Patient Registration & HIPAA Form

Patient Registration

Patient Last Name

First Name

Date of Birth

Address

City

State

Zip

Mailing Address (if different)

City

State

Zip

Home #

Cell #

Okay to Leave Message?

Yes

Employer

Work #

Spouse Name

Date of Birth

Email address

Pharmacy Location: (Long’s Manoa)

Emergency Contact

Relationship

Telephone #:

Referring Physician

Primary Care Physician

Insurance Information

PRIMARY INSURANCE

Insurance Name

Insurance ID #

Subscriber Name

Subscriber Birthdate

Patient’s relationship to subscriber

Self Spouse Child Other

SECONDARY INSURANCE

Insurance Name

Insurance ID #

Subscriber Name

Subscriber Birthdate

Patient’s relationship to subscriber

Self Spouse Child Other

TERTIARY INSURANCE

Insurance Name

Insurance ID #

Subscriber Name

Subscriber Birthdate

Release of Medical Information

I authorize the Release of Medical Information to:

Authorization for Treatment, Release of Information, Assignment of Benefits and Acknowledgement of Responsibility for Payment of Services:

I hereby give my consent to Dr. Garry Peers, Dr. Tim Roytman, Dr. Jason T. Smotherman to provide the necessary treatment. I authorize the release of medical information to my insurer and its agents, physicians, hospitals and other medical providers to determine payable benefits for services rendered. I request payment of authorized Medicare and other insurance benefits be made on my behalf to the above physicians for any services that were provided. This assignment will remain in effect until revoked in writing. I understand that I am financially responsible for all charges incurred and, in the event, that insurance payment is sent directly to me, I will remit payment to this office. If my insurance does not pay any bill submitted, I acknowledge these bills are my responsibility and will guarantee payment. I further agree to any reasonable cost, including attorney and collection agency cost, in the event my account becomes delinquent.

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.

Signature

Date

HIPAA

Notice of Privacy Practice Acknowledgement and Consent

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information (PHI). I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly or indirectly.
Obtain payment from third-party payers.
Conduct normal healthcare operations such as quality assessments and physician certifications.

I have read and understand the Notice of Privacy Practices which contain a complete description of the uses and disclosures of my health information. I understand this office has the right to change its Privacy Practices from time to time and I may obtain a current copy. Also, I understand I may revoke this Consent in writing at any time. Upon written receipt and confirmation, it shall be revoked.

Patient Name / Signature

Date

Relationship to Patient

Your information will be encrypted.