Admission Form

We Are A Center For Chronic Adult Care Disease Management

Mailing Address if Different

Medical History: Please check YES for any conditions

Past Medical History: Please check if you or your family have ever had any of the following problems.

Problems:

Please check any medications you may be currently taking or provide a copy of medication list.

Please list any medication you are currently taking

Authorization and Consent

1. I request care from Care Center of Lake Placid for treatment of my medical condition, and or for the routine care.This care may include medical test, exams, or other treatment that are needed for my condition. I agree to this care.

Care Center of Lake Placid receive payment for patient care from insurance companies, Medicare, and/or other third party program

1. I agree to have my insurance company. Medicare, or other third party payment program make payments directly to Care Center of Lake Placid.
2. l agree to let my doctor(s) and/or the morse practitioner(d) submit claims and required treatment information to my insurance company, Medicare, or other third party payment programs for my care, and receive payment directly.
3. I understand that I must all charges, co-payments, and deductibles that are not covered by my insure directly. company, Medicare, or third party payment program.

Permission to Communicate with Your Primary Care Physician and/or Other Community Care Providers: In order to ensure continuity of care, it is often necessary to communicate information to your primary care physician, other community care provides and to your insurance company. These communications may include information about your medical treatment and mental health or substance abuse treatment. This information is limited to that of which is necessary to the determination of coverage and the coordination of your care. Many insurance companies require us to document whether or not you will allow your clinician to communicate with your primary care physician and/or Health Insurance Company.

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

Due to the many constant changes in Insurance policies, we are not able to predict what an insurance will or will not cover. Many Insurances only allow members to use a particular "in network" lab, have tests done as special "in network" facilities and go to "in network specialist doctor.

Your Contract is between you and the insurance company. Please call you insurance and learn more about your coverage. Make sure that the lab work tests to be done are covered by your insurance company, that the facility and/or doctor you are going to is "In network for your Insurance. It will save a confusion. Failure to do this could result in you being responsible for all cost incurred (doctor visit, lab work, test) during your visit with our office or other office/facility.

Your Signature Below Acknowledges that you have read the above.

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

Please list all recent surgeries here.

Dear patron, As of August 1st there will be a processing fee of 3%. charged to all credit and debit cards per the processing institution.

If you wish not to pay these fees, we gladly accept cash as always for your convenience.

By signing this agreement, you are stating that agree to the above statement and will comply with all its terms.

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