Patient Registration Form

Patient Registration Form
Patient Information:
Name*

First NameLast Name
Previous Name (If applicable)

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email*
example@example.com
Preferred Method of Contact for Reminder Calls and Other Electronically Generated Messages: (Please Select Only One Option)*

VoiceText
If Voice, Please Select Preferred Number?*

HomeCellWork
Family Physician of Pediatrician:
Date of Birth:*

MonthDayYear
Date
Sex:*

MaleFemaleTransgender
Marital Status*

DivorcedMarriedSingleOther
Social Security #*
Race (please select):*

WhiteAmerican Indian or Alaska NativeAsianHispanicBlack or African AmericanNative Hawaiian or Pacific IslanderOtherDecline
Ethnicity (please select one):*

Hispanic of LatinoNot Hispanic or LatinoDecline
Preferred Language (please select one):*

EnglishBosnianIndian (including Hindi & Tamil)Sign LanguageSpanishRussianOther
Preferred Pharmacy Name & Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Name
Emergency Contact Name*
Emergency Contact Phone #*
Relationship to Patient*
Additional Information and Responsible Party

Respnsible Party - If the patient is a minor (under the age of 18), the parent or guardian bringing the patient in will be listed as the guarantor:
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security #
Phone Number
Please enter a valid phone number.
Address of Person Responsible

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Patient
Insurance Information
Primary Medical Insurance
Ins. Co. Name*
Policy Holder Name*

First NameLast Name
Policy Holder's Date of Birth:*

MonthDayYear
Date
Policy Holder's Social Security #:*
Member ID*
Group #*
Patient Relationship to Policy Holder:*
Secondary Medical Insurance
Ins. Co. Name
Policy Holder Name:

First NameLast Name
Policy Holder's Date of Birth:

MonthDayYear
Date
Policy Holder's Social Security #:
Patient Relationship to Policy Holder:
I certify that I have read and agree to Forward Care Family Practice, PLLC payment policy. I am eligible for the insurance indicated on this form and I understand that payment is my responsibility regardless of insurance coverage. I hereby assign to Forward Care Family Practice, PLLC all money to which I am entitled for medical expenses related to the services performed from time to time by Forward Care Family Practice, PLLC, but not to exceed my indebtedness to Forward Care Family Practice, PLLC. I authorize Forward Care Family Practice, PLLC to release any medical information to my insurance carrier or third-party payer to facilitate processing my insurance claims. I understand that failure to pay outstanding balances within 90 days of notification of the amount due will result in submission to an outside collection agency. A $50.00 returned check fee will be charged for checks returned due to insufficient funds. I choose to receive communications from Forward Care Family Practice, PLLC by text or e-mail at the number or address stated above, including but not limited to communications about appointments, feedback, treatment, and payment. I understand that such e-mails and texts may not be secure and there is a risk that they may be read by a third party. Comments submitted on surveys may be anonymously shared on the Forward Care Family Practice, PLLC Public Website.

MEDICARE BENEFICIARIES: I request that payment of authorized Medicare benefits be made to Forward Care Family Practice, PLLC. I authorize any holder of medical information about me to release to CMS and its agents any information needed to determine these benefits or the benefits payable for related services.
I have reviewed a copy of Forward Care Family Practice Privacy Notice*
(Initials)
Signature of Responsible Party*

Clear
Date*

MonthDayYear
Date
PRIVACY NOTICE ACKNOWLEDGEMENT AND COMMUNICATION CONSENT
Name of your family physician

First NameLast Name
Phone number of your family physician
Please enter a valid phone number.
Signature*

Clear
Date*

MonthDayYear
Date
We must call you at time to give you what is classified as protected health information. Please let us know how we can contact you with this information and if we can leave a message.
Can we leave detailed or confidential messages on your home phone?*

YesNo
Home Phone Number
Please enter a valid phone number.
Can we leave detailed of confidential messages on your cell phone?*

YesNo
Cell Phone Number
Please enter a valid phone number.
Can we mail test results to you home?*

YesNo
Exclusive/Alerts (Please not any information that you do now want release to authorized individuals):
We must call you at time to give you what is classified as protected health information. Can we speak to anyone other than you regarding lab results, radiology results, or other issues regarding your health?
Name of Contact*

First NameLast Name
Relationship*
Must Sign Below for all information given:

My signature below authorizes communication consent as well as acknowledges that I have received a copy of the Forward Care Family Practice PLLC. Notice of Privacy Practices.
Patient Name

First NameLast Name
Patient Signature*

Clear
Patient or Person Authorized to Sign*

First NameLast Name
If not patient, relationship to the patient (parent, legal guardian, personal representative, etc).

