anchormedicalcenter.com - AMC New Patient Registration

NEW PATIENT REGISTRATION
Today’s Date

MonthDayYear
Date
Name

First NameMiddle NameLast Name
Gender

MaleFemale
DOB

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Relationship

SingleMarriedDivorcedWidowed
Occupation
Referred By
Emergency Contact Name
Relationship
Phone Number
Please enter a valid phone number.

	Name	Phone	Fax
Primary Care Physician
Ob/Gyn
Urology
Other Specialty

Medical Diagnosis
Past Hospitalizations/Surgeries
Current Medications
Supplements
Medication Allergies
Food/Environmental Allergies
Social History

I am sexually active.I want to be sexually active.I have completed my family.I haven’t been able to have an orgasm.
Habits

I smoke cigarettes or cigars.I drink more than 10 alcoholic beverages a week.I used other drugs (marijuana or other).I drink more than one cup of coffee daily.
Gyn History (For Female only)
Age of first menses?
Date

MonthDayYear
Date
How Many Pregnancies?
How Many Live Births?
How Many Miscarriages/Abortions?
If Menopause, at what age?
If you have ever been on hormone replacement therapy or birth controls in the past, please specify
Date

MonthDayYear
Date
Duration
Specify the hormone therapy received
List your current health concerns in order of importance

	Cups per day
Water
Coffee
Tea
Pops
Alcohol

	Servings per day
Meat/Seafoods/Poultry
Vegetables
Fruits
Nuts

HIPAA Notice of Privacy Practice
Your Rights

You have rights regarding your health information, including the following:
- Access Your Records: You can request a copy of your medical records, either electronically or on paper. We’ll provide it within 30 days and may charge a reasonable fee.
- Correct Your Records: If you believe your information is wrong, you can ask us to correct it. We’ll respond within 60 days, explaining any refusal.
- Confidential Communications: You can ask us to contact you in a specific way (e.g., different
  phone or address). We will agree to all reasonable requests.
- Limit Information Sharing: You can request not to share certain health information for
  treatment, payment, or operations. If you pay out-of-pocket, we won’t share this information with your insurer, unless required by law.
- Get a List of Shared Information: You can ask for a list of when and with whom we’ve shared your information. This is available for up to six years and is free once a year.
- Paper Copy of This Notice: You can request a paper copy of this notice at any time, even if you’ve agreed to receive it electronically.
- Choose Someone to Act for You: If someone has legal authority to act for you, they can exercise your rights on your behalf.
- File a Complaint: If you believe we’ve violated your rights, you can file a complaint with us or the U.S. Department of Health and Human Services. We will not retaliate against you.
Your Choices
You can tell us your preferences about how we share your information, such as:
- Sharing information with family or friends involved in your care.
- Sharing in a disaster relief situation or hospital directory.
- We will not share your information for marketing, sales, or most psychotherapy notes without your written permission.
How We Use and Share Your Information
We typically use your information for:
- Treatment: Sharing with other doctors or healthcare providers to treat you.
- Operations: To run the practice and improve your care.
- Billing: To get payment for your treatment from insurance or other parties.
We may also share information for:
- Public health and safety issues (e.g., preventing disease, product recalls).
- Health research.
- Legal purposes (e.g., responding to law enforcement or a court order).
Our Responsibilities
- We are required by law to protect your health information.
- If there is a breach of your information, we will inform you promptly.
- We cannot share your information unless allowed by this notice, or with your written consent.
Changes to This Notice
We may update this notice, and any changes will apply to all the information we have about you. You
can request the latest version at any time.

Effective Date
This notice is effective as of the date signed.
Appointment Cancellation Policy
Please call at least 24 hours in advance if you need to cancel your appointment. This allows us to offer your spot to another patient. To cancel or reschedule, use the online schedule, or contact Jason, the office manager, at (412) 977-5182.

No Show Policy
A "no show" is when you miss an appointment without cancelling at least 24 hours in advance or arrive more than 15 minutes late. If this happens, we may charge a $50 fee to the credit card on file. This fee is not covered by insurance. Patients are allowed two no shows before we consider termination from the practice.
If you're more than 10 minutes late, you may be asked to reschedule.
By signing below, I agree to these policies.

Outstanding Balance
Returned Check Policy
We require all patients to have a credit or debit card on file. If a check is returned due to insufficient
funds, we will charge the card on file for the returned check and a $25 fee.

Outstanding Balance Policy
If you have an outstanding balance, you must pay it in full before receiving treatment. Balances over 90 days past due will be sent to a collection agency, which will add a 25% collection fee. Patients in collections must pay the full balance, including the collection fee, before seeing a provider.
Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

	Check	Parents/Siblings/Grandparents
Heart disease or heart attack before age 60
Diabetes I or II
High blood pressure
Obesity
Osteoporosis
Alzheimer’s Disease
Thyroid Disorder
Mental Illness
Genetic Disorder
Breast Cancer
Ovarian Cancer
Colon Cancer
Other

	Name	Daily hours
Cell phone
Watching TV
Computer/desk work

NEW PATIENT REGISTRATION

Gyn History (For Female only)

If you have ever been on hormone replacement therapy or birth controls in the past, please specify

Gut health

Lifestyle

Stress

HIPAA Notice of Privacy Practice