New Patient Registration & Consent Form
Patient Information
Please complete the following patient information.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
Sex
Male
Female
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Age
Social Security Number
Marital Status
Single
Married
Widowed
Divorced
Separated
Race
Ethnicity
Language
Preferred Pharmacy
Are you a current LWC patient?
Yes
No
Please list any other names or aliases that you may be listed under:
Employment Status
Full-Time
Part-Time
Unemployed
Other
Employer Name
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Insurance Information
Please provide the following information about your primary insurance provider.
Primary Insurance Provider
Primary Insurance ID #
Primary Insurance Group #
Subscriber Name
Subscriber Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Subscriber Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Subscriber Social Security Number
Subscriber Relationship to Patient
Secondary Insurance Information
Please provide the following information about your secondary insurance provider.
Secondary Insurance Provider
Secondary Insurance ID #
Secondary Group #
Subscriber Name
First Name
Last Name
Subscriber Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Subscriber Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Subscriber Social Security Number
Subscriber Relationship to Patient
Consent Form
I hereby give my consent to be treated and accept the following terms:
Please confirm you accept the following terms and conditions:
*
I am requesting the services of London Women’s Care rural health clinic.
I understand that this is a clinic. I understand that the clinic employs independent advanced practitioners (Certified Nurse-Midwives, Certified Nurse Practitioners, or Physician Assistants), who practice under physician approved guidelines.
I hereby give permission for my chart to be copied for the use of transfer of record information to another health care provider upon written request from that provider, or upon transfer of patient care or referral from my provider.
I am aware that health care is dependent upon the responsibility of the patient to follow the guidance of the health care provider and includes cooperation by the patient. I know I am responsible for my actions and their effect on my body.
I hereby consent for treatment of medical conditions as necessary, including the use of oral medications, injections, diet counseling, blood withdrawal, and other treatment which shall be fully explained, prior to treatment, by nurse or provider.
Individual Document Acknowledgement
I acknowledge that I have received a copy of London Women's Care notice of privacy practices (dated April 14, 2003).
Yes, I confirm I have received a copy of LWC privacy practices
Please issue a password that can be used to access your medical records.
Person you would like to have access to your records (must know password) 1 Name
First Name
Last Name
Person you would like to have access to your records (must know password) 1 Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Person you would like to have access to your records (must know password) 1 Relationship
Person you would like to have access to your records (must know password) 2 Name
First Name
Last Name
Person you would like to have access to your records (must know password) 2 Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Person you would like to have access to your records (must know password) 2 Relationship
Would you like to allow another person to access your medical records? They must know the password provided above.
Yes
No
Do you have an Advanced Directive (Living Will)?
Yes
No
Would you like more information on Advanced Directives (Living Wills)?
Yes
No
Release of Information, Benefit Assignment, Payment Authorization, Full Disclosure Statement and Agreement to Pay For Services
I hereby authorize London Women's Care (LWC) to release any information necessary to process my insurance/Medicare claim, acquired in the course of my examination or treatment; to allow a photocopy of my signature to be used to process my insurance/Medicare claim for the period of LIFETIME. I claim any insurance benefits due me for services rendered by LWC and authorize and direct my carrier to issue payment check(s) directly to LWC. Regardless of my insurance benefits, if any, I understand that I am fully financially responsible for any and all fees incurred, and I agree to pay such fees in full. The insurance information furnished here represents a full disclosure of the insurance/third party benefits to which I am entitled. I understand that failure to disclose pre-certification/second opinion requirements for any and all plans to which I subscribe, may cause me to incur full liability for professional charges, as a result of non-payment by any carrier.
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient / Responsible Party Signature
Submit
Should be Empty: