TEXAS FAMILY MEDICINE REGISTRATION FORM
Last Name:______First Name:______M.I.:______
Marital Status: Single / Married / Div / Widow Birth Date: ______/______/______Age:______
Sex: M / F Social Security #: ______Driver's License #:______
Address:______City:______State:______Zip:______
Home Ph: (______)______Cell Ph: (______) ______Work Ph: (______) ______
Email Address: ______Referred by: ______
Employer:______Occupation: ______Full or Part Time / Retired / Student
Employer's Address: ______City: ______State: ______Zip: ______
Insurance Guarantor Name:______Birth Date:______/______/______
Social Security #: ______Your Relation to the Guarantor: Spouse / Child / Self / Other
Guarantor Address: ______City: ______State: ______Zip:______
Current Medications:
Name of Medication: Strength :Frequency:
Allergies to Medications:_______
Medical Conditions:______
Major Surgeries : ____________
Frequency of Alcohol Use: ______Tobacco Use (PPD & How Long) ______
Family History (medical condition & who in your family):______
IN CASE OF EMERGENCY
Name of Local Friend/Relative: ______
Relationship to Patient: ______Phone #: (______)______
Assignment & Release: I hereby assign my benefits to be paid to Texas Family Medicine and/or Dr. DeMattia. I certify that the above information is true to the best of my knowledge. I understand that payment is due at the time of service and that I am financially responsible for any balance. I have read and understand the financial policy provided to me. I authorize the release of any information requested to process this claim and authorize the filing of forms with Medicare or other companies for the treatment of myself or my child. I understand that a copy of the HIPPA laws will be provided to me upon request. I am open to review these rules and discuss any areas in which I have questions. I can consent to or authorize the use and disclosure of the record with an authorization for release of information form. I may request restrictions on certain uses and disclosures of my record. I may receive confidential communication and may receive a copy of my record. I may request an amendment of my record. I may complain about alleged violations to the office and DHHS. I consent to and authorize the release of all medical records upon request and after the proper fees have been paid. I allow Texas Family Medicine to send communications via regular mail without being marked personal or confidential and to leave voicemail messages at my home or on my cellular phone.
Patient/Guardian Signature: ______Date: ___/_____/______
Texas Family Medicine Financial Policy
The following information is provided to avoid any misunderstanding or disagreements concerning payment for professional services:
We are committed to providing you with the best possible care. If you have medical insurance, we would like to help you receive your maximum allowable benefits.
- Payment is due at the time service is rendered. For those patients with insurance coverage, it will be necessary for you to pay your deductible, co insurance, or co-pay at the time service is rendered.
- You should be aware that your insurance is a contract between you and the insurance company. We file insurance claims as a courtesy to you. You will be responsible for all unpaid balances.
- Insurance plans differ, depending on the contract your employer has negotiated. It is your responsibility as a patient to know your insurance benefits.
- By law, your insurance carrier must remit payment or deny your insurance claim within 30 days of initial notice of claim. If an insurance problem occurs, you will be asked to assist us in contacting your insurance carrier, as we feel it is necessary to work together to resolve the insurance problem. Not all insurance plans cover all services. In the event your insurance plan determines a service to be "not covered" you will be responsible for the complete charge.
- If you are unable to keep your appointment, kindly give our office at least a five hour notice from your appointment time to avoid a $50 charge for not showing. If you know that you will be late for your appointment, please contact our office. We will still be able to see you for your appointment time as long as you are no later than 15 minutes. Otherwise, you will be considered a work in and may have to wait longer than usual as we are committed to seeing patients according to our schedule and/or you may be asked to reschedule your appointment for a later date. Regretfully, we have to implement this policy in order to give our patients the opportunity to be cared for in a timely manner. This will also ensure that our providers’ times are efficiently utilized.
- All payments are due upon receipt of a statement from our office. Balances over sixty (60) days old from the date of service will be sent to an outside collection agency, unless prior arrangements have been made with our billing department.
- We accept cash and all major credit/debit cards. We understand that temporary financial problems may affect timely payment of your account. If such problems arise, we encourage you to contact us for assistance in the management of your account.
Insurance Assignments and Financial Responsibilities
Medical health insurance is considered a method of reimbursing the patient for fees owed/payable to the doctor and is not a substitute for payment. Some insurance companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by your insurance. It is also your responsibility to provide our office with accurate and current insurance information as well as any secondary or tertiary policy information. Failure to provide this information to our office on the date of service will result in a bill. We will not file with your correct insurance company after your date of service. The balance will become your responsibility. Therefore, you authorize the release of any information necessary to determine liability for payment and to obtain reimbursement on any claim.
You assign benefits payable to which you are entitled including Medicare, private insurance, and other health plans to Texas Family Medicine/Drs. Jason & Candice DeMattia or any affiliated facility. This assignment will remain in effect until revoked by you in writing. A photocopy of this assignment is to be considered valid as an original. You understand that you are financially responsible for all charges whether or not paid by said insurance.
THIS FORM IS YOURS TO KEEP. PLEASE DO NOT TURN IT IN TO THE RECEPTIONIST UPON COMPLETION OF YOUR REGISTRATION FORM.