Patient Registration Form

Insurance Information
Do you have private insurance? *

Yes No
Please provide a copy of your insurance card upon your first appointment and complete the information below.
Name of Primary Insurance Company *
Policy/Subscriber Number *
Name of Policy Holder *

First Name Middle Name Last Name Suffix
Relationship to Client: *
Policy Holder SSN: *
Policy Holder Date of Birth: *

Month Day Year
Date
Do you have additional insurance? *

Yes No
Do you have a Preferred Pharmacy for us to use. *

Yes No
Please provide the name and location of your pharmacy. *
Ex. Walgreens on the corner of Bobby Jones and Washington Rd.
Guarantor

(Person responsible for payment)
Who is going to be responsible for payment to Medical Associates Plus? *

Someone other than myself will be responsible for payment I will be responsible for my payments
Responsible Party Full Name. *

First Name Last Name
Date of Birth *

Month Day Year
Date
Relationship to patient: *
Social Security Number: (Type 000-00-0000 if you don't have one) *
Responsible party phone number. *
Please enter a valid phone number.

CONSENT FOR USE OR DISCLOSURE OF PROTECTEDHEALTH INFORMATION FOR PAYMENT, TREATMENT AND HEALTHCARE OPERATIONS
By signing below, you hereby consent for this Practice to use or disclose information about yourself (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 health care operations. You may refuse to sign this consent form.
You hereby give Medical Associates Plus the permission to verify your prescription via our EMR system for accuracy. *

Yes No
You should read the Notice of Privacy Practices for PHI attached to this form before signing the Consent. The terms of the Notice may change from time to time, and you may always get a revised copy of it by asking the Privacy Officer for this Practice.

You have the right to request that the Practice restrict how PHI is used or disclosed to carry out treatment, payment, or health care operations. The 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 taken action in reliance on your authorization (as determined by our Privacy Officer). By signing below, you recognize that the protected health information 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 *

Yes No
Individuals that we may speak with regarding your condition or course of treatment. *
I authorize Medical Associates Plus to speak with the above mentioned individuals. *

Clear
Signature Date *

Month Day Year
Date
Communicate confidential information to me using the following address and telephone number:
Confidential Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Confidential Information Phone Number
Please enter a valid phone number.
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
Consent for Treatment Signature *

Clear
Signature Date *

Month Day Year
Date
PATIENT FINANCIAL & PAYMENT RESPONSIBILITY POLICY
Payment is expected in full when services are rendered.

The following is the Patient Financial Policy of Medical Associates Plus. MAP accepts all forms of insurance. Please present your card and picture ID at each visit. We also have a sliding fee scale discount (SFSD) program for those who are un-insured. This is a government funded program this is based off the household income. Please ask the Customer Service Representative for more information and an application for this program.

If you have insurance, you are required to pay your copayment at the time of service as set by your insurance company.

Self -Pay Patients

Full payment is due at time of service. We accept CASH, CHECKS, VISA/MASTERCARD and DEBIT.

Collection Agency

Patient is responsible for all additional fees associated with collections for delinquent accounts.

MAP will make every effort to work with patients to collect all monies due from services provided by offering payment plans and cash discounts for prompt payment.

Thank you for choosing us as your health care provider. Please let us know if you have questions or concerns.

By signing below, you acknowledge and accept our Patient Financial Policy.
Signature of Patient or Responsible Party

Clear
Signature Date *

Month Day Year
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 of 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 record 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 of 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 our quality improvement efforts. WHO WILL FOLLOW THIS NOTICE? This notice describes our practice's 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 create a record of the care and services you receive at the practice. We need this record in order to provide you with quality care and to comply with certain legal requirements. This notice applies to all of 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 for as long as 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 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. Other uses and disclosures of medical information not covered by this notice or the laws that apply to use will be made only with your written authorization. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time.

If you have any questions about this notice or would like to receive a more detailed explanation, please contact our Privacy Officer.

I acknowledge by signing below that I have reviewed may request a copy of Notice of Privacy Practices and Bill of Rights.
Patient's Signature or Representative. *

Clear
Signature Date *

Month Day Year
Date
Should be Empty:

Patient Registration Form

Patient Information

Insurance Information

Guarantor

CONSENT FOR USE OR DISCLOSURE OF PROTECTEDHEALTH INFORMATION FOR PAYMENT, TREATMENT AND HEALTHCARE OPERATIONS

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

Consent for Treatment

PATIENT FINANCIAL & PAYMENT RESPONSIBILITY POLICY

Notice of Privacy Practice