Houston Primary Care REGISTRATION FORM (Please Print)

Transcription

1 Houston Primary Care REGISTRATION FORM (Please Print) Today s date: PATIENT INFORMATION Patient s First and last name: Middle Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex: Yes No / / M F Street address: Social Security no.: Race: City: State: Zip Code: Home Phone no: Cell Phone no: ( ) ( ) Occupation: Employer: Employer phone no.: ( ) Chose clinic because/referred to clinic by (please check one box): Dr. Insurance Plan Hospital Family Friend Close to home/work Yellow Pages Other Other family members seen here: INSURANCE INFORMATION (Please give your insurance card to the receptionist.) Person responsible for bill: Birth date: Address (if different): Home phone no.: / / ( ) Is this person a patient here? Yes No Occupation: Employer: Employer address: Employer phone no.: ( ) Is this patient covered by insurance? Yes No Name of primary insurance Subscriber s name: Subscriber s S.S. no.: Birth date: Group no.: Policy no.: / / Patient s relationship to subscriber: Self Spouse Child Other Name of secondary insurance (if applicable): Subscriber s name: Group no.: Policy no.: Patient s relationship to subscriber: Self Spouse Child Other IN CASE OF EMERGENCY Name of local friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.: ( ) ( ) The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Houston Primary Care or insurance company to release any information required to process my claims. Patient/Guardian signature Date

2 Houston Primary Care 1719 Russell Parkway, Bldg 700 Warner Robins, GA PATIENT FINANCIAL POLICY Thank you for choosing us as your health care provider. We are committed to building a successful physician-patient relationship with you. Please understand that payment for services are a part of that relationship. The following is a statement of our Financial Policy, which we require you to read and sign prior to treatment. PATIENT INFORMATION: A fully completed, current patient registration will be on file in the patients chart. Patient registration will be updated yearly and will include where the patient can be reached by phone. A signature by the responsible party is required. If there is a change of residence or phone numbers it is the responsibility of the patient to notify us of the change. INSURANCE CLAIMS: PRIMARY INSURANCE: Houston Primary Care will file claims with the patient s insurance upon the patients submission of proof of coverage (i.e. insurance card, identification number and group number ) Patient is also required to bring their insurance card to every visit. Upon receipt of the insurance card Houston Primary Care will submit the health insurance claim form. SECONDARY INSURANCE: Claims will be filed with secondary insurance if adequate information is received at the time of service. However, if payment is not received in our office within 45 days after filing, the balance will be transferred to the patient and due upon receipt. While filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility for all services rendered. PATIENT FINANCIAL RESPONSIBILITY: If insurance is not to be filed by Houston Primary Care is not a participating provider, full payment is due at the time of services are rendered. Co-payments and non-covered services are due at time of service. Deductibles and Co-Insurance will be collected after we receive payment from your insurance company. We accept Checks, Money Orders, Cash and Credit Cards excluding Amex. There is a fee of $25.00 for all returned checks. Houston Primary Care THE PATIENT IS RESPONSIBLE FOR ALL FEES, COVERAGE IS NOT A GUARANTEE OF PAYMENT. IF CLAIM SUBMITTED BY OUR OFFICE IS DENIED, BALANCE WILL BE TRANSFERRED TO PATIENT. PATIENT WILL BE RESPONSIBLE FOR OBTAINING REIMBURSMENT FROM INSURANCE COMPANY UNLESS PRIOR ARRANGEMENT HAVE BEEN MADE. ASSIGNMENT & RELEASE I hereby authorize my physician to furnish my insurance company or their representatives information concerning my illness or treatments. I hereby assign the payment of my insurance benefits to my physician for medical services rendered and understand that I am responsible for any amounts not covered by insurance.

