PATIENT REGISTRATION Date:

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1 PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN SERVICES ARE RENDERED UNLESS WE PARTICIPATE WITH YOUR INSURANCE PATIENT GENERAL INFORMATION: Last Name: First Name: MI EMERGENCY CONTACT INFORMATION: Contact Name: Contact Relation: Sex: M F Date of Birth: Contact Phone: S.S. # Address: Home Phone: Cell Phone: Work Phone: May we call you at work? Yes No No Preferred Contact # Home Work Cell Language: Race: Ethnicity: Decline to Answer Marital Status: Separated Widowed Married Single Divorced Partner If Minor, Guardian Name Last name, First name, MI Primary Care Physician: How did you hear about us? Advertising Physician Referring Physician s Name: Word of Mouth Patient in the Practice Hospital Insurance Company Other: Please specify CONTACT INFORMATION FOR APPOINTMENT REMINDERS: Do you prefer to receive a: Phone Call or Text Phone #: Preferred time to call: Morning Afternoon Evening Contact Cell Phone: NEXT OF KIN: Name: Relation: Phone: EMPLOYER/SCHOOL INFORMATION: Name: Address: Phone: Occupation: GUARANTOR INFORMATION: Patient s Relationship to Guarantor: GUARANTOR (name to whom statements are sent) Last Name: First Name: MI Guarantor Date of Birth: Mailing Address Same as patient s? Address: Optional Guarantor Information: S.S.#: Phone: VMG_7_PatientRegistration_Rev_01_14.docx Page 1

2 INSURANCE INFORMATION: Policy Holder s Name: Last Name First Name MI Sex: M F Relationship to Patient: Self Mother Father Other: Date of Birth: S.S. # Address: Home Phone: Cell Phone: Work Phone: _ Policy Holder s Employer: Employer s Address: Primary Insurance Company: Policy Holder s ID: Group #: Insurance Company Address: Secondary Insurance Company: Policy Holder s ID: Group #: Insurance Company Address: PHARMACY INFORMATION: Local Pharmacy Name: Phone: Address: Mail Order Pharmacy Name: Phone: Address: PREFERRED LABORATORY: Name: Phone: Address: Fax: WORKER S COMPENSATION INFORMATION (if applicable) W/C Claim Number: W/C Carrier Name: Contact: W/C Carrier Address: Phone: Fax: *Valley Medical Group is the trading as name for Valley Physician Services, Inc., Valley Medical Services, Inc.., and Valley Physician Services, NY, PC VMG_7_PatientRegistration_Rev_01_14.docx Page 2

3 GENERAL CONSENT FOR TREATMENT Name of Procedure: 1. I hereby consent to treatment, including local anesthesia and diagnostic or therapeutic procedures. 2. The nature and effect of the procedure to be performed, the risks involved, as well as possible alternative methods of treatment, and the prognosis if no treatment is rendered, have been explained to me. I am aware that the practice of medicine is not an exact science, there are risks associated generally and that no guarantees about the outcome of this care have been made to me as a result of examinations and `treatment. 3. I authorize my doctor and staff to take any photographs required for the completion of documentation. 4. I understand and agree that Valley Medical Group (VMG)* may disclose any or all parts of my medical record in order to obtain payment for any service rendered to me. 5. I understand that in order to facilitate the best care and treatment, my doctor may need to access information about me from my other providers and facilities where I have received care and services, such as specialists, diagnostic center, laboratories, and he/she may need to access my prescription history information. 6. I understand and agree that VMG may disclose any or all parts of my medical record to other providers for health care services or goods in order to make arrangements for coordinated health care delivery. 7. I understand and agree that the information, which my doctor may disclose, may include information about and/or reference HIV/AIDS related diagnoses/conditions, drug or alcohol use or abuse, pain management and psychiatric or psychological information, reports, evaluations and diagnoses, as well as history and physical examinations results, consultations and treatment recommendations. 8. I understand and agree that other practitioners may assist with the procedure(s) as necessary, and may perform important tasks related to the surgery. 9. After treatment is received, I will follow the medical advice and instructions given and I will continue treatment and follow-up care with the physician/provider to whom I am referred as indicated on this record. 10. I, the undersigned agree, whether the patient or an authorized agent of the patient, that in consideration of the services to be rendered to the patient, I hereby individually obligate myself to pay the account of the practice in accordance with the regular rates and terms of VMG. I certify that I have read and understand this consent form, and that I have been given the opportunity to have any questions related to this treatment which have been answered by the clinical staff of this facility. Patient or Authorized Representative Signature Name of Person Signing Witness Date Relationship to Patient Date *Valley Medical Group is the trading as name for Valley Physician Services, Inc., Valley Medical Services, Inc., and Valley Physician Services, NY, PC VMG_P_6_ConsentForTreatment_Rev_11_13.doc

