New Patient Registration Form (Page 2 of 3) in pdf

Patient Authorization for ePRESCRIBE

ePrecribing is a physician's ability to electronically send an accurate, error free, and understandable prescription directly to a

pharmacy from the practice. ePrescribing greatly reduces medication errors and enhances patient safety. Understanding all of

the above, I hereby authorize the physician and/or staff of UDFMC to enroll me in the ePrescribe Program. .

Patient signature ____________________________________________

Date ___________________________

Patient Authorization for PHARMACY BENEFITS MANAGER

I authorize the physician and/or staff of UDFMC to request and obtain my prescription medication history from other healthcare

providers, the pharmacy benefit manager and/or any third party pharmacy payors for treatment purposes.

Patient signature ____________________________________________

Date ___________________________

Patient Authorization for MEDICARE PATIENTS

I authorize the physician and/or staff of UDFMC to release to the social security administration, Health Care Financing

Administration or its intermediaries or carriers any information needed for this or any Medicare claim. I permit a copy of this

Authorization to be used in place of the original and request payment of medical insurance benefits either to myself or to the

party who may cause Medicare payment information to cross over automatically to my supplement insurer. I understand that I

am financially responsible for any services deemed non-covered by Medicare.

Patient signature ____________________________________________

Date ___________________________

Patient Authorization for PPO and HMO PATIENTS

I authorize the physician and/or staff of UDFMC to release to my insurance company or its representative any information

including the diagnosis and records of any treatment or examination rendered to me during medical or surgical care. I

authorize and request my above named insurance company to pay directly to UNITED DOCTORS FAMILY MEDICAL

CENTER the amount due for medical or surgical services. I understand that I am financially responsible for any services

deemed non-covered by my insurance company.

Patient signature ____________________________________________

Date ___________________________

Patient Authorization for ALL PATIENTS

I understand that I am financially responsible for services in the office and that refunds from services charged on a credit card

will be returned to the same credit card. Furthermore, I also understand that any account balance that is not paid may be sent

to a collection agency. Should any delinquent account balance be referred to a collection agency, I understand that I will be

financially responsible for any and all cost and fees relating to the collection of my debt. I also authorize my physician and

UDFMC to photograph me for medically related documentation purposes.

Patient signature ____________________________________________

Date ___________________________

Special Accommodations

If a patient requires an accommodation for their appointment, the individual or his/her representative must notify UDFMC of the

needed accommodation one week prior to the first new patient appointment. Subsequent appointments also require one

week’s notice.

Under the American with Disabilities Act, “Providers are responsible for incurring all costs of providing

reasonable aid and cannot pass that charge onto the patient or to his/her insurance company.” If a patient who has requested

accommodations does not provide a minimum of 24 hours’ notice to cancel the appointment or does not show to the scheduled

appointment, all charges incurred by UDFMC is the patient’s responsibilities.

Patient signature ____________________________________________

Date ___________________________

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

Notice to patients: We are required to provide you with a copy of our Notice of Privacy Practices which states how we may use

and/or disclose your health information. Please sign this form to acknowledge receipt of the notice. You may refuse to sign the

acknowledgement, if you wish. I acknowledge that I have received a copy of the UDFMC’S Notice of Privacy Practices.

____________________________________

_________________________________________

_______________

Printed name

Signature

Date signed

New Patient Registration Form Page 2

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