Patient Registration Form

Patient's Personal Information

Last Name

First Name

Initial

Date of Birth

Address

City

State

Zip Code

Home Phone

Social Security #

Cell Phone

Employer

Cell Phone

Email address

PRIMARY INSURANCE INFORMATION (Please provide copy of Insurance Card)

Attach picture(s) of your insurance card

Add file

Please upload a file

Subscriber's Last Name

Subscriber's First Name

Date of Birth

Address

City

State

Zip Code

Home Phone

Social Security #

Cell Phone

Relationship to Patient

Occupation

Employer

Work Phone

Insurance Name

Address

Subscriber ID #

Group #

Effective Date

SECONDARY INSURANCE INFORMATION (Please provide copy of Insurance Card)

Subscriber's Last Name

Subscriber's First Name

Date of Birth

Address

City

State

Zip Code

Home Phone

Social Security #

Cell Phone

Relationship to Patient

Occupation

Employer

Work Phone

Insurance Name

Address

Subscriber ID #

Group #

Effective Date

PATIENT'S REFERRAL INFORMATION

Primary Care Physician

Referred by

Address

City

State

Zip Code

Person to Contact in An Emergency

Relationship

Day Phone

Evening Phone

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 Signature (Or Parent, if Minor)

Date

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):

Home Telephone

Ok to leave message with detailed information

Leave message with call-back number only

Written Communication

OK to mail to my home address

OK to mail to my work / office address

OK to fax to this number

Work Telephone

Ok to leave message with detailed information

Leave message with call-back number only

Family members authorized to receive medical information

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 Name / Signature

Birthdate

Patient Name / Signature or authorized representative / Relationship if applicable

Date

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.

This visit is for

A new problem

A follow up for an existing problem

For medication refills

To review laboratory or X-rays results

This visit concerns

The chest

The nose and sinuses

The eyes

The ears

The skin

The stomach and digestive system

Coughing

Food allergy

Other

If other, Please specify

Additional Name

Additional Medication

Additional Allergies

Have you received a flu shot (influenza) this year?

Yes No

If yes, when?

Where?

Have you ever received a vaccination against pneumonia?

Yes No

Name of Vaccine

If yes, when?

Where?

Names of other family members seen in this office

FINANCIAL POLICY

PRIVATE INSURANCE PLANS

Copayments (Copays) are due in full on the date of service. Insurance claims are filed as a courtesy to you. Deductibles and co-insurance will be billed to you after your insurance has paid their share in full.

Your insurance coverage is a contract between you, the insurance company, and, if your employer provides your medical insurance, your employer. Our involvement for disputes arising between you and your insurance carrier with respect to copayments, deductibles or coverage for provider services is limited to providing factual information as required. To avoid financial surprizes it is in your best interest to know and understand the benefits, deductibles, coinsurance amounts, and prerequisite actions required before your seek any medical service.

Cash Patients

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.

HMO Insurance Plans

We are contracted through Mills Peninsula Medical Group (MPMG/PAMF) and Direct Network. These organizations have their own rules regarding referrals 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.

Dual Insurance Coverage

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.

Cancelled or Missed Appointments

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.

Acceptance and Assignment or Benefits

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.

Name / Signature of Responsible Party

Patient's Name if Different Person

Name of Responsible Party

Date

Your information will be encrypted.