• PATIENT REGISTRATION FORM

  • Patient Information

  • Is this your legal name?
  • Birth Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex
  • Format: (000) 000-0000.

  • Responsible Party Information

    Must be completed
  • Birth Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Is this person a Patient Here*

  • Primary Insurance Information

  • Covered by Insurance
  • Format: (000) 000-0000.
  • Subscriber Birth Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Patient's relationship to subscriber

  • Secondary Insurance Information

  • Subscriber Birth Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Patients relationship to subscriber

  • In case of Emergency

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Hazem Elzufari MD PA or insurance company to release any information requires to process my claims.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • MEDICAL HISTORY

  • Please indicate if a parent or sibling has ever had any of the following:
  • Have you ever smoked?
  • Do you drink alcohol?
  • Have you ever used recreational drugs?

  • NURSE PRACTITIONER CONSENT

    This facility has on staff Nurse Practitioners to assist in the delivery of medical (Family Practice Specialty) care.

    A Nurse Practitioner is not a doctor. A Nurse Practitioner is a Registered Nurse who has received advanced education and training in the provision of healthcare. A Nurse Practitioner can diagnose, treat and monitor common illnesses and chronic diseases as well as provide health maintenance care. In addition, the Nurse Practitioner may treat minor lacerations and other minor injuries.

    I have read the above and hereby consent to the services of a Nurse Practitioner for my healthcare needs.

    I understand that at any time I can refuse to see the Nurse Practitioner and request to see a Physician.

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Physician Financial Disclosure Notification

    Hazem Elzufari MD PA has a financial investment in Aspire Hospital.

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • NOTICE OF PRIVACY PRACTICE/HIPPA

    Hazem Elzufari MD PA has provided a copy of their HIPPA and Privacy Practice Notification for review and will provide a copy at your request.

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • No-Show Policy

    Hazem Elzufari MD PA imposes the following policy with regard to patients who fail to keep their scheduled appointments. Patients who fail to come in for their scheduled appointment or do not contact our office to cancel or reschedule their appointment at least 24 hours prior to their scheduled appointment time, shall be subject to a "No Show" penalty of $25.00. Insurance plans will not cover charges for No Show fees. No Show fees are the sole responsibility of the patient and must be paid in full before the patient's next appointment.

    Medicaid: If a patient has Medicaid and no-shows in our office 3 times the patient will be terminated from our practice and will no longer be able to make any future appointments in our office.

    By signing below you are acknowledging that you have read and understood the above information.

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Schedule II Prescriptions

    Due to the increased workload and time spent processing prescriptions, as of November 6, 2014, we will charge a $10.00 processing fee for ALL CII prescriptions that have to be written and picked up at the office. This will not be billed to your insurance. The money will be due when the prescription is picked up. (Per state regulations: Medicaid and workers compensation patients are excluded)

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

  • Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year

  • I request and authorize information of the patient named above to:

  • This request and authorization applies to: 

  • Healthcare information relating to the following treatment, condition, or dates

  • Definition: Sexually Transmitted Disease (STD) as defined by las, RCW 70.24 et seq., includes herpes, herpes simplex, human papillomavirus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (acquired Immunodeficiency Syndrome), and gonorrhea.

  • I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.
  • I authorize the relapse of any records regarding drug, alcohol or mental health treatment to the person(s) listed above.
  • Date Signed
     - -
    2 digit month, 2 digit day, 4 digit year

  • THIS AUTHORIZATION EXPIRES AFTER NINETY DAYS

  • Should be Empty: