Patient Registration

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Patient Information

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Emergency Contact

Responsible Party Information

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Payment Information

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

Authorization to Release Information

I hereby authorize the release of all medical records (or selected dates of service) of the patient listed above to my primary care physician, referring and other necessary physicians as requested by the parent or patient. I authorize the release of any medical information necessary to my family or caregivers with permission as above named and laboratories, radiology centers, and insurance companies. I authorize Dr. Stacy Hausmann and North Woodmere Medical Care, PLLC to release any medical information that may also be necessary for processing laboratory/diagnostic orders and for payment purposes and insurance claims. I hereby assign to and authorize directly to North Woodmere Medical Care, PLLC all services payable to this organization.

Consent to Email: I give Dr. Stacy Hausmann and North Woodmere Medical Care, PLLC permission to email protected health information (COVID-19 Test Results) for myself or my child via a secure encrypted email to the email that I provide. I understand that the email I provide may not be encrypted.

I have read this disclosure and agree to the terms above and that North Woodmere Medical Care, PLLC, and its employees and/or agents may contact me/us as described above.

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

Consent for Treatment

I consent to medical care and treatment necessary or desirable to the care of the patient mentioned above, including but not restricted to, physical examination, injections, pharmaceutical agents, and/or any necessary emergency care that may be used by the physician, or qualified designee.

I understand and consent to COVID-19 testing by Dr. Hausmann. I do not hold Dr. Hausmann responsible for the results and agree to follow up with my primary care physician for either positive or negative results, and for an evaluation, diagnosis, treatment, and follow-up of my symptoms. I also agree to contact my primary care physician for evaluation, diagnosis, management, and follow-up of any co-infections or co-illnesses and for any symptoms and illnesses related to COVID-19. I agree that my primary care physician will manage any symptoms and or worsening symptoms of COVID-19.

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

Financial Agreement

I understand that the patient or responsible party is solely responsible for payment of all services, I am fully informed and understand that North Woodmere Medical Care, PLLC does not accept insurance or submit insurance claims for reimbursement. I am fully informed and agree to make payment for all services rendered by credit card on the day of service. I understand and accept that should I cancel within 24 hours of the appointment that there will be a cancellation fee. I acknowledge and accept that insurance is not accepted and that I am responsible for the entire bill. I agree to pay the entire bill at the time of service.

I agree that North Woodmere Medical Care, PLLC, and/or its agents, in order to service my account or collect monies I may owe, may contact me by telephone at any number associated with my account, including wireless telephone numbers which could incur usage charges. I also agree that I may be contacted through the email that I provide. Contact methods may include prerecorded or artificial voice messages and/or the use of automatic dialing devices.

I have read this disclosure and agree to the terms above and that North Woodmere Medical Care, PLLC, and its employees and/or agents may contact me/us as described above.

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

Your information will be encrypted.

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