Patient Registration Forms

Name

First Name Last Name

I give permission for J.C. Healthcare & Associates, LLC to give me medical treatment.

2.I understand that J.C. Healthcare & Associates will not submit a claim for insurance benefits to pay for the care I receive.

I understand that:
- All services I receive must be paid by debit or credit card in full at time of service.
- It is my responsibility that if I have insurance, I will contact my insurance company to discuss reimbursement of services paid for.
- I must pay for the cost of these services if even if my insurance does not pay or I do not have insurance.

3. I understand:

I have the right to discuss all medical treatments with my healthcare provider.
I have the right to request to be seen or referred to another healthcare provider such as a physician or nurse practitioner.
I have the right to refuse any procedure or treatment.

Patient's Signature

Clear

Parent/Guardian Signature (for minors under 18)

Clear

Parent/Guardian Signature (for minors under 18) Date

Print name

Date

Name

First Name Last Name

Middle Name

Age

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Date of Birth

Date

Social Security No.

Your Email address:

example@example.com

Phone Number

Area Code Phone Number

Responsible Party or Insurance Policy Holder (Skip if no health insurance)

First Name

Last Name

MI

Gender

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home Number

Area Code Phone Number

Cell Number

Area Code Phone Number

Medical Insurance Company Information

Name of Primary Insurance Company

Name of Secondary Insurance Company

Name of Policy Holder

SS#

ID#

Group#

Name of Primary Care Physician

Phone

Meaningful Use (required by law)

Race (select all that apply)

Black/African American White/Caucasian Asian/Native Hawaiian/Pacific Islander Native American/Native Alaskan Refuse to answer

Ethnicity

Hispanic Non Hispanic Refuse to answer

Languages spoken fluently

Who may we thank for referring you to our office?

By signing below I hereby certify that the above information is true and correct to the best of my knowledge and belief.

Clear

Meaningful use (required by law)

Type option 1 Type option 2 Type option 3 Type option 4

You will be required to provide a government issued photo ID at the time of service.

Race

Black/African American American Indian, Alaskan Native White Asian, Native Hawaiian or other Pacific Islander Hispanic Refuse to report

Ethnicity

Hispanic Non-Hispanic

Date

Language

English Spanish Type option 3 Type option 4

Patient's Name

By signing below I hereby certify that the above information is true and correct to the best of my knowledge and belief.

Date of Birth

Date

Signature

Clear

Form completed by

Relation (if other than patient)

What medical concern brings you in today?

Gender

Male Female

Gender

Male Female

If female, are you pregnant

Yes No

Last colonoscopy

Last Dexa Scan

Last mammogram

Last pap smear

Drug or Food Allergies?

Yes No

List of food or drug allergies and reactions

Please list your current medications, when you began taking this medication and the end date or put current if still taking.

What is your pharmacy name & number?

Have you ever been hospitalized or had surgery? If yes please list reasons and date.

Please list all medical conditions.

Please list family medical history and family member (e.g. cancer, heart disease, anemia, diabetes etc.)

Occupation:

Are you:

□ Single □ Married □ Partner □ Separated/Divorced □ Widowed

J.C. Healthcare & Associates reserves the right to charge a fee for any scheduled visits that are:

1. Cancelled with less than 24 hours notice (please initial)

List Drug and Good allergies and reactionary

2. Missed without calling to cancel (please initial)

Cancellation Fee:

New Patient $25.00

Established Patient: $15.00

Patient / Parent or Guardian Signature:

Clear

Date.

If yes, please list reason for hospitalization or surgeries and dates

HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

The practice reserves the right to change the privacy policy as allowed by law.
The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
The patient has the right to revoke th is consent in writing at any time and all full disclosures will then cease.
The practice may condition receipt of treatment upon execution of this consent.

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

If yes, please list (e.g. high blood pressure, diabetes, high cholesterol etc...)

May we phone, email, or send a text to you to confirm appointments?

Yes No

May we phone, email or send a text to you to discuss your medical Information?

Yes No

Family History - Please list family member and medical history e.g. cancer, heart disease, anemia, diabetes etc

May we leave a message on your answering machine at home or on your cell phone?

Yes No

May we discuss your medical condition with any member of your family?

Yes No

If yes, please list family members

Signature

Clear

Date

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. This is readily available to view anytime on our website at www.jchealthcareassociates.com. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, signed by you. However, such a revocation shall not affect disclosures we have already made in reliance on your prior consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA

Protected health information may be disclosed or used for treatment, payment or health care operations • The Practice has a Notice to Privacy Practices and that the patient has the opportunity to review this Notice

This Acknowledgement was signed by:

Patient Signature

Clear

Relationship to Patient (if other than patient):

Practice Representative: Jessica Chung

Date:

Date

Type a question

PATIENT ACKNOWLEDGEMENT FORM