• New Patient Registration

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  • Emergency Contact:

  • If Patient is under age 21 or under age 26 (using parent's insurance), or not the guarantor, please complete the following:

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  • Primary Insurance

    Please provide us with a copy of your insurance card
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  • Secondary Insurance

    Please provide us with a copy of your insurance card
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  • If you have an attorney representing you with respect to your injuries please provide:

  • 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.

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  • PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

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  • 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.

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  • 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.
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  • Patient Medical History Form

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  • 4. Past Medical History

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  • 12. Doctors:

  • Current Medication List

  • Patient Authorization for Release of Medical

    Records from another Office to Our Office
  • 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,

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