Patient Registration Form

Please correct the errors described below.

FINANCIAL POLICY

PRIVATE INSURANCE PLANS

  • Full payment is expected at the time of service. We are glad to discuss estimated medical care costs before service is provided however actual costs are determined by the medical care provided at the time of service.
  • We are contracted through Mills Peninsula Medical Group (MPMG/PAMF) and Direct Network. These organizations have their own rules regarding referrals.s It is your responsibility to obtain appropriate referrals from your primary care physician (PCP). These referrals must be presented before or at the time of service. From time to time you may be required to obtain new or renewed referrals from your HMO or PCP.
  • It is your responsibility to ensure coordination of benefits prior to the first visit by contacting both of your insurance companies. Failure to do so could result in denial of coverage from one or both plans resulting in the balance of payment becoming your responsibility.
  • We require twenty-four (24) hour notice (72 hour notice for Monday appointments) for cancellation or rescheduling of appointments. When contacting us after business hours such notice should be left on our voicemail (650-696-8230) and not our email. You may be charged for visits that are missed or cancelled without adequate notification.

I understand and accept that irrespective of my insurance status I am responsible for the balance of my account for any medical service provided by this Practice. I have read the Financial Policy and have completed the Patient Registration Form. I have had an adequate opportunity to ask questions. I certify that this information is true and correct to the best of my knowledge.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Personal Information

PRIMARY INSURANCE INFORMATION (Please provide copy of Insurance Card)

    Please upload a file

    SECONDARY INSURANCE INFORMATION (Please provide copy of Insurance Card)

    PATIENT'S REFERRAL INFORMATION

    Assignment of Benefits Financial Agreement

    I hereby give lifetime authorization for payment of insurance benefits to be made directly to Dr. Machtinger for services rendered. I have fully disclosed all information concerning the insurance/third-party benefits to which I am entitled. I understand that I am financially responsible for all charges Whether or not they are covered by insurance. Understand that if If oil to cancel my appointment with 24 hours notice, I Will be charged a processing fee of a minimum of $25.00. I Understand and accept that if my insurance company has not remitted payment within sixty (60) days of submission of the bill that I will then be billed directly with payment due immediately at that time. In the event of default, I agree to pay all costs of collection and reasonable attorney’s foes. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original

    DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

    Patient Record of Disclosures

    In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home.

    I wish to be contacted in the following manner (check all that apply):

    DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

    The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of , and request for PHI to the minimum necessary to accomplish the intended purpose. The provisions do not apply to uses or disclosures made pursuant to an authorization requested by the individual.

    Healthcare entities must keep records of PHI disclosures. Information provided below, if completed properly will constitute an adequate record.

    Note: Uses and disclosures to TPO may be permitted without prior consent in an emergency

    WHILE WAITING TO SEE YOUR PHYSICIAN PLEASE ASSIST US BY ANSWERING THESE QUESTIONS ABOUT YOURSELF OR YOUR CHILD. THERE MAY BE MORE THAN ONE RESPONSE TO EACH QUESTION.

    Additional Name

    Additional Medication

    Additional Allergies

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