Patient Information Forms

Patient Information Forms
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Your First Appointment*

MonthDayYear
Date
Social Security Number*
Marital Status*
Driver's License or ID Number*
Landlord (if renting)
Landlord's Phone Number
Name of Employer*
Occupation
Work Phone Number
Name of Spouse
Spouse Date of Birth

MonthDayYear
Date
Spouse's Phone Number
Please enter a valid phone number.
Nearest Relative Not Living with You
Relationship
Relative's Phone Number
Nearest Friend Not Living with You
Friend's Phone Number
Please enter a valid phone number.
In Case of Emergency, Notify*
Emergency Contact's Phone Number*
Please enter a valid phone number.
Who May We Thank for Referring You to Us?
Family Physician (past or present)*
Past or Present Physician Phone Number*
Please enter a valid phone number.
Family Dentist
Family Dentist Phone Number
Please enter a valid phone number.
Preferred Pharmacy*
Please include city and state.
Mail Order Pharmacy
Who is Financially Responsible for Payment?*
I will be paying for my first visit by:*

CashCheckDebit/Credit Card
By signing this document, I understand and agree that I am ultimately responsible for payment. I certify this information is true and correct to the best of my knowledge.*

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DUE TO THE PRIVACY CONFIDENTIALLY ACT,

please list the people that you approve to have access to your information as stated below:
Appointment Scheduling*
Please include your relationship to those listed.
Billing Information*
Please include your relationship to those listed.
Medical Records Information*
Please include your relationship to those listed.
AUTHORIZATION TO LEAVE MESSAGES:

I authorize Lakeside Clinic physicians and staff to leave messages regarding my medical condition, such as lab reports, other test results, and medications on my voicemail. This authorization will be in effect until I have given written notice to Lakeside Clinic.
Yes, I authorize Lakeside Clinic to leave voicemails regarding my medical condition.No, I do not authorize Lakeside Clinic to leave voicemails regarding my medical condition.
AUTHORIZATION TO CONTACT AT EMPLOYMENT:

I authorize Lakeside Clinic physicians and staff to leave messages at my work place if they are unable to leave a message with my primary phone number for any reason. I may revoke this authorization by giving written notice to Lakeside Clinic.
Yes, I authorize Lakeside Clinic to leave messages at my work place.No, I do not authorize Lakeside Clinic to leave messages at my work place.
By signing this document, I agree to the privacy and confidentiality conditions chosen above.*

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Today's Date*

MonthDayYear
Date

Guaranty of Payment for Medical Services

We are committed to providing you with the best possible care. If you have no medical insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our payment policy.
Accepted Payments/Insurance Changes

Payment for services is due at the time services are rendered unless payment arrangements have been approved in advance by our staff. We accept cash, checks, and all major credit/debit cards. We will be happy to file most primary insurance for you as a courtesy. Changes in insurance information should be communicated with our office as soon as possible.
Please Note:

1) Your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract. 2) Not all services are covered by all insurance contracts. 3) We may need to release medical information concerning you to your insurance carrier as part of the processing of your claim. By signing this form, you consent to the release of such information for that limited purpose.
We must emphasize that as your medical care provider, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered. All copays are due at the time of service. There is a $20 fee for returned checks. Accounts over 90 days past due may be turned over to an agency for collection, unless payment arrangements have been made with this office. Your future status with this office will be considered at such time. By signing this form, you agree that you will be responsible for the reasonable costs, to include attorneys' fees and interest we incur if your account becomes past due and is turned over for collections. We value you, our patient, and will continue to provide you with the best professional care. If you have any questions about the above information, or any uncertainty regarding insurance coverage, please do not hesitate to ask us. We are here to help you.
Signature*

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Today's Date*

MonthDayYear
Date
ONCE THIS FORM IS COMPLETED, PLEASE RETURN TO LAKESIDECLINICGUNTERSVILLE.COM AND COMPLETE PART TWO OF YOUR PAPERWORK!
Should be Empty:

Patient Information Forms

DUE TO THE PRIVACY CONFIDENTIALLY ACT,

AUTHORIZATION TO LEAVE MESSAGES:

AUTHORIZATION TO CONTACT AT EMPLOYMENT:

Authorization for Release/Request of Protected Health Information

I authorize Lakeside Clinic, LLC to obtain information from:

Guaranty of Payment for Medical Services

Accepted Payments/Insurance Changes

Please Note: