Immediate Care Patient Registration

IMMEDIATE CARE PATIENT REGISTRATION

Today’s Date: ______Arrival Time: ______(PAYMENT IS DUE AT THE TIME OF SERVICE)

Primary Care Physician: ______Phone Number: ______

WHAT IS THE REASON FOR YOUR VISIT HERE TODAY? ______

Date of Onset of symptoms, or Date of Accident or Injury: ______

If you are here for an injury, is it:  Work Related?  Auto Related?

Ethnicity:  Hispanic or Latino  Non-Hispanic or Latino  Unknown or Not Reported  Refused or Undetermined

Race: American Indian or Alaskan Native  Asian  Black or African American  Multiracial

 Native Hawaiian or Other Pacific Islander  Refused or Undetermined  White

PATIENT INFORMATION

Patient’s Full Name: ______Sex: Male  Female

FIRST, MIDDLE, LAST

Date of Birth: ______Age: ______Social Security Number: ______

(If 18 years of age or older.)

Street Address: ______Primary Language Spoken: ______

City: ______State: ______Zip: ______

Home: ______Work: ______Cell: ______

Email: ______

PATIENT EMPLOYER INFORMATION

Employer Name: ______Employer Phone Number: ______

Employer Address: ______

ADULT ACCOMPANYING PATIENT IF PATIENT IS UNDER 18

Full Name: ______Relationship to Patient: ______

FIRST, MIDDLE, LAST

Date of Birth: ______Social Security Number: ______Sex: Male  Female

Street Address: ______

City: ______State: ______Zip: ______

Home: ______Work: ______Cell: ______

INSURANCE INFORMATION
PRIMARY INSURANCE: / SECONDARY INSURANCE:
ID#: / ID#:
GROUP#: / COPAY: / GROUP#: / COPAY:
PATIENT RELATIONSHIP TO THE SUBSCRIBER:
 Self  Spouse  Child  Other ______/ PATIENT RELATIONSHIP TO THE SUBSCRIBER:
 Self  Spouse  Child  Other ______
SUBSCRIBER INFORMATION/POLICY HOLDER
(if different than patient)
NAME: ______
ADDRESS: ______
ADDRESS(2): ______
PHONE: ______
SS#: ______
DOB: ______/ SUBSCRIBER INFORMATION/POLICY HOLDER
NAME: ______
ADDRESS: ______
ADDRESS(2):______
PHONE: ______
SS#: ______
DOB: ______

** PLEASE SEE REVERSE SIDE **

FMH IMMEDIATE CARE PATIENT REGISTRATION

Release of Information and Medical Consent

I understand that I am under the supervision of my attending and/or treating physicians. I consent to any medical procedure, treatment/exam, or services rendered to me under the general and special instructions of my physicians. I authorize FMH to disclose all or any part of my medical records to any insurance company, third party payor, community service agency, nursing facility or to any representative or agent of such insurance company or third party-payor for the purpose of obtaining payment or relevant to my continuum of care for services provided to me. I intend this authorization and consent to apply to information relative to chemical dependency and/or mental health diagnosis and/or treatment, to the extent and only in such amount as is necessary to allow for the purpose described above.

Patient Signature: ______Date: ______

Patient Representative: ______Date: ______

Assignment of Benefits/Financial Agreement

I hereby authorize payment of health insurance benefits directly to FMH Immediate Care, not to exceed the balance due of the Provider’s customary charges for the services rendered. I understand that I will be responsible for all fees and charges deemed as my responsibility according to FMH Immediate Care and my health plan. I understand that if I do not provide a VALID insurance card before services are provided, I will be held financially responsible for all services. I further agree that I will pay any outstanding amounts in accordance with FMH Immediate Care’s rate and terms. Should the account be referred to an attorney for collection, I will pay reasonable attorney’s fees and collection expenses, and I understand that all delinquent accounts bear interest at the legal rate. I also understand that it is my responsibility todetermine which laboratory participates with my insurance plan. Errors in this determination may result in denial of payment by the insurance company, in which case the financial responsibility will be my own.

I CERTIFY THAT I HAVE READ THE FOREGOING AND THAT I AM THE PATIENT OR DULY AUTHORIZED TO ACT ON BEHALF OF THE PATIENT. I AGREE TO THE TERMS STATED ABOVE.

Patient Signature: ______Date: ______

Patient Representative: ______Date: ______

Acknowledgement of Receipt of Privacy Notice

I acknowledge that I have been given the opportunity to read the Privacy Policy for FMH Immediate Care, and understand my rights according to this policy. I understand that the HIPAA law grants FMH Immediate Care Providers authorization to use and disclose my medical information for the purpose of treatment and payment operations.

Patient Signature: ______Date: ______

Patient Representative: ______Date: ______

Communications Authorization

If representatives of FMH Immediate Care are unable to reach me regarding lab results, I authorize them to leave messages regarding those results at my  HOME /  CELL phone number (please check boxes).

Patient Signature: ______Date: ______

Patient Representative: ______Date: ______

Release of Information (If 18 years of age or older)

I understand that because I am 18 years or older, FMH Immediate Care and its representatives are not authorized to share my medical information with anyone other than staff members directly involved in my care (including spouses). Because of this, I would like to authorize the following person(s) to access my medical records:

Name: ______Relationship: ______

Name: ______Relationship: ______

I understand that this authorization can be cancelled at any time through a written request.

Patient Name: ______Date: ______

Patient Signature: ______Date: ______