HOPE MEDICAL,LLC. – PERSONAL INJURY REGISTRATION FORMS
PERSONAL INFORMATION
Name ______SS#______Sex: M/F______
DOB______Place of Birth______Marital Status S / M / D / W / Sep
Street Address ______
City______State______Zip______
Education: □ None ______Yrs High School ______Yrs College ______Yrs Post Graduate □ Other
Telephone: Home______Office______Email______
Spouse’s Name (if any) ______
Spouse’s Employer/Address ______
Emergency Contact ______Tel # ______Relationship ______
Referred by ______
PATIENT’S EMPLOYMENT INFORMATION
Occupation ______Employer’s Name ______
Employer’s street address ______
City ______State______Zipcode______
Telephone Number ______
INSURANCE INFORMATION
Insured Name (if not patient): ______
SS# of Insured: ______DOB______Tel#______
Address of Insured:
City______State, Zip______Relationship to Patient______
Primary Insurance Co. Name______Tel #______
ID#______Group#______HMO/PPO/POS/INDEMNITY
Insured Name on PeachCare / Medicaid / Medicare (Circle applicable option)
ID# (if applicable) ______Expiration Date ______
Name of Patient’s Primary Physician (or one assigned to Insured Card, if any) ______
Address of Physician ______Tel # ______
How many times have you (or patient) seen a physician in the last 12 months? ______times/year
GBHC Authorization/approval (for Hope Staff only):
IRREVOCAL ASSIGNMENT OF BENEFITS:
______, with this information, I hereby authorize the assignment of all medical, insurance, and disability benefits (where applicable) to Hope Medical Group, and/or their Physicians, for serviced rendered to me. I also authorize the release of any medical information necessary to process this claim. I permit a copy of this authorization to be used in place of the original. I fully understand that regardless of any insurance coverage I might have, I am still (and solely) responsible for all the charges incurred during my treatment. I understand that I am responsible for any co-payments and deductibles at the time of service. In the event of non-payment, I further agree to bear the cost of collection, and/or court cost, including legal fees. Returned personal checks will incur additional fifty dollars ($50.00), to cover bank and administrative cost. The cost of collection, which is forty percent (40%) of outstanding balance, will be added to delinquent accounts, after 60 days, if such account is placed with a Collection Agency.
Signature ______Relationship to Patient______Date______
FOR PERSONAL INJURY PATIENTS ONLY
The undersigned, being the Attorney of Record, for the above named Patient, by such signature below acknowledges receiving and accepting a copy of this Irrevocable Assignment of benefits.
Name______Law Firm______ Date ______
Date ______
Dear Patient:
We need this confidential information answered completely to help us assess your needs for care. If we do not sincerely believe your condition will respond to chiropractic care, we will not accept you as a patient. Thank you.
