PATIENT REGISTRATION SHEET- PrimeMED

PATIENT REGISTRATION SHEET
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Social Security Number*
Date of Birth*

MonthDayYear
Date
Sex*
Marital Status*
Single, Married, Widowed, Divorced
In Case of Emergency*
Please provide name and number
Employer*
Occupation*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Is Your Visit Work Related?*

YesNo
Is Your Visit Auto Related?*

YesNo
If Applicable, Date of Accident

MonthDayYear
Date

INSURANCE INFORMATION
PRIMARY INSURANCE
Subscriber Name*

First NameLast Name
Subscriber Date of Birth*

MonthDayYear
Date
Company Name*
Member ID*
Group Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SECONDARY INSURANCE
Subscriber Name

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Date
Company Name
Member ID
Group Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Release of Information/Medical Records

I hereby authorize the attending physician to release my information acquired in the course of treatment and medical records and allow a photocopy of my signature to be used for insurance purposed only.
Signature*

Clear
Date*

MonthDayYear
Date
Patient & Claim Authorization

The subscriber hereby authorizes his/her insurance company(s) at its option to issue indemnity checks to the provider rendering services. The patient takes full responsibility for charges not covered under the insured plan.
Signature*

Clear
Date*

MonthDayYear
Date

AUTHORIZATION FOR TREATMENT & FINANCIAL AGREEMENT
- I, the undersigned, understand that medical treatment is necessary and that such medical care, treatment, and procedures will be performed by the physicians, therapists, and employees of PrimeMED. I hereby grant my authorization and consent to such treatment and procedures. Additionally, I understand that guarantees or assurance have not been made as to the results which may be obtained.
- I, the undersigned, understand and agree to be financially responsible for all medical charges and services rendered, whether covered or not by my insurance. Additionally, I agree to pay any cost of collections including, but not limited to, attorney's fees, court costs, and legal interests which my be incurred by PrimeMED/Neurotech, Inc. while enforcing this obligation.
- I, the undersigned, understand the PrimeMED/Neurotech, Inc. may enforce a $25.00 "No-Show" fee if I do not show for my appointment or do not call the office to cancel my appointment at least 24 hours in advance. This fee may only be waived at the discretion of the office.
- I, the undersigned, understand and agree to conform to the medical instruction of the doctors and staff employed by PrimeMED/Neurotech, Inc. with regards to all therapies and medications. While treatment is being rendered, I agree to utilize one designated pharmacy for all prescribed medications. I further agree not to solicit any other physician or medical facility for any pain medications. I fully understand that any violation of this agreement will relieve the providers and PrimeMED/Neurotech, Inc. of any other medical responsibility and may result in immediate dismissal.
- In order to properly file your insurance claim, we must have a current copy of your insurance card and all pertinent information. We ARE NOT responsible for correctly filing without accurate, current information. If your claim is denied for any reason, you are ultimatley responsible for payment of claims.
- I, the undersigned, authorize release of any and all medical information in connection with these services for insurance billing and collection purposes. I also authorize by my signature, direct payment and assignment of all medical insurance benefits to PrimeMED/Neurotech, Inc., as applicable, for professional, medical and rehabilitative services rendered to me, and authorize submission of insurance claims with the undersigned signature. This assignment may only be revoked with the expressed written consent of the medical provider.
I have read and fully understand the above agreements and acknowledgements.
Signature*

Clear
Date*

MonthDayYear
Date

INFORMATION CONSENT TO USE PATIENT PORTAL

optional
Patient Information
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Purpose of This Form

PrimeMED offers secure viewing and communication as a service to patients who wish to view parts of their records and communicate with our staff. Secure messaging can be a valuable communication tool, but has certain risks. In order to manage these risks, we need to impose some conditions of participation. This form is, therefore, intended to show that you have been informed of these risks and the conditions of participation, and that you accept the risks and the conditions of participation, and that you accept the risks and agree to the conditions of participation.

How the Secure Patient Portal Works

A secure web portal is a kind of webpage that uses encryption to keep unauthorized persons from readng communications, information, or attachments. Secure messages and information can only be read by someone who knows the right password or pass-phrase to log into the portal site.

How to Participate in Our Patient Portal

You can compose, pick-up and reply to secure messages or view information sent to you through a website hosted by our electronic records company. Once this form is agreed to and signed, we will send you an email notification that tell you how to register for the first time. This notificiation will give you the URL (internet browser), which will open the website. You will then be able to login using the username and password provided. Next you will be able to look in your "message box" and see any new or old messages, or view other parts of your electronic record. Because the connection channel between your computer and the website uses "secure sockets layer" technology, you can read or view information on your computer, but it is still encrypted in transmission between the website and your computer.

You can view more clinic specific information or access the portal through www.PrimeMed4U.com.

Protecting Your Private Health Information and Risks

This method of communication and viewing prevents unauthorized parties from being able to access or read messages while they are in transmission. However, keeping messages secure depends on two individual factors: the secure message must reach the correct email address, and only the correct individual (or someone authorized by that individual) must be able to get access to it.

Only you can make sure these two factors are present. We need you to make sure we hae your correct email address and informed if it ever changes. You also need to keep track of who has access to your email account. So that you, or someone you authorize, can see the messages you recieve from us.

If you pick up secure messages from a website, you need to keep unauthorized individuals from hearing your password. If you think someone has learned your password, you should promply got the website and change it.

It is our intent to offer this as a free service, but we reserve the right ot change this policy if needed in the future, but will provide adequate notice should this have to happen.

We understand the importance of privacy in regards to your health care and will continue to strive in making sure all infomation is as confidential as possible and will never sell or give any private information, including email addresses, without your written consent.

Conditons of Participating in the Patient Portal

Access to this secure web portal is an optional service and we may suspend or terminate it at any time and for any reason. If we do suspend or terminate this service, we will notify you as promptly as we reasonably can. You agree to not hold PrimeMED or any of its staff laible for network infractions beyond their control.

Before you were given this form, we provided you with our polices and procedures for using this web portal. We need you to understand and comply with these, and by signing this form below, you will acknowledge that they were explained to you and that you agree to comply with them. If you do not understand, or do not agree to comply with our policies and procedures, do not sign the form. If you have any questions, we will gladly provide more information.
Signature

Clear
Date

MonthDayYear
Date

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OR PRIVACY PRACTICES
We are required by law to provide you with a copy of the Notice of Privacy Practices. To ensure that our records are accurate, please sign this form stating that you have been provided with a copy of our Privacy Polices.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

PATIENT REGISTRATION SHEET

INSURANCE INFORMATION

AUTHORIZATION FOR TREATMENT & FINANCIAL AGREEMENT

INFORMATION CONSENT TO USE PATIENT PORTAL

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OR PRIVACY PRACTICES