care team communications and improve patient care and satisfaction. CMMC strives to keep all the information in your records updated, complete and secure. Secure messages and information on the patient portal can only be read by someone who has access to the correct password to log onto the portal site. The Patient Portal is designed to provide the following services: 1. Access and view your Personal Health Record (PHR) 2. secure, non-emergent needs to the care team 3. Request a referral 4. Update your demographic information 5. Request an appointment It is the responsibility of the patient to keep unauthorized individuals from learning their passwords and allowing access to their information or portal account. It is also the responsibility of the patient to notify CMMC of any address changes. CMMC offers a patient portal access to patients 18 years and older. CMMC provides the patient portal as a courtesy to our valued patients. O I do wish to participate in the patient portal and therefore acknowledge and have read and fully understand the above agreement and certify that I am 18 years or older. O I do NOT wish to participate in the patient portal. Patient Name Patient Signature CMMC Employee ***Please note that the patient portal is not for use to communicated emergencies, triage, to provide treatment, or refill medications or narcotics.

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