New Patient Form

DATE:

Patient’s Full Name:

Address:

City:

State:

Zip Code:

Phone #:

Age:

Birth Date:

Emergency Phone #:

Name/Relationship:

Occupation:

Place of work:

Spouses Name:

Date of Birth:

Place of Employment:

City:

Family Doctor:

Referred By:

Email address

REASON FOR VISIT:

HEIGHT

WEIGHT

HAVE YOU HAD ANY UNTOWARD (BAD) REACTIONS TO DRUGS, TREATMENT PROCEDURES, MATERIALS, ETC.? If yes, please explain:

LIST ANY PAST SURGERIES ANDAPPROXIMATE DATES THEY WERE DONE:

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Allergies (Reaction)- Select None if no allergies

NONE

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HAVE YOU EVER BEEN TREATED FOR OR ARE YOU CURRENTLY BEING TREATED FOR: check if ever had (or) currently are having

LIST ALL MEDICAL CONDITIONS OR ILLNESSES YOU HAVE:

LIST ALL CURRENT MEDICATION YOU ARE TAKING AND THEIR DOSAGE:

Patient Signature:

DATE

Doctor Signature:

DATE

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

For the Purpose of Treatment, Payment, and Healthcare Operations

In the course of providing treatment, obtaining payment for my health care bills or to conduct other necessary health care operations Dr. Robert Jackson, Dr. Chris Lowery, Dr. Sarah Young, Dr. Emily Lo, Surgeons, Inc., Surgical Associates of Indiana LLC, Indy Surgeons LLC, Happy Clinic Indy LLC, and/or Hamilton Surgical Arts LLC may need to disclosure some or all of my protected health information (“PHI”).

PHI means my health information, including demographic information collected from me and created or received by Dr. Robert Jackson, Dr. Chris Lowery, Dr. Sarah Young, Dr. Emily Lo, Surgeons, Inc., Surgical Associates of Indiana LLC, Indy Surgeons LLC, Happy Clinic Indy LLC, and/or Hamilton Surgical Arts LLC, my health care provider, my health plan, my employer or a health care billing clearing house. This PHI relates to my past, present, or future physical or mental health condition that identifies me, or there is a reasonable basis to believe the information may identify me. (Cross out any of the above entities you do not want to include.)

I understand I have the right to review Surgeons, Inc., Indy Surgeons LLC, Surgical Associates of Indiana LLC, and/or Hamilton Surgical Art’s LLC Notice of Privacy Practices (“NPP”), available in their offices, prior to signing this document. The NPP describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations provided by Dr. Robert Jackson, Dr. Chris Lowery, Dr. Sarah Young, Dr. Emily Lo, Surgeons, Inc., Surgical Associates of Indiana LLC, Indy Surgeons LLC, Happy Clinic Indy LLC, and/or Hamilton Surgical Arts LLC. The NPP for Dr. Robert F. Jackson, Dr. Chris Lowery, Dr. Sarah Young, Dr. Emily Lo, and/or Hamilton Surgical Arts applies to Hamilton Surgical Arts LLC in Noblesville, Indiana. The NPP also describes my rights and Surgeons, Inc., Surgical Associates of Indiana LLC, Indy Surgeons LLC, Happy Clinic Indy LLC, and/or Hamilton Surgical Arts LLC’s duties with respect to my PHI.
I understand Surgeons, Inc., Surgical Associates of Indiana LLC, Indy Surgeons LLC, Happy Clinic Indy LLC, and/or Hamilton Surgical Arts LLC reserves the right to change the privacy practices that are described in their NPP. I may obtain a revised notice of privacy practices by contacting the of Hamilton Surgical Arts, 9660 East 146th Street Suite 100, Noblesville, Indiana and requesting a revised copy be sent in the mail or by asking for a copy any time I visit one of the above offices.

