• Patient Registration Form

    Thank you for choosing Medical Associates Plus as your Healthcare Provider.

  • Bring the following items to your office visit

    PLEASE ARRIVE 30 MINUTES PRIOR TO YOUR APPOINTMENT

    1. Completed registration packet. 
    2. A current valid Picture Identification or Driver’s license is REQUIRED to be seen.
    3. All insurance cards.  We will make copies of these.(if applicable).
      • If you do not have insurance, we offer the Sliding fee program. Proof of income is needed for you and any other adult listed on the application.
        • Proof of income indicated by one of the following documents:
        • Recent Federal Income Tax Return
        • Wage statement from the Dept. of Labor (If no income)
        • 4 pay stubs if paid weekly
        • 2 pay stubs if paid bi-weekly
        • 1 pay stub if paid monthly
        • A notarized letter from the employer can also be accepted
        • Notarized statement from person verifying they are not employed
        • Statement from Social Security Administration.
        • Disability statements
        • Pension
    4. Copay (if applicable)
    5. Your medicine bottles and glucose meter(if applicable).  Please bring any over-the-counter drugs or supplements that you are taking regularly.

    We look forward to providing you with exceptional care!

  • Patient Information

  • Date of Birth*
     - -
  • Marital Status:*
  • Sex (at time of birth):*
  • Demographic Factors:*
  • Demographic Factors:*
  • Primary Language*
  • Which phone numbers are best to reach you?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you have a primary email address for the practice to communicate information for you?*
  • Do we need to contact you through an alternate method (phone number) for confidential issues?*
  • Format: (000) 000-0000.
  • Is your mailing address different than above?*
  • Do you have an Advanced Directive/Living Will/DNR Order?*
  • Do you have an Emergency Contact you would like listed on your account?*
  • Employment Status*
  • Public Housing: Is your address considered public housing?*
  • Annual Household Income Range:*
  • Indicate all of the places where you have seen MAP advertised.*
  • Primary Caregiver Name:*
  • Legal Guardian Name:*
  • Are you a Veteran?*
  • Are you a migratory worker?*
  • Are you a seasonal worker?*
  • Are you homeless? (For example, staying at Salvation army, church or community supported shelter(s), home not habitable for humans, transitional home, on the street or car, sleeping on someone’s couch or floor or living from house-to-house?*

  • Insurance Information

  • Do you have private insurance?*

  • Please provide a copy of your insurance card upon your first appointment and complete the information below.

  • Policy Holder Date of Birth:*
     - -
  • Do you have additional insurance?*
  • Do you have a Preferred Pharmacy for us to use.*

  • Guarantor

    (Person responsible for payment)
  • Who is going to be responsible for payment to Medical Associates Plus?*
  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • CONSENT FOR TREATMENT AND USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR PAYMENT, TREATMENT, AND HEALTHCARE OPERATIONS

  • By signing below, I voluntarily consent for the providers at Medical Associates Plus (MAP) to perform reasonable and necessary medical examinations, testing, and treatment to include medical and health services as well as family planning. I understand that part of my treatment may require referral(s) to outside sources for examinations, diagnostic procedures, therapy, and treatment. I understand that this practice will use or disclose information about me (or another person for whom you have the authority to sign) that is protected under federal law, for the sole purposes of treatment, payment, and healthcare operations. You may refuse to sign this consent form.

    Immunization Tracking: By signing below, I acknowledge and understand that MAP uses the Georgia Registry of Immunization Transactions and Services (GRITS) system to keep track of immunizations that have been given to patients in the state of Georgia. I will inform my provider if I have elected to opt out of the GRITS database.

    Electronic Prescriptions: By signing below, I have been made aware and understand that this practice uses an electronic prescription system which allows prescriptions and related information to be electronically sent between my providers and my pharmacy. I have been informed and understand that my providers using the electronic prescribing system will be able to see and verify the accuracy of information about medications I am already taking, including those prescribed by other providers.