3 ACCOUNTS PAST DUE: Visa/MasterCard/Discover payments are accepted by phone. In the event an account is turned over to collection, the person financially responsible for the account will be responsible for all collection costs. A patient may remit in full all outstanding charges after the account has been placed with collections but the collection charge will also be due even if presented at office. Houston Primary Care is charged collection fees once the account has been processed through collections and is still responsible to repay fees collected in office. ACCOUNT CONSULTATION: Physicians do not discuss financial issues. Our billing Company Iron Comet Billing is trained to discuss your account and will be happy to help you. If you need further assistance, you may contact them by at BillingInquiresHoustonPrimary@IronComet.com MEDICAL RECORDS: If you require a copy of your records there is a charge for this. The charge varies depending on how many pages are needed to be copied. There is no charge for records to be sent to another facility but please notify us as soon as possible. Legally we have 30 days after we receive written authorization from the patient. NO SHOW/CANCELLATION CHARGE: In order to be respectful of the medical needs of the community, please be courteous and call our office promptly if you are unable to attend an appointment. We require at least 24 hours notice, so that your appointment time can be reallocated to someone else. Late cancellations will be considered as a no show. A no show is someone who misses an appointment without canceling it at least 24 hours in advance or who fails to keep a scheduled appointment. In the event a 24 hour notice is not given, a fee of $35.00 will be charged for missed office visits at the discretion of your physician. I have reviewed and understand Houston Primary Care Financial Policy. SIGNATURE OF PATIENT / RESPONSIBLE PARTY PATIENT NAME DATE DATE OF BIRTH WITNESS DATE

4 HOUSTON PRIMARY CARE LIFETIME AUTHORIZATION INSURANCE ASSIGNMENTS AND AUTHORIZATION TO RELEASE INFORMATION I. RELEASE OF INFORMATION - I, the below-named patient, do hereby authorize any physician examining and/or treating me to release to any third payer (such as an insurance company or governmental agency, example: Blue Shield of Georgia or Medicare) any medical condition and records concerning diagnosis and treatment when requested by such third party for its use in connection with determining a claim for payment for such treatment and/or diagnosis. II. PHYSICIAN INSURANCE ASSIGNMENT - I, the below-named subscriber, hereby authorize payment directly to any physician examining or treating me of any group and/or individual surgical and/or medical benefits herein specified and otherwise payable to me for their services as described but not to exceed the reasonable and customary charge for these services. III. MEDICARE/MEDICAID - Patient s certification authorization to release information and payment request: I, the below-named patient, certify that the information given by me in applying for payment under Title XVIII/XIX of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to Social Security Administration/Division of Family Services or its intermediaries or carries any information needed for this of a related Medicare/Medicaid claim. I hereby certify all insurance pertaining to treatment shall be assigned to the physician treating me. IV. I PERMIT A COPY OF THESE AUTHORIZATIONS AND ASSIGNMENTS TO BE USED IN PLACE OF THE ORIGINAL WHICH IS ON FILE AT THE PHYSICIAN S OFFICE. This assignment will remain in effect until revoked by me in writing. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. I understand it is my responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by my insurance or third payer within a reasonable period of time not to exceed 90 days. If this account is assigned to an attorney for collection and/or suit, the prevailing party shall be entitled to reasonable attorney s fees and costs of collection. Date: _ Patient Name (please print): Patient Authorization: DOB / / Signature SUBSCRIBER (if different from patient) Signature ORIGINAL SIGNATURE ON FILE AT PHYSICIAN S OFFICE