I understand I have the right to request a restriction as to how my PHI is used or disclosed to carry out treatment, payment, or other healthcare operations of the practice; and that Surgeons, Inc., Surgical Associates of Indiana LLC, Indy Surgeons LLC, Happy Clinic Indy LLC, and/or Hamilton Surgical Arts LLC are not required to agree to the restrictions that I may request. However, if Surgeons, Inc., Surgical Associates of Indiana LLC, Indy Surgeons LLC, Happy Clinic Indy LLC, and/or Hamilton Surgical Arts LLC agrees to a restriction that I request, the restriction is binding on Dr. Robert Jackson, Dr. Chris Lowery, Dr. Sarah Young, Dr. Emily Lo, Surgeons, Inc., Surgical Associates of Indiana LLC, Indy Surgeons LLC, Happy Clinic Indy LLC, and/or Hamilton Surgical Arts LLC.

I understand I have the right to revoke this Authorization, in writing, at any time. Such revocation will not affect actions taken by Dr. Robert Jackson, Dr. Chris Lowery, Dr. Sarah Young, Dr. Emily Lo, Surgeons, Inc., Surgical Associates of Indiana LLC, Indy Surgeons LLC, Happy Clinic Indy LLC, and/or Hamilton Surgical Arts LLC prior to the date he or she received the written revocation. I understand that Dr. Robert Jackson, Dr. Chris Lowery, Dr. Sarah Young, Dr. Emily Lo, Surgeons, Inc., Surgical Associates of Indiana LLC, Indy Surgeons LLC, Happy Clinic Indy LLC, and/or Hamilton Surgical Arts LLC. cannot condition medical treatment on whether I sign this Authorization.

If I sign this Authorization, it will expire five years after completion of my treatment or on

I authorize the use or disclosure of my protected health information (“PHI”) by Dr. Robert Jackson, Dr. Chris Lowery, Dr. Sarah Young, Dr. Emily Lo, Surgeons, Inc., Surgical Associates of Indiana LLC, Indy Surgeons LLC, Happy Clinic Indy LLC, and/or Hamilton Surgical Arts LLC, the custodian of my PHI, for the purpose of diagnosing, providing treatment, obtaining payment for my health care bills, or to conduct other necessary health care operations.(Note any restriction on the back of this form). I understand I am responsible for my bill/account and with any balance on my account I am to contact the office to make and/or set up payment arranges to pay until account is paid in full. I am also aware that I am responsible for any cost of collection including registered/certified letters, attorney fees and court costs, etc. on my account.

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.

Signature of patient or authorized representative

DATE

Permission to give medical information

I (Pease input Name below) hereby authorize the physician/s and staff of Surgeon’s Inc./Surgical Associates of Indiana/Indy Surgeons LLC/Happy Clinic Indy/Hamilton Surgical Arts to give the following person/s information concerning my health and well being:

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The following information may be given to the above person/s:(Indicate Yes or No on each line below)

Appointment Time – office and/or x-rays etc

Test Results:

Medication:

Procedure/s:

Any other information regarding my health:

Account Information:

If delay in treatment results because we cannot relay information to another person, Surgeon’s Inc and/or Hamilton Surgical Arts will not be held responsible. I acknowledge that it is my responsibility to call for x-rays, laboratory results etc.

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.

Patient Name:

Date:

Acknowledgement of Receipt of Notice of Privacy Practice

Surgeon’s Inc, and/or Hamilton Surgical Arts

I received or was offered a copy of Surgeon’s Inc./Surgical Associates of Indiana/Indy Surgeons LLC/Happy Clinic Indy/Hamilton Surgical Arts and Robert F. Jackson, MD, Chris Lowery, DO, Sarah Young, DO, Emily Lo, MD’s “Notice of Privacy Practice”.

I am aware that if I have any questions and/or do not agree with part or all of the “Notice of Privacy Practice”, I can contact Lissa, Kelly, Dr. Jackson, Dr. Young, Dr. Lo or Dr. Lowery with my concerns.

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.

Date:

Patient Name:

Patient Signature:

Name of Personal Representative:

Relationship to patient:

Signature of Personal Representative:

Signature of Witness:

Your information will be encrypted.