  • You hereby give Medical Associates Plus the permission to verify your prescription via our EMR system for accuracy.*

  • Pain Management: MAP primary care providers treat pain appropriately according to diagnosis. If you are transferring care to this office and currently on narcotic prescriptions, please understand that we must confirm your diagnosis that requires narcotics, the workup that was done, check your pharmacy for the length of time you have received medications, and that you only receive medications from one physician. We do not guarantee that your narcotic will be filled on the first visit and we do not guarantee that we will continue your current narcotic. We will however refer you to pain management at your discretion. By signing this Consent, I acknowledge and agree to these pain management protocols.

    Title X Family Planning Services: I understand that acceptance of Family Planning services is not a prerequisite for eligibility for services. MAP does not require written consent of parents or guardians for the provision of services to minors. Furthermore, no staff member may notify a parent or guardian before or after a minor has required and/or received family planning services (42 CFR 59.5 (a) (1) Georgia law allows for a minor to self-consent for services related to prevention and diagnosis of pregnancy and reportable sexually transmitted diseases (GA. CODE ANN. §31-9-2 (2012).).

    Special Protections for Substance Use Disorder Records: Certain records related to substance use disorder diagnosis, treatment, or referral for treatment are protected under federal law, including 42 U.S.C. § 290dd-2 and its implementing regulations at 42 CFR Part 2. These records may not be used or disclosed without your written consent except as permitted by law. If you provide written consent for the use or disclosure of your substance use disorder treatment records, those records may be redisclosed for purposes of treatment, payment, and health care operations as permitted by federal privacy regulations. You have the right to revoke your consent at any time, except to the extent that action has already been taken in reliance on that consent. Federal law prohibits the use or disclosure of substance use disorder treatment records in criminal, civil, administrative, or legislative proceedings against you unless specifically authorized by law.

    AI-Assisted Documentation: I understand that my provider(s) may use secure AI technology to assist with clinical documentation during visits. This technology supports accurate notetaking and allows providers to focus more on patient care. I will inform my provider(s) if I elect to opt out of using this technology during my visits.                  

      After-hours Care: FOR MEDICAL EMERGENCIES AFTERHOURS, PLEASE CALL 911. IF YOU NEED OTHER ASSISTANCE, YOU MUST SPEAK WITH THE ON-CALL PRIMARY CARE PROVIDER.

     Contact the after-hours line by calling this practice and selecting the menu option for the answering service for assistance. A medical provider will return your call.

    FOR ENDOCRINOLOGY PATIENTS: If you need immediate assistance after hours, consider an urgent care evaluation or contact your primary care (Family Practice or Internal Medicine) physician or nurse practitioner. If your primary care provider is at MAP, please call (877)205-5066 and ask for the provider to be called to help you.

    Notice of Privacy Practices: I have received and read the Notice of Privacy Practices for PHI attached to this form before signing the Consent. I understand that the terms of the Notice may change from time to time, and that I may always request a revised copy from this practice. I have the right to request that the practice restricts how PHI is used or disclosed to carry out the treatment, payment, or healthcare operations. Practice is not required to agree to requested restrictions; however, if the Practice agrees to  your requested restrictions, the restriction is binding on it. Information about you is protected under federal law, and you have the right to revoke this Consent, unless we have acted in reliance on your authorization (as determined by our Privacy Officer). By signing below, you recognize that the PHI used or disclosed pursuant to this Consent may be subject to re-disclosure by the recipient and may no longer be protected under federal law.

  • Would you like us to add other individuals to your account that we may speak with regarding your condition or course of treatment*
  • Signature Date*
     - -

  • Communicate confidential information to me using the following address and telephone number:

  • Format: (000) 000-0000.

  • Consent for Treatment

  • I voluntarily consent for the providers at MAP to perform reasonable and necessary medical examinations, testing, and treatment to include medical and health services as well as family planning. I understand that part of my treatment plan may require referral(s) to outside sources for examinations, diagnostic procedures, therapy, and treatment.

    I certify that I have read this form and understand its contents

  • Signature Date*
     - -

  • PATIENT FINANCIAL & PAYMENT RESPONSIBILITY POLICY

  • Payment is expected in full when services are rendered.

    • MAP accepts all forms of insurance. Please present your card and picture ID at each visit.
    • We also have a sliding fee discount (SF) program for qualified patients.
    • If you have insurance, you are required to pay your co-payment at the time of service as set by your insurance company.   

