PATIENT REGISTRATION FORM
Thank you for completing this form as completely & accurately as possible. Please print.
Patient Name: (Last, First, Middle)______
Mailing Address______
City______State______Zip______
Date of Birth______Age_____ Telephone # (Home) ______(Cell)______
Sex: M F Social Security# ______- _____ - ______Marital Status: S M W D Sep
Race: ______Ethnicity: ______Religion: ______Primary Language: ______
Your Primary Care Provider: ______How did you hear about our office?______
Employment Status: (Circle One) FT PT Unemployed Retired Student
If employed, please complete the following:
Employer Name______Telephone______
Employer Address______
**Workers Comp Treatment Authorized By______
**Date & Time of Injury______/______Occupation ______
Person responsible for payment (if other than patient) ______
Address:______
Telephone # ( )______Relationship______
Referred by: ______
Spouse / (If Child) Guardian Name:______
Employer______Date of Birth______
Emergency Contact Name:______
Telephone # ( ) ______Relationship______
Insurance Information
We are happy to file your insurance claim for you, if we have the necessary information with which to do so. Please complete the questions below and bring your insurance cards to the desk so that we can make a copy.
Primary Insurance Company: ______
Insured Name (if other than patient) ______
ID# ______Group Name/#______
SS# ______Date of Birth ______/______/______
Secondary Insurance Company: ______
Insured Name (if other than patient) ______
ID# ______Group Name/#______
SS# ______Date of Birth ______/______/______
FINANCIAL POLICY: Payment of deductibles and co-payments is expected at the time of service. Cash, Check, MasterCard, and Visa are acceptable methods of payment. Insurance claims for each service date will be submitted to your insurance company twice, after which time the responsibility for payment will become yours. In the event this account is placed with a collection agency you will be responsible for collections fees and/or attorney fees.
PATIENT AUTHORIZATION & ASSIGNMENT: I hereby authorize this physician/clinic to release any information required in the course of my examination or treatment. I authorize payment directly to the billing office of this physician/clinic for the medical and/or surgical benefits, if any, otherwise payable to me for services. I understand that I am financially responsible for the charges not covered by my insurance.
Signature______Date______
To whom may we release information about your condition, diagnosis, or treatment?
______
Request for Release of Medical Records
I hereby request that my medical records be released from ______
______(physician)
located at (address): ______
______
and sent to: NWGA Orthopedics Dr.______(physician) whose office is located at
(address): 106 Hospital Court ______1
Calhoun, GA 30701 1
Fax: 706-602-3101 1
Special Instructions: ______
______
______(Patient’s Name, Print) ______(D.O.B.)
______(Patient’s Signature) ______(SS#)
______(Date) ______(Witness)
Pain Management Notification
To Our Patients:
From time to time everyone has a pain related concern that brings them to their physician for evaluation and treatment. It is the goal at Northwest Georgia Orthopedics and Sports Medicine to provide all of our patients with the highest standards of care and compassion.
Our Physician and staff will gladly evaluate an acute injury and treat it as appropriately as possible. The clinic does NOT however treat or manage long term pain.
If you are a patient who would fall into one of these categories you are welcome to be evaluated, however you must understand that we will follow the policies stated above. If you feel that you cannot be treated without continuing pain management at this time then you may be better serviced by a clinic that offers pain management.
Here at Northwest Georgia Orthopedics and Sports Medicine we take pride in the care that we give to our patients. To continue to provide this high level of care to all of our patients, we ask that you please cooperate with the above guidelines.
I have read and understand the above statements regarding pain management.
______
Patient Signature Date
______
Employee Signature
Form of Written Acknowledgment of Receipt
Of Northwest Georgia Orthopedics and Sports Medicine Notice of Patient Privacy Practices
By signing this Written Acknowledgment of Receipt of Northwest Georgia Orthopedics and Sports Medicine Notice of Patient Privacy Practices (“Acknowledgment”), I hereby expressly acknowledge my receipt of Northwest Georgia Orthopedics and Sports Medicine Notice of Patient Privacy Practices.
______
Patient, or Legal Representative, Signature
______
Printed Patient, or Legal Representative, Name (or label)
______
Date
Acknowledgment NOT obtained because:
____ Patient, or legal representative, declined Notice of Patient Privacy Practices;
____ Patient treated in emergency room and discharged before obtaining Acknowledgment;
____ Other (briefly describe)
______
______
Employee Signature
______
Employee Printed Name
ADVANCE DIRECTIVE CHECKLIST
Please read the following three statements. Please initial that you understand these statements:
1. I have been given written materials on my rights to accept or refuse medical and surgical treatment and my rights to formulate advance directives.
2. I understand that I am not required to have an advance directive in order to receive medical treatment at Gordon Hospital Clinics.
3. I understand that the terms of any advance directive that I execute will be followed by Gordon Hospital Clinics to the extent permitted by the law in accordance with the facility’s politics and procedures.
______(Patient’s initials)
Please check one of the following statements:
_____I do have a Durable Power of Attorney for Health Care and/or a living will and will provide a copy to the facility or services. I understand that the staff and physicians of Gordon Hospital Clinics will not be able to follow the terms of my advance directives until I provide a copy of it to the staff.
_____I do not have a Durable Power of Attorney and/or a Living Will and do not wish to discuss an advance directive any further at this time.
_____I do not have a Durable Power of Attorney and/or a Living Will and would like some information to prepare one.
______
Patient Witness
______
Date
Information was provided to the patient on ______(date) by: ______
At least three attempts should be made to obtain copies of the Durable Power of Attorney and/or Living Will:
1. Date: ______Reason: ______Signature ______
2. Date: ______Reason: ______Signature ______
3. Date: ______Reason: ______Signature ______