GENERAL INFORMATION
Name ______Sex ______Date of Birth______
Address ______
City______State______Zip Code______
Home Phone______Work Phone______
NATURE OF ACCIDENT
1.What was the time and date of this present injury? DATE______AM/PM
2. Please explain the details of your accident. ______
______
3. Were you ______driver ______passenger ______front seat ______back seat
4. What direction were you headed at time of accident? North / South / East / West (Please circle)
5. What direction was the other vehicle headed at time of accident? North / South / East / West (Please circle)
6. Were you struck from? BEHIND / FRONT / LEFT SIDE / RIGHT SIDE (please circle)
7. How many vehicles were involved in the accident? ______
8. Were you wearing a seat belt? ______Other protective devices? ______
9. Did you come in contact with any objects in the car? ______If yes, what objects? (i.e. windshield, steering wheel, door frame). ______
______
10. What part of your body came into contact with the above objects? ______
______
11. Were you unconscious as a result of the injury? ______If yes, how long? ______
12. Were you bleeding as a result of the injury? ______
13. Where did you feel pain or unusual feeling immediately after the accident? ______
______
14. Were the police notified? ______
15. Where were you taken after the accident? ______
16. What treatment did you receive? ______
17. Was any other doctor consulted after your accident? ______
18. Describe the doctor’s diagnosis? ______
19. What treatment did you receive? ______
20. Are you still under doctor’s care? ______If yes, please explain. ______
______
PAST HISTORY
1.Have you enjoyed good health prior to this accident? ______. If no, please explain ______
______
2. Have you ever injured this area before? ______If yes, when? ______
3. Have you been treated previously by a chiropractor? ______If yes, explain. ______
______
4. Have you been involved in any previous accidents of any kind (personal, automobile accident, or worker’s compensation?) ______If yes, explain details and date ______
______
PRESENT INFORMATION/DISABILITY
- Have you returned to work? ______If yes, what date ______
- Job description: ______
______
- Are your work activities restricted as results of this accident? ______If yes, explain ______
______
- Do you notice any activity restrictions as a result of this accident? ______If yes, please explain ______
______
- Since this injury are your symptoms improving ______getting worse ______or the same? ______
LEGAL REPRESENTATION
- Have you retained an attorney? ______Please gives us the name and address ______
______
I, certify that I have read and understand the above questions. To the best of my knowledge, the above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.
______
Patient’s signature Date
______
Doctor’s Signature (upon review)Date
Hope Medical Group, P.C. & Hope Medical Group, Urgent Care, Inc.
5300 Memorial Drive, Suite 112, Stone Mountain, Georgia 30083
Tel: (678) 704 – 0306 Fax: (678) 704 – 0706
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES
______has received a copy of Hope Medical Group, P.C. Notice of Privacy Practices.
Print Name ______
Signature ______
Date ______
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For Office Use Only
On ______at ______we made a good faith attempt to obtain written acknowledgement of receipt of our NPP, but acknowledgement could not be obtained because of the following reasons:
______*Patient refused to sign
______*Communication barriers prevented obtaining a receipt
______*An emergency prevented obtaining a receipt
______*Other, ______
Hope Medical Group, P.C. & Hope Medical Group, Urgent Care, Inc.
5300 Memorial Drive, Suite 112, Stone Mountain, Georgia 30083
Tel: (678) 704 – 0306 Fax: (678) 704 – 0706
INSURANCE LIEN
______
PATIENT’S NAMEDATE OF BIRTHDATE OF LOSS
DOCTOR: HOPE MEDICAL GROUP, P.C. & HOPE MEDICAL GROUP URGENT CARE, INC.
I do hereby authorize the above insurance company to pay all medical expenses furnished by the above Doctor’s diagnosis for my self in regards to the accident in which was involved.
I fully understand that I am directly and fully responsible to said doctor’s for all medical bills submitted by him/her for services rendered to me and the agreement is made solely for said Doctor’s additional protection and in consideration of his/her awaiting payment. And I further understand that neither such payment is nor contingent on any settlement judgment or verdict by which I may eventually covered said fee.
______
Patient Policy Holder SignatureDate
Hope Medical Group, P.C. & Hope Medical Group, Urgent Care, Inc.
5300 Memorial Drive, Suite 112, Stone Mountain, Georgia 30083
Tel: (678) 704 – 0306 Fax: (678) 704 – 0706
PATIENT AGREEMENT FOR COMMUNICATIONS
I, ______understand that as part of my health care, Hope Medical Group, P.C. will need to contact me from the time for the purpose of reminding me of an appointment, relaying results of test, advising me of special precautions and measures that I need to follow prior to a procedure, etc. I hereby authorize Hope Medical Group, P.C. to contact me in the following ways:
Home Phone ______
Cell Phone ______
Office Phone______
Email ______
Fax ______
Other ______
I understand that Hope Medical group, P.C. will use the minimum necessary information needed when they communicate with me indirectly. I understand that I can revoke or amend this agreement at any time. Any revocation or change will not apply to communications already completed.