    Self -Pay Patients

    • Full payment is due at the time of service. 
    • We accept cash, checks, VISA/MasterCard and debit.  

    Collection Agency

    • MAP will make every effort to work with patients to collect all monies due for services.
    • We offer payment plans and cash discounts for prompt payment.  
    • Patient is responsible for all additional fees associated with collections for delinquent accounts.

    Same-Day Cancellations

    I understand that if I do not show up for a scheduled appointment without calling within 24 hours or if I cancel on the same day in the absence of emergency, I may be charged a no-show fee . After a total of three (3) no-shows or same-day cancellations, I am aware that it is up to the discretion of the physician to dismiss me as a patient from the practice.

    By signing below, you acknowledge and accept our Patient Financial and Payment Responsibility Policy

     

     

  • Signature Date*
     - -

  • Notice of Privacy Practice

  • HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU. The following categories describe different ways that we use and disclose medical information. For each category of uses or disclosures, we will elaborate on the meaning and provide more specific examples, if you request Not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the categories.

    For Payment. We may use and disclose medical information about you so that the treatment and services you receive at the practice may be billed to and payment may be collected from you, an insurance company or a third party. For example: we may disclose your records to an insurance company, so that we can get paid for treating you.

    For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you at the practice or the hospital. For example, we may disclose medical information about you to people outside the practice who may be involved in your medical care, such as family members, clergy or other persons that are part of your care.

    For Health Care Operations. We may use and disclose medical information about you for health care operations. These uses and disclosures are necessary to run the practice and ensure that all our patients receive quality care. We may also disclose information to doctors, nurses, technicians, medical students, and other practice personnel for review and learning purposes. For example, we may review your record to assist with our quality improvement efforts.

    WHO WILL FOLLOW THIS NOTICE. This notice describes our practice policies and procedures and that of any health care professional authorized to enter information into your medical chart, any member of a volunteer group which we allow to help you, as well as all employees, staff, and other practice personnel.

    POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION. We created a record of the care and services you receive at the practice. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all the records of your care generated by the practice, whether made by practice personnel or by your personal doctor. The law requires us to: make sure that medical information that identifies you is kept private; give you this notice of our legal duties and privacy practices with respect to medical information about you; and to follow the terms of the notice that is currently in effect. Other ways we may use or disclose your protected healthcare information include appointment reminders; as required by law; for health- related benefits and services; to individuals involved in your care or payment for your care; research; to avert a serious threat to health or safety; and for treatment alternatives. Other uses and disclosures of your personal information could include disclosure to, or for: coroners, medical examiners, and funeral directors; health oversight activities; inmates; law enforcement; lawsuits and disputes; military and veterans; national security and intelligence activities; organ and tissue donation; protective services for the President and others; public health risks; and worker's compensation. 

    NOTICE OF INDIVIDUAL RIGHTS. You have the following rights regarding medical information we maintain about you:

    Right to a Paper Copy of this Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of it, at any time.

    Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. We may deny your request to inspect and copy in certain very limited circumstances.

    Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment if the information is kept by, or for, the practice. To request an amendment, your request must be made in writing and submitted to the Privacy Officer, and you must provide a reason that supports your request. We may deny your request for an amendment.

    Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. To request restrictions, you must make your request in writing to the Privacy Officer.

    Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. You must make your request in writing, and you must specify how or where you wish to be contacted.

    Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you. To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Officer.

    CHANGES TO THIS NOTICE. We reserve the right to change this notice. We will post a copy of the current notice in the practice's waiting room.

    COMPLAINTS. If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer at 706-849-3374 or Compliance Officer at 706-796-3931 or with the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint.

    OTHER USES OF MEDICAL INFORMATION. If you have any questions about this notice or would like to receive a more detailed explanation, please contact our Privacy Officer. We may make your medical information available electronically through state, regional, or national information exchange services which help make your medical information available to other healthcare providers who may need access to it to provide care or treatment to you. Participation in health information exchange services also provides that we may see information about you from other participants.

    I acknowledge by signing below that I have reviewed may request a copy of Notice of Privacy Practices and Bill of Rights.

  • Signature Date*
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  • Should be Empty: