Sample Patient Registration Form printable pdf download

___Healthway Primary Care ___Austin Plaza Primary Care ___WCMH-Urgent Care ___Bonne Terre Medical Group ___Potosi Rural Health Clinic

Patient Registration Form

Patient Name_______________________________________ Sex: M / F Date of Birth______________ SS#___________________

Mailing Address_____________________________________________City_______________________Zip Code_______________

Home Ph ___________________Cell Ph__________________ Status: S M D W Separated Smoker: Y / N Smokeless Tobacco: Y/ N

Race: Oriental/Black or African American/White/Multi-Racial/Other/Decline

Ethnicity: Hispanic / Non-Hispanic

Last Physician & Date__________ ________Emergency Contact & Relation ________________________Ph #_________________

Patient Employer __________________________Address __________________________Phone #___________________________

Spouse______________________ Date of Birth______________ SS#__________________ Spouse Employer___________________

Parent or Insured Party (if not parent)

Father/Stepfather__________________________ DOB____________SS#___________________ Employer____________________

Mother/Stepmother_________________________ DOB_____________SS#_________________ Employer____________________

Guardian/Relationship____________________________ DOB___________SS#_______________ Employer____________________

Absent Parent_______________________ DOB______________SS#________________ Address & Ph #_______________________

Insurance (bring proof of insurance to each visit)

Primary Ins_________________________________ Member ID#_______________________ Group#_________________________

Secondary Ins_______________________________ Member ID#_______________________ Group#_________________________

Care Preferences

Pharmacy of Choice _______________________City___________________ Ph# ____________________Fax #__________________

Do we have your permission to:

•

Leave a message on your answering machine or voice mail?

Yes

•

Leave a message at your place of employment?

Yes

N/A

•

Discuss your medical condition with any member of your household?

Yes

•

Discuss your medical condition with a specific friend or relative?

Yes

If so, whom?__________________________________ Relationship____________________________________

Notification of Advanced Directives

Please indicate by initializing below if you have any of the following types of advanced directives to let your physician and family know what your

desires for medical care are if you become unable to communicate them. If in place please provide a chart copy.

(

) Durable Power of Attorney for Health Care (

) Health Care Choices Directive

(

) Living Will

(

) None

Authorization to Release Information and Assignment of Benefits

•

I hereby give authorization for payment of insurance benefits to be made directly to WCMH - RHC and any assisting physicians, for services rendered. I understand

that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collection, and

reasonable attorney's fees. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits.

•

I further agree that a photocopy of this agreement shall be as valid as the original.

•

I understand by signing below that I am giving permission for the Practice to deliver medical care to me.

•

I acknowledge that I have been provided with WCMH-RHC's Notice of Privacy Practices.

•

I authorize any holder of medical or other information about me to release to the Social Security Administration and CMS or its intermediaries or carriers any

information needed for this or related MCR claim.

•

I understand that it is mandatory to notify the healthcare provider of any other party who may be responsible for paying for my treatment. (Section 1128B of SS act

and 31 U.S.C. 3801-3812 provide penalties for withholding this information). Regulations pertaining to MCR assignments of benefits also apply.

•

I understand that should I qualify for the Sliding Scale Program it is my responsibility to obtain the required information within the allotted time frame or the

charges revert back to standard rates.

•

Authorization to obtain medication list both current and inactive via pharmacy records, insurance company and or Sure Scripts.

•

Some healthcare services at this facility may be offered via telemedicine. Potential risks of this technology include interruptions, unauthorized access and technical

difficulties. I understand that telemedicine is a billable service from provider and a possible facility fee charge. Telehealth presenters may be present during my

encounter to manager the cameras and perform any hands on activities to complete the exam. In emergent consultation, the specialist’s responsibility will conclude

upon the termination of the video conference connection.

List all legal guardians & relationship of minor for consent of treatment ________________________________________________

Signature

______________________________________________________ Date______________________________

WCMH

300 Health Way

Potosi, MO 63664

Revised 9/15/14