Clear
Date*

MonthDayYear
Date
Financial Policy

YOU WILL BE REQUIRED TO SIGN A NEW FINANCIAL AGREEMENT EVERY CALENDAR YEAR
Thank you for choosing Forward Care Family Practice. We are committed to providing the finest personalized family care. Please carefully read and sign the following statement of our office policies prior to your treatment. Feel free to speak to our practice manager or billing department if you have any questions.

INSURANCE:

It is ultimately the patient's responsibility or their responsible party to know their insurance coverage and therefore responsible for copays, deductibles, denied services by insurance. Due to a large amount of Insurance plans/policies, it is impossible for the physician or staff to know what services are/or are not covered. It is the patient's responsibility to be aware of the services covered by your health plan. You are ultimately responsible for payment of services if your insurance carrier does not pay for any reason. IT IS THE RESPONSIBILITY OF THE PATIENT OR THEIR RESPONSIBLE PARTY/REPRESENTATIVE TO KNOW THEIR INSURANCE COVERAGE. Please present your insurance card at each visit. Insurance companies deny claims that are not submitted within 90 days of the date of service. If you do not submit your current insurance to the office at the time of your visit, you may be responsible for denied claims. We attempt to verify coverage before your visit with the information you provide. Verification of coverage does not guarantee the insurance company will pay for your visit. Insurance policies exclude some non-covered services; however, this does not mean services or tests are not necessary. It means the policy you have does not cover certain necessary services. Please keep in mind your insurance policy is a contract between you and the insurance company. The physician has no control over which services the insurance company does or does not cover.

The patient is responsible for obtaining all necessary information regarding referrals or authorizations to another physician. Failure to do so may result in denial or delay of payments. Referral will be done at appointment only. Please be sure to bring your insurance card to every visit to ensure we have the most up to date information.

NO SHOW/LATE CANCELLATION FEE:

If you need to cancel your appointment, please contact our office at least 24 hours before your appointment time. Because of the high demand for appointments, missed appointments prevent us from scheduling appropriately and to care for others in need of urgent care. A $50.00 fee will be assessed for all missed appointments not canceled with at least 24 hour advance notice. Two appointment reschedules will automatically incur a $50 No Show fee. Should you no show or late cancel repetitively, we may discharge you from our practice.

BILLING:

As a courtesy to you, we will bill your insurance company for services rendered. In order to do so, we must have a complete billing information, picture identification, and your insurance card. Arizona law requires insurance companies operating in the state to process claims within 30 days. It is your responsibility to promptly provide your insurance company with any requested information needed to process your claim.

In order to keep billing costs to a minimum, all co-pays, co-insurance, and deductibles are to be paid on the day of the visit without exception. We reserve the right to reschedule your appointment if the applicable co-payment is not paid in full at the time of appointment check-in. For your convenience, we accept credit, and debit cards from Master Card, Visa, and Cash.

In addition to co-payments and deductibles, you are responsible to pay for denied or non-covered services as determined by your insurance company. If our physician is an “out of network provider” for your insurance, the deductibles and co-insurance amounts may be higher. Your insurance policy, not our office, determines the amounts. After your insurance company processes your claims, you will receive a statement every month from our office showing your account balance. Your statement will indicate which portion of the balance is due from you. Patient balances are due and payable in full upon receipt of your statement. Accounts which remain unpaid after 30 days will be assessed a late fee of $5.00 per month. Delinquent accounts will be transferred to a collection agency or our attorney after 90 days.

In the event of default, you will be required to pay collection costs and reasonable attorney fees. Accounts sent to collections are reported to all three major credit bureaus and are on file for as long as the law provides.

Please understand maintaining financial viability is the only way our office is able to continue providing quality medical care for our patients. Your understanding and cooperation enables us to deliver the quality healthcare you deserve and expect.

PRESCRIPTION REFILLS:

Please plan ahead for prescription refills. We encourage you to address refills at the time of your office visit. Any changes in medication, new prescription, or mail-in prescription problems require an office visit. No prescription refills will be granted on weekends, after hours, or during routine well visits.

We respect your time and every attempt is made to run on schedule. Therefore, we ask you to arrive on time for your appointment. If you are late, you may be asked to reschedule. If your provider is running behind due to emergencies and you need to reschedule, please notify the office staff. If you choose to stay, your visit will be given the same consideration.

