Adult Patient Registration Form

Welcome to the Adult Patient Registration Form

Thank you for choosing our practice for your healthcare needs. This form is designed to collect essential information that will help us provide you with the best possible care.

Your Privacy Matters

We are committed to protecting your privacy and ensuring the confidentiality of your health information. All data collected through this form will be handled in accordance with the Health Insurance Portability and Accountability Act (HIPAA) regulations, specifically 45 CFR Parts 160 and 164, which govern the privacy and security of your health information. Your information will only be used for the purposes of your treatment, payment, and healthcare operations.

Please fill out the form completely and accurately. If you have any questions or concerns about how your information will be used, feel free to ask our staff for assistance.

Patient Information

Page 1 of 9

Today's Date:

First Name: MI: Last Name:

Date of Birth: Age: Gender:

Address:

City: State: Zip:

Phone Number: Email Address:

Employer's Name: Employer's Phone:

Spouse's Name: Spouse's Phone:

Emergency Contact

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Emergency Contact: Emergency Contact's Phone:

Relationship To Patient:

Insurance Information

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Primary Insurance: Primary Policy Number:

Primary Insured: Primary Insured Relation:

Secondary Insurance: Secondary Policy Number:

Secondary Insured: Secondary Insured Relation:

I, , authorize to obtain medical information / test results on my behalf from Pediatrics and Family Medicine of Buena Vista, LLC for Healthcare purposes.

I hereby authorize and consent to any and all medical care and treatment for the above-named child which is deemed necessary and appropriate by the practitioners of Pediatrics and Family Medicine of Buena Vista, LLC.

Signature:

Patient History

Page 4 of 9

If yes for any response, please provide detail. Please answer each question.

Do you use Tobacco?: Yes No

Do you consume Alcohol?: Yes No

Do you use or have Drug exposure?: Yes No

Do you have any recurring problems?: Yes No

Are you allergic to anything?: Yes No

Do you have a Dentist? Provide Dentist name.: Yes No

Concerns with your health?: Yes No

Hospitalizations or surgeries?: Yes No

Patient History (Continued)

Page 5 of 9

Household Exposures

Please select all that apply.

Illnesses

Please select all that apply.

Other?

Family History

Please select all that apply.

Other?

Any other concerns you would like to discuss with the Physician?

Patient Financial Responsibility Agreement

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We are committed to providing you with the best possible medical care. It is important that we have a good understanding with our patients regarding financial responsibility.

Patient Responsibilities

Bring your identification and your insurance card to each visit.
Notify our office of any changes to your insurance. If you do not provide us with up to date Insurance information then you will be responsible for any unpaid balance or denied coverage for the time of service. IT IS VERY IMPORTANT FOR YOU TO PROVIDE THE CORRECT INSURANCE INFORMATION AND OR ANY CHANGES THAT MAY AFFECT YOUR COVERAGE.
Know your insurance company benefits and your coverage.
It is your responsibility to check with your insurance company on any testing you will have done or ordered on your behalf to see what your responsibility will be. We will not know until the claim is filed with the Insurance company on what your responsibility will be.
All copays are due at the time of service. (No exceptions will be made.)
Any balances you have such as Co-insurance, Deductables and or amounts not covered by your insurance must be paid in full unless you contact the Billing department regarding payment arrangements, again this does not apply to Copays which must be paid prior to visit.

Please understand that the financial responsibilities for medical services rest between you and your Health Insurance. We are happy to be of service by filing your medical insurance for you, however we are not responsible for any limitations in coverage that may be included in your plan. It is your responsibility as a Patient to pay any denied or uncovered portion in full.

I, , have read the above and agree to my responsibility.

Signature:

Authorization for Use/Disclosure of Health Information

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Authorization for Use/Disclosure of Information: I voluntarily consent to and authorize my health care provider, Pedatrics and Family Medicine of Buena Vista to use or disclose my health information during the term of the Authorization to the recipient(s) that I have identified below.

Recipient: I authorize my health care information to be released to the following recipient(s):

Refusal to sign/Right to revoke: I understand that signing this form is voluntary and that if I don't sign, it will not affect the commencement, continuation or quality or my treatment at USC. If I change me mind, I understand that I can revoke this authorization by providing a written notice of revocation to the USC Office of Compliance at the address listed below. The revocation will be effective immediately upon my health care provider's receipt of my written notice, except that the revocation will not have any effect on any action taken by my health care provider in reliance on this Authorization before it received my written notice of revocation.

Questions: I may contact the USC Office of Compliance for answers to my questions about the privacy of my health information at 3500 Figueroa, Suite 105, Los Angeles, CA 90089-8007, or by telephone at (213) 740-8258.

Signature: Signature for Witness:

Date:

If the individual is unable to sign this Authorization, please complete the information below:

Signature: Signature for Witness:

Date:

05.11

Privacy Notice

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This notice is effective January 2nd, 2012. This notice will expire six (6) years after the date upon which the record was created. By signing below, I acknowledge that I received a copy of this notice and that it was explained to me. Click here to review the Privacy Notice, or click the button below.

Patient Signature:

or

Parent of Child if Minor:

or

Representative Signature:

Date:

I refuse to read or accept this document. I understand it's my right to do so.

Refusal Signature:

Authorization to Disclose Protected Health Information

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Patient Name: Today's Date:

Social Security #: Date of Birth:

I authorize to disclose information of the above named individual to Pediatrics & Family Medicine of Buena Vista, LLC. Please mail all Medical Records to 519 Buena Vista Street, Lakeland, Florida 33805; (863) 337-4994 Phone.
I understand that the information in my Health record may include information relating to Sexual Transmitted Disease, Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV). It may also include information about Behavorial or Mental Health Services and or treatment for alcohol or drug abuse.

Purpose of Disclosure Personal Records Continued Healthcare Insurance Purpose Other - Specify

I understand that I have a right to revoke this authorization at any time.
I understand that if I revoke this authorization, I must do so in writing and present my written recovation to the Health Information Management Department.
I understand the revocation will not apply to my Insurance Company when the law provides my Insurer with the right to contest a claim under my policy.
I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by Federal Privacy Laws or Regulations.
I understand that authorizing the use or disclosure of the information identified above is voluntary and I need not sign this form to ensure Healthcare treatment.

Signature of Patient or Legal Guardian:

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