572 Maddox Drive Suite 217
Ellijay, GA 30540
(706) 698‐5433
NEW PATIENT INFORMATION
MARITAL STATUS
PATIENT’S NAME (PLEASE PRINT)
SS#
DATE OF BIRTH
AGE
Single Married Widowed Divorced
SEX‐ Male / Female
Separated
STREET ADDRESS
CITY AND STATE
ZIP CODE
HOME TELEPHONE NUMBER
PATIENT DRUG ALLERGIES
SPOUSE OR PARENT’S NAME
SPOUSE DATE OF BIRTH
HAS ANY MEMBER OF YOUR FAMILY BEEN TREATED BY OUR
PREVIOUS PHYSICIAN
PERMISSION TO RELEASE INFORMATION TO:
PHYSICIAN BEFORE? INCLUDE PHYSICIAN AND FAMILY MEMBER
HOW DID YOU HEAR ABOUT OUR PRACTICE? NEWSPAPER INSURANCE COMPANY YELLOW PAGES FRIEND OTHER
(NAME)
INSURANCE AUTHORIZATION AND ASSIGNMENT OF BENEFITS
NAME OF POLICY HOLDER
POLICY HOLDER DATE OF BIRTH
INSURANCE ID_____________________________________
POLICY NUMBER__________________________________
I REQUEST THAT PAYMENT OF AUTHORIZED MEDICARE/OTHER INSURANCE COMPANY BENEFITS BE MADE EITHER TO ME OR ON MY BEHALF TO LIFETIME MEDICAL CENTER P.C. FOR ANY
SERVICES FURNISHED ME BY THAT PARTY WHO ACCEPTS ASSIGNMENT/PHYSICIAN. REGULATIONS PERTAINING TO MEDICARE ASSIGNMENT BENEFITS APPLY. I AUTHORIZE ANY HOLDER OF
MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION AND CENTERS FOR MEDICARE AND MEDICAID SERVICES OR ITS INTERMEDIARIES OR
CARRIERS ANY INFORMATION NEEDED FOR THIS OR A RELATED MEDICARE CLAIM/OTHER INSURANCE COMPANY 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 ACCEPTS ASSIGNEMENT. I UNDERSTAND THAT IT IS MANDATORY TO
NOTIFY THE HEALTH CARE PROVIDER OF ANY OTHER PARTY WHO MAY BE RESPONSIBLE FOR PAYING FOR MY TREATMENT (Section 1128B of the Social Security Act and 31 U.S.C. 3801‐3812
provides penalties for withholding this information. )
X
SIGNATURE OF POLICY HOLDER
DATE
NOTICE
OF
PRIVACY
PRACTICES
R
N
P
P
ECEIPT OF
OTICE OF
RIVACY
RACTICES
I acknowledge that I have received / read a copy of LIFETIME MEDICAL CENTER PC’s Notice of Privacy Practices.
YOU ARE ULTIMATELY RESPONSIBLE FOR YOUR BILL
ALL PROFESSIONAL SERVICES RENDERED ARE CHARGED TO THE PATIENT. NECESSARY FORMS WILL BE COMPLETED TO HELP EXPEDITE INSURANCE CARRIER PAYMENTS. HOWEVER, THE
PATIENT IS RESPONSIBLE FOR ALL FEES, REGARDLESS OF INSURANCE COVERAGE. IT IS ALSO CUSTOMARY TO PAY FOR SERVICES WHEN RENDERED UNLESS OTHER ARRANGEMENTS HAVE
BEEN MADE IN ADVANCE WITH OUR BILLING DEPARTMENT. ALL CHARGES ARE DUE AT THE TIME SERVICES ARE RENDERED. I AGREE TO PAY ALL COLLECTION COSTS, COURT COSTS, AND
REASONABLE ATTORNEY FEES IF I FAIL TO PROMPTLY PAY THIS ACCOUNT WHEN DUE AND ANY UNPAID BALANCE IS PLACED WITH A COLLECTION SERVICE.
Insurance is billed as a courtesy for our patients‐ you are ultimately
responsible for any and all charges incurred at this office.
We will make (3) three attempts to bill your insurance. If after that, the charges
are not paid, you will be required to pay the charges in full and then you may file
with your
insurance for reimbursement.
X
PATIENT / GUARANTOR (for minors) SIGNATURE
ACKNOWLEDGEMENT OF INSURANCE AUTHORIZATION, NOTICE OF PRIVICY PRACTICES, RESPONSIBILITY FOR BILL
By signing on the above line, I acknowledge consent to all (3) three sections listed above.