______
PATIENT’S SIGNATUREPATIENT’S SSNDATE OF BIRTH
______
DATE
Hope Medical Group, P.C. & Hope Medical Group, Urgent Care, Inc.
5300 Memorial Drive, Suite 112, Stone Mountain, Georgia 30083
Tel: (678) 704 – 0306 Fax: (678) 704 – 0706
DOCTOR’S LIEN
______
PATIENT’S NAMEDATE OF BIRTHDATE OF LOSS
TO ATTORNEY______
______
______ / DOCTOR
HOPE MEDICAL GROUP, P.C.
5300 Memorial Drive
Suite 112
Stone Mountain, GA 30083
I hereby do authorize the above Doctor to furnish you, my attorney with a full report of his examination, diagnosis treatment, prognosis, etc. of my self in regards to the accident in which I was involved.
I hereby authorize and direct you, my attorney to pay directly to said doctor such sums as may be due and paying for medical services rendered to me both by reason of this accident and by reason of any other bills that are due his office and to withhold such sums from any settlement, judgment, or verdict as may be necessary adequately protect said doctor. Any hereby further give a lien on my case to said doctor against any all proceeds of settlement, judgment, or verdict which may be paid to you, my attorney, or myself as the result of my injuries for which I have connection there with.
I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by his services rendered and that agreement is made solely for said doctor’s additional protection and in consideration of his awaiting payment. I further understand that such payment is not contingent on any settlement, judgment, or verdict by which I may eventually recover said fee.
______
PRINT YOUR NAMESIGNATUREDATE
The undersigned being attorney of record for the above patient does hereby agree to observe all the term the above and agree to withhold such sums from any settlement, judgment, or verdict as may necessary to adequately protect said doctor named above.
______
PRINT ATTORNEY NAMEATTORNEY’S SIGNATUREDATE
Hope Medical Group, P.C. & Hope Medical Group, Urgent Care, Inc.
5300 Memorial Drive, Suite 112, Stone Mountain, Georgia 30083
Tel: (678) 704 – 0306 Fax: (678) 704 – 0706
NOTICE OF PRIVACY PRACTICE
Effective April 14, 2003 a new federal healthcare law took effect across America. The Health insurance Portability and Accountability Act (HIPAA) Rule. This rule provides specific requirements aimed at protecting your privacy.
Hope Medical Group, P.C. and Hope Medical Group Urgent Care, Inc. values the importance of trust and privacy involved in the physician-patient relationship and is committed to complying with these and all other regulations pertaining to your privacy.
We have provided this general information about the Privacy Rule to help you better understand your rights and roles in protecting those rights.
What is Privacy Rule?
The privacy rule is a federal law requiring doctors and others involved in providing your healthcare to develop procedures regarding the use and the release of your health information. It requires that our privacy practices, called Notice of Privacy Practices, be shared with you.
The Rule permits the use and release of information necessary for your treatment, payment of your healthcare, and our healthcare operation. The Privacy Rule requires your consent before releasing your information for purposes other than treatment, payment of your healthcare and the healthcare operations of our practice.
How does HIPAA help protect my privacy?
- It gives you more control over your healthcare information
- It sets boundaries on the use and release of healthcare information
- It establishes safeguards to protect the privacy of health information
- It holds violators accountable
- It enables you to find out how your information may be used and what releases of your information have been made.
- It limits release of information to the minimum needed to accomplish the purpose for the release
- It gives you the right to examine and obtain a copy of your health records and request that corrections or amendments be made.
I, ______, have read and completely understand the above information. I also understand that if I have any further questions, I can ask my doctor’s office for assistance or I can contact the U.S. department of Health and Human Services at 200 Independence Ave., Washington, DC, 20201, 1-8777-696-6775 or for a copy of the HIPAA Privacy Rule.
______
PATIENT’S SIGNATURERELATIONSHIP TO PATIENT DATE