FORMS:

FMLA (Family Medical Leave Act) of Short Term Disability forms are not included with your medical care. We will complete your forms if you qualify. There is a fee of $95.00 for each form due and payable prior to the provider completing the form(s). You must make an appointment in order to determine eligibility. This is not covered benefit by your insurance company.
I have read and understand the above policy and I agree to abide by the terms stated within. *
(Initials)
Printed Name of Patient*

First NameLast Name
Signature of Patient/Responsible party*

Clear
Date*

MonthDayYear
Date
Consent to Treat
Patient Consent for Treatment:

I voluntarily consent to any and all health care treatment and diagnostic procedures provided by Forward Care Family Practice and its associated physicians, clinicians, and other personnel. I am aware that the practice of medicine and other health care professions is not an exact science and I further state that I understand that no guarantee has been or can be made as to the results of the treatments or examinations at Forward Care Family Practice.

I consent to the use and disclosure of my/the patient's protected health information for purposes of obtaining payment for services rendered to me/the patient, treatment and health care operations consistent with the Forward Care Family Practice Notice of Privacy Practices.

I authorize payment of medical benefits to Forward Care Family Practice physicians or their designee for services rendered.

I give permission to obtain all my medication/prescription history when using an electronic system to process prescriptions for my medical treatment.

Consent to leave voicemail

I have received a copy of the Notice of Privacy Practice, Financial Policy Notice and the Release of Information.

I am granting permission to Forward Care Family Practice to leave phone messages regarding my child’s medical health to the number(s) provided on the registration form.
Patient of Authorized Person's Name*

First NameLast Name
Patient or Authorized Person's Signature*

Clear
Date*

MonthDayYear
Date
Patient Medical Release Form
Patient Information
Patient Name

First NameLast Name
Account #
Former Name (If any)
Daytime Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Information To Be Release From
I hereby authorize (name of organization)
To release the following medical information contained in patient's medical record.
Information To Be Released To
Name of Physician/Organization
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Purpose for the request: (Please select one)

MovingTreatment or consultationDissatisfactionChange of Insurance PlansAt patients request
Other (Specify)
TYPE OF INFORMATION TO BE RELEASED

No information will be release unless a box is checked
General Release
Medical Records/Excluding Protected Records. (This will be limited to 1year of information including Lab, x-ray reports, unless otherwise stated)Other Records (specify)
Dates of Treatment
From:
To:
Other Records (specify)
Information Protected by State/Federal Law
All of my records including:

AIDS/HIV and Other Communicable Disease Information, Behavioral Health Care/Psychiatric Care, Alcohol and/or Drug Abuse Treatment
Dates of Treatment
From:
To:
THIS AUTHORIZATION WILL AUTOMATICALLY EXPIRE AFTER ONE YEAR (or 60 days for drug and alcohol abuse records) from the date of signing. The undersigned may revoke this authorization at any time by providing written notice of revocation.

With respect to drug and alcohol abuse treatment, information or records regarding communicable disease-related information, the recipient of this information understands that it is prohibited from making any disclosure of this information unless further disclosure is expressly permitted by written consent of the undersigned or otherwise permitted by applicable law.

Signature of Patient or Personal Representative Who May request Disclosure
I understand that Forward Care Family Practice physicians may not condition my treatment on whether I sign this authorization form unless specified above under Purpose for Request. I can inspect or receive a copy of the protected health information to be used or disclosed.

I authorize Forward Care Family Practice to use and disclose the protected health information specified above.
Signature of Patient OR Legal Representative:*

Clear
Date*

MonthDayYear
Date
Name of Signing Party*

First NameLast Name
Should be Empty:

Patient Registration Form

Patient Information:

Additional Information and Responsible Party

Insurance Information

Primary Medical Insurance

Secondary Medical Insurance

PRIVACY NOTICE ACKNOWLEDGEMENT AND COMMUNICATION CONSENT

We must call you at time to give you what is classified as protected health information. Please let us know how we can contact you with this information and if we can leave a message.

We must call you at time to give you what is classified as protected health information. Can we speak to anyone other than you regarding lab results, radiology results, or other issues regarding your health?

Must Sign Below for all information given:

Financial Policy

Consent to Treat

Patient Medical Release Form

Patient Information

Information To Be Release From

Information To Be Released To

TYPE OF INFORMATION TO BE RELEASED

General Release

Dates of Treatment

Information Protected by State/Federal Law

Dates of Treatment