5 Houston Primary Care Medical History Allergies to Medications, X-ray Dyes, or Other Substances No Yes (If yes, please list names of medicine and type of reaction): Past Medical History and Review of Systems (Please circle if you have had problems with or are presently complaining of any of the following): 1. High Blood Pressure 13. Bronchitis 25. Change in bowel habits 37. Arthritis 2. Diabetes 14. Pneumonia 26. Unexplained weight gain/loss 38. Low back problems 3. Cancer 15. Persistent Cough 27. Hemorrhoids 39. Skin diseases 4. Heart disease 16. T.B. 28. Gall bladder disease 40. Blood disorders 5. Chest pain/chest tightness 17. Hay fever 29. Colitis 41. Venereal disease 6. Shortness of breath 18. Abdominal discomfort 30. Hepatitis or jaundice 42. Anxiety 7. Swollen Ankles 19. Indigestion 31. Thyroid Disease 43. Depression 8. Palpitations 20. Nausea 32. Head or Neck radiation 44. Anemia 9. Lightheadedness 21. Vomiting 33. Headache 45. Alcohol Abuse 10. Frequent Urination 22. Constipation 34. Kidney disease 46. Drug Abuse 11. Rheumatic Fever 23. Diarrhea 35. Kidney Stones 47. Gout 12. Asthma 24. Blood in stool 36. Difficulty urinating 49. Gynecologic and Obstetric History Age at onset of periods: Frequency: Pregnancies: Abortions: Births: Miscarriage: Prolonged or abnormal bleeding: No Yes (Please Describe): Leakage of urine: No Yes (Please Describe): Pelvic Pain: No Yes (Please Describe): Abnormal discharge: No Yes (Please Describe): History of abnormal Pap smear No Yes (Please Describe): Medications (Prescriptions, Over-the-Counter, Vitamins, Herbs, etc.) Drug Name Date Drug Name Date Pharmacy Name Phone Number Location

6 Please List and Supply the Dates of: Operations: Hospitalizations other than for surgery: Immunizations history have you had: Pneumovax immunization? No Yes When? Hepatitis B? No Yes When? Flu immunization? No Yes When? Other? No Yes When? Tetanus immunizations? No Yes When? When was your last: Pap Smear? Mammogram? Breast Exam? Stool Check for blood? Cholesterol? Prostate Exam? Family History Has any member of your family (including parents, grandparents, and siblings) ever had the following? Illness Which Family Members? Approx. age when Diagnosed? Cancer (describe type) Hypertension (High Blood Pressure) Heart disease Diabetes Strokes Mental disease (anxiety, Depression) Drug or alcohol addiction Glaucoma Bleeding disease Other Prevention Do you wear seat belts? No Yes If no, why not? Do you wear a bike helmet? No Yes N/A Do you Smoke? No Yes If yes, How many packs per day? Do you drink alcoholic beverages? No Yes If yes, how much per week? Do you drink coffee? No Yes If yes, how many cups per day? Do you drink tea? No Yes If yes, how many cups per day? If there is a gun in your home, is it out of No Yes N/A children s reach and unloaded? Do you use drugs? (marijuana, cocaine, crack, etc.) No Yes If yes, explain: Have you ever engaged in any activity which has No Yes If yes, explain: Put you at risk of getting AIDS? Do you wish to be tested for AIDS? No Yes Have you ever worked with chemicals, paints, No Yes If yes, explain: Asbestos, or other hazardous materials? Are you in a relationship in which you have been No Yes physically hurt (e.g. slapped, kicked, punched, bruised) by your partner? Do you ever feel afraid of your partner? No Yes Do you have a living will? No Yes Do you have a donor card? No Yes Method of birth Control?

7 Houston Primary Care, Inc 1719 Russell Parkway, Building 700 Warner Robins, GA Tel / Fax Notice of Privacy Practices Acknowledgement of Receipt We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Privacy Officer in person or by phone at our main phone number listed above. Signature below is only acknowledgement that you have received this Notice of our Privacy Practices: Nane Signature Date HIPAA I wish to be contacted in the following manner (check all that apply): Home Telephone O.K. to leave message with detailed information Leave message with call-back number only Home Telephone O.K. to leave message with detailed information Leave message with call-back number only Written Communication O.K. to mail to my home address Communication O.K. to communicate via Cellular Telephone O.K. to leave message with detailed information Leave message with call-back number only Patient Signature Date Print name Birth date