Registration form Germantown Ped & Family Med

Germantown Pediatrics and Family Medicine

3180 Professional Plaza, Suite 111 Germantown TN, 38138

901-854-5455

Please fill the sections carefully and ensure that all sections are filled. .Please ensure that there are no errors made in filling the form, as this could lead to non payment by insurance companies.

Last Name of Individual completing form

First name

Relationship to patient

Patient's First Name

Patient's Last Name

Patient's Middle Initial

Street address

City

State

Zip Code

Patient's social security no.

Patient's Date of birth

Gender Identity

Male Female Trans-Male Trans-Female Prefer to not disclose

Marital Status

Single Married Divorced Widowed Prefer not to disclose

Please provide the email address for us to contact you

Race /Ethnicity

Black or African-American Asian Caucasian (white) Native American Hispanic Prefer to not respond

Primary Phone number

Secondary or Work Phone Number

Occupation

Employer

Emergency Contact

Emergency Contact Phone Number

Primary Insurance- Please present a copy of your card at the office when you check in. Any omissions or errors will lead to non payment and you will be responsible for the bill

Front and back of Primary Insurance Card

Add file

Please upload a file

Subscriber's Last Name

Subscriber's first name

Subscriber Date of birth

Subscriber's relationship to patient

Name of Insurance

Insurance ID No

Insurance Group No

Co-Payment:

Employer name

TennCare Medicaid

Y N

Secondary Insurance- Please bring card to the office at the time of the visit

Front and back of Secondary insurance card

Add file

Please upload a file

Patient has secondary insurance. Please fill all fields below if the answer is YES

Yes No

Subscriber's Last Name

Subscriber's First Name

Subscriber's Date of birth

Subscriber's relationship to patient

Name of Insurance Company

Insurance ID No.

Insurance Group No.:

Co-Payment:

Employer name

TennCare Medicaid

Y N

How did you hear about our office?

Friend or family Google search Another Physician/urgent care/ER Insurance

CONSENT FOR CARE

I hereby give my consent for treatment at Germantown Pediatric and Family Medicine .

FINANCIAL POLICY

I hereby authorize payment to Germantown Pediatrics and Family Medicine for services rendered to me or my dependents. I hereby authorize release of information necessary to expedite the claim process.

LIFETIME AUTHORIZATION TO FILE MEDICARE

I request the payment of authorized Medicare benefits to be made either to me or on my behalf to Germantown Pediatrics and Family Medicine for services furnished at the clinic. I also authorize any holder of medical information about me to release to the Center for Medicare/Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services.

When scheduling an appointment, we will make every attempt to verify your insurance and eligibility prior to checking in. Your insurance policy is a contract between you and your insurance company

It is your responsibility to notify us of any changes to your insurance.

We need to see your insurance card and ID at every visit.

You are responsible for verifying your insurance coverage, which includes, but is not limited to co-insurance, copayments, deductibles, and verification of what is covered ( in house labs, preventive care visits, etc). You are responsible for any payments that are not covered by your insurance or that your insurance assigns as your responsibility.

COLLECTIONS AGREEMENT

Germantown Pediatrics and Family Medicine will bill my insurance carrier based on the information provided above. I am responsible for I agree to pay any outstanding charges should be account be turned over to an outside collection agency. Germantown Pediatrics and Family Medicine will bill my insurance carrier. However, I understand and agree that I am responsible for payment of all charges for services provided, regardless of any insurance coverage(s).

RETURNED CHECK FEE

We assign a fee of $50 for any returned checks, and will not allow you to write any future checks.

NO-SHOW/LATE CANCELLATION POLICY

Your medical health is important to us, and we want to continue our relationship with you. However, when patients fail to appear for their appointment without giving our office advance notice, we are unable to schedule other patients for that time.
• Patients must call at least 24 hours prior to their scheduled time, when they knowingly are unable to make their appointment. Cancellations within 24-hours of appointment will be considered a late cancellation.
• We reserve the right to discharge a patient from our practice after three (3) no shows/late cancellations for a family.
• If a patient is more than 15 minutes late for an appointment, we will try to accommodate you, but patients who arrive on time will be given priority.
Patients who are late for appointments after 4:15 pm will be rescheduled so that the employees are able to leave on time. .
Exceptions to the No Show/Late Cancellation Policy will be determined by the provider.
Patients will receive telephone reminders of appointment dates/times the workday prior to scheduled appointment . It is the family’s responsibility to update phone numbers, and it is the patient's responsibility to be aware of appointments.

I hereby acknowledge I am aware of and agree to abide by the above policies.

First and Last Name

PHOTO CONSENT I hereby authorize Germantown Pediatric and Family Medicine to take my picture for my electronic medical record.

Yes No

First and Last Name

Relationship to patient

Date

Please provide a list of anyone besides yourself who has permission to receive information regarding the contents of your medical record. This can include any family member or other healthcare provider.

First and Last Name

By signing below, I understand that I may revoke this authorization at any time by notifying the Health Care Provider in writing. The revocation will only be effective from the date it is received in this office and will not apply retroactively.