4 ACKNOWLEDGEMENT OF OUR NOTICE OF PRIVACY PRACTICES I hereby acknowledge by signing below that I have received or have been given the opportunity to receive a copy of Valley Medical Group Notice of Privacy Practices. HIPAA Patient Name (please print clearly) Date Patient/Guardian Signature Person Signing on behalf of the patient Relationship to Patient *Valley Medical Group is the trading as name for Valley Physician Services, Inc., Valley Medical Services, Inc., and Valley Physician Services, NY, PC VMG_5a_AcknowledgementOfOurNoticeOfPrivacyPractices_11_13.docx

5 PATIENT RESPONSIBILITIES AND STATEMENT OF UNDERSTANDING In the current healthcare environment, it is increasingly difficult for medical providers to be paid for their services. Dealing with insurance companies is also becoming more confusing to our patients. As a result, we would like to clarify your responsibilities as a Valley Medical Group patient. Insurance Coverage Your insurance policy is a contract between you and your insurance company, not your provider. Changes to your insurance coverage must be communicated to our office at the time of service upon check-in. Your insurance company may require you to choose a primary care physician in order to receive in network benefits. If you have chosen a Valley Medical Group physician as your PCP and his or her name does not appear on your insurance card, you must verify that your insurance company has the correct information before services are rendered. If your claim is processed incorrectly by your insurer, you give Valley Medical Group permission to appeal the claim on your behalf by your signature below. If your insurance plan requires a PCP and the Valley Medical Group physician is not your PCP, you may be responsible for deductibles, co-insurance, and other non-covered services. If your plan requires referrals from your Valley Medical Group PCP to specialists, it is your responsibility to obtain the referral from our office prior to your appointment with the specialists. Please be aware that non-emergent referrals can take up to two weeks to process. In addition, referrals will NOT be dated retroactively. Financial Obligations 1. Co-payments are due at the time of service. 2. Valley Medical Group will bill participating insurance companies after verifying coverage. If claims are not paid, Valley Medical Group will bill you for services rendered. 3. Payment for non-covered services, deductibles, and co-insurance amounts are due within thirty (30) days of receipt of invoice. 4. If insurance payments are paid to you in error instead of Valley Medical Group, the payment must be forwarded to us. You may issue a personal check to Valley Medical Group. Be sure to include a copy of your insurance company s documentation or explanation of benefits. 5. If you do not have insurance that Valley Medical Group participates with, you are responsible for payment in full for today s services. 6. Processing fees may be imposed for non-payment of out-of-pocket expenses referenced in #1 and #5 above, and for checks returned by the bank for non-payment. 7. Valley Medical Group bills an additional fee for weekend and holiday visits. 8. If requested, you are responsible for providing your insurance company with any other insurance coverage, details of an injury, dependent student information, and other non-medical information. Failure to comply with an insurance company request for information will result in your being responsible for payment. I HAVE READ AND UNDERSTAND THE INFORMATION AND MY RESPONSIBLITIES AS STATED ABOVE: Patient/Guardian: Date: Witness: Date: A copy of this form is available upon request. *Valley Medical Group is the trading as name for Valley Physician Services, Inc., Valley Medical Services, Inc., and Valley Physician Services, NY, PC VMG_3_PtResp&Statement_Rev_11_13.doc

6 AUTHORIZATION TO DISCUSS HEALTH INFORMATION WITH OTHERS AND/OR LEAVE TELEPHONE MESSAGES The purpose of this document is to inform us if we have your permission to: Relay information to other people regarding your care and treatment. Leave information about your care and treatment on your telephone answering machine. Call you at work, and/or on your cell phone or other telephone number. Patient Name: Date of Birth: Address: When our physicians or office staff need to speak with you about your healthcare, we generally place a telephone call and ask to speak with you, our patient, first. Some examples of when we may need to call you are: to see how you are feeling after a visit to us; with follow-up instructions after a visit; and/or with laboratory, radiology, or other diagnostic test results, etc. If you are unavailable when we telephone you, May we leave such information on your answering machine? No Yes Comment: May we leave such information with other people in your household? No Yes Comment: If Yes, please note specifically who: May we contact you at work? No Yes Telephone: May we contact you via cell phone? No Yes Cell phone: Is there any other telephone number you would like us to call to reach you or another person you would like us to contact to discuss your health care? PLEASE INDICATE YOUR PREFERRED METHOD FOR OUR FOLLOW-UP COMMUNICATIONS WITH YOU: Home Phone Cell Phone Work Phone Other: ( can only be used to contact you when all other means fail.) Is there someone you have given the authority to schedule, confirm, or cancel appointments for you? No Yes If Yes, please specify: Patient Signature: Date: Valley Medical Group will abide by the guidelines given in this document unless you instruct us differently. *Valley Medical Group is the trading as name for Valley Physician Services, Inc., Valley Medical Services, Inc.,, and Valley Physician Services, NY, PC VMG_1_AuthToDiscuss_Rev_11_13.doc

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