Southcare Medical LLC

SouthCare Medical LLC

Adult Demographic Information

Patient: ______

Last First M.I

Date or Birth: ______Sex: Male / Female SSN #: ______

Address: ______

City: ______State: ______Zip code:______

Home Phone Number: (_____)______

Marital status : ( )Single( )Married( )Separated( )Divorced( )Widow/er

Occupation: ______Employer’s name and address: ______

If Unemployed (please circle one): retired, disabled, Unemployed, student

Electronic Chart/Appointment reminder will be sent to the cell phone & email address below

Cell Phone (including area code) (______)______

Email Address:

Race/Ethnicity:

Asian African American/Black Caucasian/White Hispanic Other 

Primary Language ______

Smoking Status: ( ) Never ( ) Current, if yes (Someday / Everyday) ( ) Former

Billing Information:

Primary Insurance Name: ______ID number: ______Group number: ______

Address: ______City: ______State: ______Zip code:______

Secondary Insurance Name: ______ID number: ______Group number: ______

Address: ______City:______State: ______Zip code:______

Person to Contact in Case of Emergency:

Name: ______Relationship: ______

Address: ______Phone Number: (_____) ______

Patient Acknowledgement

Acknowledge of HIPAA Privacy Practice is provided in the office/ southcaremed.com

______

Patient/ Parent signature Relationship Date

AUTHORIZATION AND CONSENT

CONSENT REGARDING TREATMENT:

Consent is hereby given, voluntarily and knowingly by the undersigned patient to the performance of invasive and other procedures, treatments, blood test, examination which I may receive while client(s) with SouthCare Medical or members of the medical and employee staff which they, or any of them, in their best judgments may deem proper for my best interest. I further authorize any and all other procedures or treatments the clinic deems necessary in the best interest of patient(s) care. I hereby authorize disposal of any specimens taken from my body during my care.

Patient have the right to accept or refuse any treatment provided the decision is made on an informed basis and the patient/guardian have the mental capacity to make and understand the implications of such decision.

AUTHORIZATION

I, the undersigned give authorization for release of information contained in the medical record to the insurance companies or other third parties paying my clinic bill in whole or part.

I hereby authorize payment to SouthCare Medical LLC, 1305 N. State St, Abbeville, LA, 70510, for benefits otherwise payable to, but not to exceed the clinic’s regular charges for services received at each clinic visit.

I understand that I am financially responsible to the clinic and hospital for charges not covered by this arrangement unless I have presented an active Medicaid card.

I agree that a Photostatic copy of this authorization shall be considered as effective and valid as the original.

I certify that the information given by me in applying for payment under Title XVIII of the SSA Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers or any other insurer any information needed for this or any related Medicare/Medicaid claims. I request that payment of authorized benefits be made in my behalf.

PATIENT CONSENT FOR E-PRESCRIBING

I have been informed and understand that the medical practice use an electronic prescription, so that the providers will be able to see information about my medication, including prescribed by other provider. I give my consent to my providers to see this protected health information.

PATIENT CONSENT TO RELEASE MEDICAL INFORMATION TO THE FOLLOWING ADULTS:

______Relationship: ______

I attest that I have read the above and am aware of its contents.

______cristyanasugeng

Signature Date RelationshipWitness signature

FINANCIAL AGREEMENT

Initial

______I have no insurance coverage. I understand that I am responsible for payment of services rendered to myself or independent at the time of service.

______I understand if I fail to pay amounts owed, the clinic has the right to secure an outside collection agency and/ or attorney to collect the unpaid debt and to report the unpaid debt to a credit-reporting agency. I further understand that I will be responsible for any additional charges of fees necessitated by securing the collection agency or attorney including reasonable attorney’s fee

______I hereby authorize the release of any information necessary to process insurance claims and request payment of benefits to made for services rendered to my dependent or myself.

______I understand I am responsible at the time of service for paying any required co-payment and deductible

Medicare Authorization

______I authorize any holder of medical information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers any information needed for this or a related 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 accepts assignment. I understand 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.) Regulations pertaining to Medicare assignment of benefits also apply.

Policy Number : ______

Medigap Authorization

______I authorize any holder of medical or other information about me to release information needed for this or a related Medigap 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 assignment.

Policy Number : ______

______There will be $25.00 charge on all returned checks.

I have read and understand the payment policy of this office and agree to abide by the said policy.

Patient Name : ______

Signature : ______Date: ______

CONTROLLED SUBTANCE CONTRACT

This Agreement is between ______(Patient)______(Date of Birth) and the SouthCare Medical . My doctor may prescribe one or more medicines that considered controlled substance medication. These medicines are high risk and can be misused, abused, or lead to addiction. In order to comply with federal and state regulation and for my safety, I agree to the following statements. I know that if I do not follow the statements below, my controlled substance prescriptions and/or treatment at SouthCare Medical may be ended immediately.

I know that controlled substances are one part of my treatment plan to help my condition and make my quality of life better. I know that controlled substances will not cure my condition. I understand that if my function does not improve while on these medications, the medicine may be discontinued or the dose lowered.
I understand that in order to best treat my condition, it will require me to commit to a healthy lifestyle; including eating a healthy diet, staying as physically active as possible and managing my stress. I agree to work with my provider to achieve a healthy lifestyle.
I know that my treatment may change as my provider evaluates my progress or more medical information is available. If my doctor feels I need to see a specialist, I agree to get a consultation.
I know that if I stop the medication suddenly, I may have severe withdrawal symptoms.
I am responsible for my controlled substance medications.I understand that sharing, selling, or trading my medication is illegal and is a felony. If the paper prescription and/or medication is lost, misplaced, or stolen, or if I use it up too soon, I know that the medication will not be replaced I agree to bring in my medications for pill counts at the request of my provider.
I will not ask for or take controlled substance medications from another doctor or person. If I am given these medications by another physician or in a time of emergency, I will call (SouthCare Medical) the next business day to let my provider know.
Refills of controlled substances will only be given if I keep my scheduled appointment(s). I will call at least 3 business days ahead if I need a refill on the controlled substance medication(s) and know that refills will only be granted during regular business hours, Monday through Friday.
I know that any controlled substance may interfere with or impair my ability to drive, perform intricate tasks and make important decisions. I understand that it is my responsibility to refrain from any activities that will endanger me or others while taking a controlled substance.
I will not use illegal drugs, including marijuana. I agree to give random urine for drug testing to make sure I am safely using my medications. If other drugs are found in my urine that are not prescribed or illegal, I understand that my provider will be unable to prescribe further controlled substances and that I will be referred for help with chemical dependency.
For Females of child bearing potential.I understand that taking controlled substances while pregnant is

dangerous. Taking controlled substances during pregnancy can cause harm to a fetus and can lead to severe neonatal withdrawal after birth.

I have read and I understand this agreement.

Patient’s Signature ______Date______

Witness’s Signaturecristyanasugeng