Hazem Elzufari MD PA New Patient Registration Form

PATIENT REGISTRATION FORM
Today's Date
Patient Information
Name

First NameLast Name
Marital Status
Is this your legal name?

YesNo
Full Legal Name

First NameLast Name
Birth Date

MonthDayYear
Date
Sex

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Email Address
example@example.com
Occupation
Responsible Party Information

Must be completed
Name of person responsible for bill *

First NameLast Name
Birth Date*

MonthDayYear
Date
Address ( if different than patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone #*
Please enter a valid phone number.
Is this person a Patient Here*

YesNo
Primary Insurance Information
Covered by Insurance

YesNo
Insurance Claim Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance phone #
Please enter a valid phone number.
Subscribers/Policy Holders Name

First NameLast Name
Subscriber Birth Date

MonthDayYear
Date
ID/Policy #
Group #
Patient's relationship to subscriber

SelfSpouseChildOther
Secondary Insurance Information
N/A
Secondary Insurance name & phone #

First NameLast Name
Subscriber/Policy holder name:

First NameLast Name
Subscriber Birth Date

MonthDayYear
Date
ID/Policy #
Patients relationship to subscriber

SelfSpouseChildOther
Group #
In case of Emergency
Name of local friend or relative

First NameLast Name
Relationship to patient
Home Phone #
Please enter a valid phone number.
Work Phone #
Please enter a valid phone number.
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.
Patient/Guardian Signature

Clear
Date

MonthDayYear
Date
MEDICAL HISTORY
Previous surgeries (Name & Date)
Please indicate if a parent or sibling has ever had any of the following:

ArthritisAsthmaBreast cancerColon polypsTuberculosisDiabetesThyroid issuesHigh cholesterolStomach ulcersHigh blood pressureStrokeHeart trouble
When was your last tetanus shot?
Have you ever smoked?

YesNo
Do you drink alcohol?

YesNo
If yes, how much?
Have you ever used recreational drugs?

YesNo
If yes, how much?
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.
Patient Signature

Clear
Date

MonthDayYear
Date
Physician Financial Disclosure Notification

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

MonthDayYear
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.
Patient Initials
Date

MonthDayYear
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.
Patient Signature

Clear
Date

MonthDayYear
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)
Patient Signature

Clear
Date

MonthDayYear
Date
AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
Patient's Name
Date of Birth

MonthDayYear
Date
Previous Name
Social Security #
I request and authorize information of the patient named above to:
Name
Address
This request and authorization applies to:
Healthcare information relating to the following treatment, condition, or dates

YesNoAll healthcare informationOther
List 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.

YesNo
I authorize the relapse of any records regarding drug, alcohol or mental health treatment to the person(s) listed above.

YesNo
Patient/Guardian Signature

Clear
Date Signed

MonthDayYear
Date
Guardian's printed name
Relationship to patient
THIS AUTHORIZATION EXPIRES AFTER NINETY DAYS
Should be Empty:

PATIENT REGISTRATION FORM

Patient Information

Responsible Party Information

Primary Insurance Information

Secondary Insurance Information

In case of Emergency

MEDICAL HISTORY