Patient Registration Form

PATIENT REGISTRATION FORM

Name

First NameLast Name

Birth Date

Date

Gender

Email

Phone Number

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Information

Insurance Provider

Policy Number

Please take a photo of the front of your primary insurance card and / or you may also include the front photo of the secondary insurance card

Please take a photo of the back of your primary insurance card and / or you may also include the back photo of the secondary insurance card

Please list any medication allergies

Please list any food allergies

Please list all your past medical history

Please list all your past surgical history

Do you suffer from any mental illness ?

Pharmacy Name

Pharmacy Zip Code

Reason for Visit

How did you hear about us ?

PATIENT CONSENT AND WAIVER FORM

Abramov Services in Adult Health NP, P.C. provides healthcare services through office visits, telehealth visits, and other healthcare services as medically appropriate.

This form explains your rights and responsibilities regarding treatment, telehealth services, privacy practices, and financial obligations. By signing this document, you acknowledge that you have read, understood, and agreed to the terms described below.

CONSENT FOR TREATMENT

I voluntarily consent to receive healthcare services from Abramov Services in Adult Health NP, P.C., including but not limited to:

• Office Visits

• Telehealth Visits

• Preventive Care

• Physical Examinations

• Medical Evaluations

• Laboratory Testing

• Diagnostic Services

• Medication Management

• Chronic Disease Management

• Health Education and Counseling

• Specialist Referrals

I understand that healthcare outcomes cannot be guaranteed and that the practice of medicine and nursing is not an exact science.

TELEHEALTH SERVICES

Telehealth involves the use of electronic communications that enable healthcare providers and patients in different locations to communicate for diagnosis, treatment, follow-up care, education, and care coordination.

Telehealth services may include:

• Live two-way audio and video communication

• Telephone consultations when appropriate

• Review of medical records and diagnostic information

• Remote patient education and counseling

Telehealth visits are conducted through Tebra, a HIPAA-compliant and secure platform. By participating in telehealth services, I acknowledge and accept the terms of use and privacy protections associated with the platform.

I understand that telehealth has limitations and may not be a substitute for an in-person physical examination. My provider may recommend an office visit, urgent care evaluation, specialist consultation, or emergency treatment if clinically necessary.

HIPAA ACKNOWLEDGMENT

I acknowledge that I have received, reviewed, or been offered access to Abramov Medical Care in Adult Health NP, P.C.'s Notice of Privacy Practices.

I understand that my protected health information may be used and disclosed for:

• Treatment

• Payment

• Healthcare Operations

• Care Coordination

• Laboratory Services

• Specialist Referrals

• Other purposes authorized or required by law

I understand my rights under HIPAA, including my right to access my medical records, request amendments, request restrictions, and receive confidential communications.

FINANCIAL RESPONSIBILITY

I understand that I am financially responsible for all services rendered, including applicable:

• Copayments

• Coinsurance

• Deductibles

• Non-covered Services

• Outstanding Balances

I authorize payment of insurance benefits directly to Abramov Medical Care in Adult Health NP, P.C.

If my insurance carrier denies payment for services, including telehealth services, I agree to remain financially responsible for all charges incurred.

PATIENT ACKNOWLEDGMENT

I certify that I have read, understand, and agree to the terms outlined in this Patient Consent and Waiver Form. I have had the opportunity to ask questions regarding its contents, and all of my questions have been answered to my satisfaction.

By signing below, I voluntarily consent to receive medical evaluation and treatment, including in-office and telehealth services, as deemed appropriate by my healthcare provider. I acknowledge that I have received or have been offered a copy of the Notice of Privacy Practices and understand how my protected health information may be used and disclosed.

I further acknowledge that I am financially responsible for all charges related to the healthcare services provided, including any amounts not covered by my insurance, in accordance with the practice's financial policy.

Date

Signature