First and Last Name

Relationship to patient

Date

Notice of Privacy Practices for Protected Health Information (PHI)

Germantown Pediatric and Family Medicine LLC

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY!

Effective date: January 2021

The Practice of Germantown Pediatric and Family Medicine is required by applicable federal and state laws to maintain the privacy of your health information. Protected health information (PHI) is the information we create and maintain in the course of providing our services to you. Such information may include documentation of your symptoms, examination and test results, diagnoses and treatment protocols. It also may include billing documents for those services. We are permitted by federal privacy law (the Health Insurance Portability & Accountability Act of 1996 (HIPAA), to use and disclose your PHI, without your written authorization, for purposes of treatment, payment, and health care operations. Your Health Information can be used for payment purposes, for treatment purposes, and for health care operation purposes.

Your Health Information Rights

The health and billing records we maintain are the physical property of the Practice. The information in them, however, belongs to you. You have a right to:

Access your medical records and other information. You may request this by sending to us this request in writing.
Request changes or amendments to your PHI.
Request an accounting of disclosures of your PHI.
Request certain restrictions on the use and disclosure of your PHI.
Request that you be contacted at different places or via different means by sending this request in writing.
•Obtain a paper copy of our current Notice of Privacy Practices for PHI ("the Notice");
•Receive Notification of a breach of your unsecured PHI.
Revoke any of your prior authorizations to use or disclose information by sending the revocation in writing (except to the extent action has already been taken based on a prior authorization).

Our Responsibilities

The Practice is required to:

•Maintain the privacy of your health information as required by law;
•Notify you following a breach of your unsecured PHI;
•Provide you with a notice (‘Notice’) describing our duties and privacy practices with respect to the information we collect and maintain about you and abide by the terms of the Notice;
•Notify you if we cannot accommodate a requested restriction or request; and,
•Accommodate your reasonable requests regarding methods for communicating with you about your health information and comply with your written request to refrain from disclosing your PHI to your health plan if you pay for an item or service we provide you in full and out-of-pocket at the time of service.

We reserve the right to amend, change, or eliminate provisions of our privacy practices and to enact new provisions regarding the PHI we maintain about you. If our information practices change, we will amend our Notice. You are entitled to receive a copy of the revised Notice upon request by phone or by visiting our website or Practice.

Other Uses and Disclosures of your PHI

Public Health

We may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability; to report reactions to medications or problems with products; to notify people of recalls; or to notify a person who may have been exposed to a disease or who is at risk for contracting or spreading a disease or condition.

As Required by Law

Law Enforcement and Correctional Institutions.

Health Oversight Federal law may require us to release your PHI to appropriate health oversight agencies .

Judicial/Administrative Proceedings -We may disclose your PHI with your authorization, or as directed by a proper court order.

For Specialized Governmental Functions or Serious Threat

Coroners, Medical Examiners, and Funeral Directors

Other uses and disclosures of your PHI not described in this Notice will only be made with your authorization, unless otherwise permitted or required by law.

To Request Information, Exercise a Patient Right, or File a Complaint

If you have questions, would like additional information, want to exercise a Patient Right described above, or believe your (or someone else’s) privacy rights have been violated, you may contact the Practice’s Privacy Officer at 901-854-5455, or in writing to us at our practice address.

Please note that all complaints must be submitted in writing to the Privacy Officer at the above address. You may also file a complaint with the Secretary of Health and Human Services (HHS), Office for Civil Rights (OCR). Your complaint must be filed in writing, either on paper or electronically, by mail, fax, or e-mail. The address for the Colorado regional office is: Office for Civil Rights, U.S. Department of Health and Human Services, 999 18th Street, Suite 417, Denver, CO 80202; or call (800) 368-1019. More information regarding the steps to file a complaint can be found at: www.hhs.gov/ocr/privacy/hipaa/complaints.

•We cannot, and will not, require you to waive the right to file a complaint with the Secretary ofHHS as a condition of receiving treatment from the Practice.
•We cannot, and will not, retaliate against you for filing a complaint with the Secretary of HHS.

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES.I acknowledge that a copy of the notice of privacy practices for has been made available to me. In connection with the notice I also acknowledge that I've been provided with an opportunity to ask questions regarding the notice and its contents. I understand that the most current version of the notice will be available to me by asking the Privacy officer or the front desk

First and Last Name

Please attach documents such as immunization records, legal paperwork , notes from other clinics or specialties

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Please upload a file

By writing my name below, I am verifying that I have had the opportunity to read over the entire form carefully,

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Registration form Germantown Ped & Family Med - Over 18yrs

Germantown Pediatrics and Family Medicine

Primary Insurance- Please present a copy of your card at the office when you check in. Any omissions or errors will lead to non payment and you will be responsible for the bill

Secondary Insurance- Please bring card to the office at the time of the visit

FINANCIAL POLICY

Germantown Pediatrics and Family Medicine