wsfmed.com - Patient Registration

New Patient Application

Complete this before your appointment and your provider can be better prepared during their time with you.
Patient Information

This information will be sent to your provider and will be kept as part of your patient records.
Name

First NameLast Name
Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Mobile phone number
Please enter a valid phone number.
Which number do you prefer
Email
example@example.com
Sex
Marital Status

SingleMarriedSeparatedDivorcedWidowed
Race
Ethnicity
Language(s)
Employer
Occupation
Emergency Contact
Relationship
Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.

Insurance Information
Responsible Party
Date of Birth

MonthDayYear
Date
Relationship
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Primary Insurance
Phone Number
Please enter a valid phone number.
Primary Insured Name
Birthdate

MonthDayYear
Date
Policy
Group
Secondary Insurance
Phone Number
Please enter a valid phone number.
Secondary Insured Name
Birthdate

MonthDayYear
Date
Policy
Group

Medications
Preferred Pharmacy
Phone Number
Please enter a valid phone number.
Address
PFM Providers Will Not Provide Chronic Pain Medication Such As Prescription Opiate

If you are seeing a specialist for your pain, please list:
Specialist Name
Medical issue/s being treated
Current Pain Medications
Please list all current Pain Medications, Dose and Frequency
Other Current Medications
Please list all Medications, Dose, and Frequency
Allergies to Medications
Please list all Medications and Reaction

	Please list all the problems. If died, please specify died at what age.
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Father
Mother
Sibling
Children

Notice of Privacy Practices
I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can will be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
- Obtain payment from third-party payers.
- Conduct normal health care operations such as quality assessments and physician certification.
I understand that this organization has the right to change the Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I understand you are not required to agree to my requested restrictions, but if you do agree, you are bound to abide by such restrictions.
Patient Signature

Clear
Date

MonthDayYear
Date

Authorization for Protected Communication
I (the person named below) prefer to be contacted in the following manner.
Patient portal – Preferred E-mail Address
example@example.com
Telephone – Preferred Phone Number
Please enter a valid phone number.
Written Communication – Home Address
Other
Access to Information
Pavilion Family Medicine may share or access medical information about me from/with the following person(s):
Please list Name - Relationship - Telephone # - Is this person also an emergency contact? (Yes/No)
Patient Signature

Clear
Date

MonthDayYear
Date

Agreement of Financial Responsibility
Thank you for choosing us as your health care provider. We are committed to providing quality care and service to all our patients. The following is a statement of our financial policy, which we require that you read and agree to prior to any treatment.
- Please understand that payment of your bill is considered part of your treatment. Fees are payable when services are rendered. We accept cash, check, credit cards, and pre-approved insurance for which we are a contracted provider and are the designated Primary Care Provider (PCP), if applicable.
- It is your responsibility to know your own insurance benefits, including whether we are a contracted provider with your insurance company, your covered benefits and any exclusions in your insurance policy, and any pre-authorization requirements of your insurance company.
- We will attempt to confirm your insurance coverage prior to your treatment. It is your responsibility to provide current and accurate insurance information, including any updates or changes in coverage. Should you fail to provide this information, you will be financially responsible.
- If we have a contract with your insurance company we will bill your insurance company first, less any copayment(s) or deductible(s), and then bill you for any amount determined to be your responsibility. This process generally takes 45-60 days from the time the claim is received by the insurance company.
- If we do not contract with your insurance company, you will be expected to pay for all services rendered at the end of your visit. We will provide you with a statement that you can submit to your insurance company for reimbursement.
- Proof of payment and photo ID are required for all patients. We will ask to make a copy of your ID and insurance card for our records. Providing a copy of your insurance card does not confirm that your coverage is effective or that the services rendered will be covered by your insurance company.
- Please understand some insurance coverages have Out-of-Network benefits that have co-insurance charges, higher co-payments and limited annual benefits. If you receive services are part of an Out-of-Network benefit, your portion of financial responsibility may be higher than the In-Network rate.
I have read the financial policies contained above, and my signature below serves as acknowledgement of a clear understanding of my financial responsibility. I understand that if my insurance company denies coverage and/or payment for services provided to me, I assume financial responsibility and will pay all such charges in full.
Signature of Patient /Responsible Party

Clear
Date

MonthDayYear
Date
Print Name of Patient/Responsible Party
Relationship to Patient

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

IF A PATIENT WANTS ARCHIVED RECORDS SENT TO THEMSELVES, RECORDS WILL BE COPIED ON DISC AT A FEE OF $22.00. PRE-PAYMENT REQUIRED
Patient’s Full Name

First NameLast Name
DOB

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
1. Provider authorized to release Patient’s information, including: Name, Fax Number, Phone Number, and Address.
2. Provider authorized to receive Patient's information

YesNo
3. The specific information that should be disclosed

ALL OFFICE NOTES/LABS/X-RAYSLAST 24 MONTHS OFFICE NOTES/LABS/X-RAYSOTHER (BE SPECIFIC IN THE BOX BELOW)
Pick upFaxedMailed
4. The purpose for the disclosure is
5. This authorization will expire on the following date or event
If no expiration date or event is listed, the authorization will expire one year after the date of the authorization.
Signature

Clear
Date

MonthDayYear
Date
Patient
Parent/Legal Guardian/POA
Should be Empty:

New Patient Application

Patient Information

Insurance Information

Medications

Current Pain Medications

Other Current Medications

Allergies to Medications

Medical History

Past Surgical History

Family History

Health Maintenance

Males

Social History:

Notice of Privacy Practices

Authorization for Protected Communication

Access to Information

Agreement of Financial Responsibility

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION