Patient Release Form - Lemire Clinic printable pdf download

Patient Release Form

Please Print Clearly

Patient First Name _______________________ Middle Name _______________________ Last Name_______________________

Social Security Number _______-____-__________ Date of Birth ____ / ____ / _______ Sex

Male

Female

Marital Status:

Single

Married

Divorced

Separated

Widowed

Patient Address ________________________________________ City __________________ State ___________ Zip ___________

Alternate Address _______________________________________ City __________________ State ___________ Zip ___________

Home Phone _________________________ Work Phone ________________________ Other Phone ________________________

E-mail ______________________________________________________________________

we will NEVER give your email address to anyone.

Occupation _________________________________________ Employer________________________________________________

Emergency Contact Name _________________________________ Relationship _________________ Phone __________________

Yes No

Please bring in copy.

Advanced Directives

How were you referred to our office? ________________________________________________

__________________________________________________________________________

Type of medical insurance:

Commercial Insurance

Medicare

Medicaid

None

Insured Name ______________________ _______________Phone ______________________________________

Insured’s Social Security Number _______-____-__________ Insured Date of Birth ______ / ______ / _______

Primary Insurance Carrier: _______________________________________________ Policy #_________________________________

Secondary Insurance Carrier _____________________________________________ Policy # _________________________________

I acknowledge Lemire Clinic’s Confidentiality of Health Information Procedure’s and Privacy Practices.

I understand that confidential information will not be disclosed by Lemire Clinic in violation of applicable law, including but not limited

to Health Insurance Portability and Accounting Act (HIPAA). Any information containing patient identity that is no longer needed will

be shredded immediately. Every precaution will be taken to keep patient information private. Patient charts or computer screens with

patient information will not be visible to other patients or individuals. Telephone conversations when a patients name will be mentioned

should not be made where others may hear and patient sign in will be kept confidential.

I have been provided with Lemire Clinic’s Notice of Privacy Practices and am signing below in acknowledgement of

receipt of these procedures.

I understand that I am financially responsible for any balance not covered by my insurance carrier. I also understand that charges for any

services not covered by my insurance are due at the time of service. I also understand it is my responsibility to inform the staff of which

laboratory (Blood work) and diagnostic center (X-rays, ECT.) my insurance company will allow me to use.

I understand it is entirely my responsibility to keep my scheduled appointments.

I understand that, regardless of the reason, failing to keep any of my scheduled appointments without providing sufficient advanced

notice of at least 24 business hours will result in a $45 fee, which is my responsibility to pay BEFORE any other appointments will be

scheduled.

I understand that leaving a voice message outside of normal business hours such as evenings, weekends, or holidays to cancel my

scheduled appointment for the next business day does not constitute 24 business hours’ notice, and will result in a fee, which is my

responsibility to pay BEFORE any other appointments will be scheduled.

I understand that repeatedly failing to keep my scheduled appointments without providing sufficient advanced notice will result in my

being discharged from the practice.

I understand that if I am 15 minutes late to my scheduled appointment, my appointment may be rescheduled.

I understand that if I or anyone with me wear any scented lotions, perfumes or colognes my appointment will be rescheduled.

I HEREBY STATE THAT THE INFORMATION GIVEN ABOVE IS CORRECT AND I HAVE READ, UNDERSTAND, AND AGREE TO THE

ABOVE STATED TERMS. IF I AM UNDER THE AGE OF 18 MY PARENTS OR LEGAL GUARDIAN WILL SIGN.

________________________________________________________

Date ____ / ____ / _______

Signed

IN CASE OF MINOR OR GUARDIANSHIP: Person responsible for bills if different than Patient.

Name __________________________________________ Relationship _____________________ Phone ______________________

D.O.B. _________________________________________ S.S. # ______________________________________________________

Address ______________________________________________ City ____________________ State _______ Zip _______________

11115 SW 93

Court Rd

Suite 600

Ocala, FL. 34481

Phone: (352) 291-9459

Fax: (352) 291-9465

Patient Release Form - Lemire Clinic

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