hiltonheadorthopedics.com - New Patient Registration

New Patient Registration
Patient Name:

First NameMiddle NameLast Name
Permanent Mailing Address:
Street Address (if different)
Home Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Email:
example@example.com
Local Address (if different)
Local Phone:
Please enter a valid phone number.
Drivers License Number:
Social Security Number:
Birthdate:

MonthDayYear
Date
Employer's Name:
Your Position:
Employer's Address:
Employer's Phone:
Please enter a valid phone number.
Emergency Contact:
Name:
Phone Number:
Please enter a valid phone number.
Address:
Your relationship to this person:
If Patient is under age 21 or under age 26 (using parent's insurance), or not the guarantor, please complete the following:
Relationship to patient: - must be parent's info for the parent who is named on the insurance card.

MotherFatherGuardian
Name

First NameMiddle NameLast Name
Address:
Home Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Social Security Number:
Drivers License State and Number:
Cell Phone:
Please enter a valid phone number.
Email:
example@example.com
Parent Birthdate:

MonthDayYear
Date
Employer's Name:
Employer's Address:
If parents have separated addresses pls. Provide second parent's name:
Address:
Phone Number:
Please enter a valid phone number.

Primary Insurance

Please provide us with a copy of your insurance card
Company:
Insured's name:
Identification number:
Phone Number:
Please enter a valid phone number.
Upload insurance card front & back pictures:

Cancelof
Upload personal ID picture

Cancelof
Secondary Insurance

Please provide us with a copy of your insurance card
Company:
Insured's name:
Identification number:
Phone Number:
Please enter a valid phone number.
Upload insurance card front & back pictures:

Cancelof
If you were referred here please tell us by whom:
Is your visit due to injuries sustained in an auto accident?

YesNo
Auto Ins. Co. responsible for medical bills:
Name of insurance representative or contact:
Phone Number:
Please enter a valid phone number.
Claim number:
Policy number:
Is your visit due to injuries sustained at your employment?

YesNo
Yes If so, please provide: Name of Employer:
Employer contact and phone:
Address of Employer:
Worker's compensation Insurance information:
Ins. Co. name
Name of insurance representative or contact:
Phone number of Ins. Co. contact:
Please enter a valid phone number.
Date of injury:

MonthDayYear
Date
Date injury reported to employer:

MonthDayYear
Date
To whom did you report the injury?
Claim number:
If you have an attorney representing you with respect to your injuries please provide:
Attorney name:
Phone Number:
Please enter a valid phone number.
Address:
I hereby authorize payment be made directly to Tobin Bone and Joint Surgery, Inc.("TB&J”) for their services by my insurance carrier, Worker's compensation carrier, or Auto Insurance of benefits otherwise payable to me. I further authorize direct payment of benefits under Title 19 of the Social Security Act to TB&J in a claim related to injuries for which medical services are provided to me by TB&J whether categorized as damages, medical fees or otherwise. I understand and agree that I am financially responsible to TB&J for all charges not covered by this assignment of benefits, unless prohibited by law. Should timely payments of this account not be made, I authorize TB&J. to retain the services of an attorney and/or collection agency and agree to reimburse the collection fees which may be based upon a percentage at a maximum of 33% of the debt, and all costs, expenses, including reasonable attorney fees. Any expenses incurred by such action shall become an additional liability for which I assume responsibility. Additionally, I understand that interest at the rate of 1.5% per month will be added to any balances past due after 60 days. I further authorize the release to any insurance company, health care facility or agency, or to the court in case of legal action, such information as may be necessary for the completion of my claim or to otherwise secure payment for medical services rendered. I also authorize the release of medical information regarding my case to other consulting and/ referring health care professionals. I permit a copy of this authorization to be used in place of the original.
Payment is due at the time of service unless other arrangements have been made in advance.
Signature:

Clear
Date:

MonthDayYear
Date

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Patient's Name:
Today's Date:

MonthDayYear
Date
I acknowledge Tobin Bone and Joint Surgery, Inc.'s Notice of Privacy Practices has been made available to me to read. This Notice describes how medical information about me may be used and disclosed and how I can get access to this information. It describes information about privacy practices followed by employees, staff and other office personnel of Tobin Bone and Joint Surgery, Inc.
Patient's Signature

Clear
Signature of Parent or Guardian if Patient is a minor

Clear
Signature of Patient's Personal Representative if Patient is not signing

Clear
Printed Name of Person signing if other that the Patient
(e.g. Personal Representative of Patient or Patient's Parent or Guardian)

HIPAA Compliance Patient Consent Form
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected heath information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:
- Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
- The practice reserves the right to change the privacy policy as allowed by law.
- The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
- The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
- The practice may condition receipt of treatment upon execution of this consent.
May we phone, email, or send a text to you to confirm appointments?

YESNO
May we leave a message on your answering machine at home or on your cell phone?

YESNO
May we discuss your medical condition with any member of your family?

YESNO
If YES, please name the members allowed:
This consent was signed by:
PRINT NAME PLEASE
Signature:

Clear
Date:

MonthDayYear
Date

Current Medication List
Patient Name
Emergency Contact Name/ Phone
Date Last Updated
Prescription Medication
Medication Allergies:

Patient Authorization for Release of Medical

Records from another Office to Our Office
To:
I hereby authorize release of all my medical records in your possession (including office visit notes, operative reports, lab reports, MRI, X-Rays or any other imaging studies) to be disclosed and forwarded (by mail, delivery, email or facsimile) to the following:

Joseph P. Tobin, M.D.
Tobin Bone and Joint Surgery, Inc.
12 Lafayette Place, Suite A
Hilton Head, S.C. 29926
FAX: 843 342-9101
PHONE: 843 342-9100

Please send these medical records as soon as possible.

Sincerely,
Patient Signature:

Clear
Today's date:

MonthDayYear
Date
Patient's Name:
Patient's Date of Birth:

MonthDayYear
Date
Should be Empty:

	Yes	No
High Blood Pressure
Pace Marker
Pregnant
Heart Condition
Seizures
Diabetes
Strokes
Cancer
HIV/AIDS
Osteoarthritis
Allergies
Fibromyalgia
Lupus
Arthritis
Vascular Condition
High Cholesterol
Lung Problems

New Patient Registration

Primary Insurance

Secondary Insurance

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

HIPAA Compliance Patient Consent Form

Patient Medical History Form

4. Past Medical History

Current Medication List

Patient Authorization for Release of Medical