Patient Information Registration

To properly identify and provide you with the best medical services, please complete and sign the following
CONSENT FOR TREATMENT:I consent to necessary medical treatment and services which may include injection or ingestion of drugs or medications, the performance of certain tests, procedures, surgeries, and/or other studies which may be used by the treating physician or clinical staff.
AUTHORIZATION FOR RELEASE OF INFORMATION: I authorize SAMA HealthCare Services (SAMA) to furnish any medical information properly requested by insurance companies with whom I have coverage, any public agency which may be assisting in payment of my care, or my employer who is providing payment of my medical bills due to an on-the-job or work related injury. I also authorize SAMA to obtain medical history and information from outside sources to include electronic media.
NOTICE OF PRIVACY PRACTICES RECEIPT:I acknowledge the offer and/or receipt of SAMA’s Notice of Privacy Practices. I authorize SAMA to release my medical information to those individuals whom, in SAMA’s professional judgment, are involved in my medical care unless specified on the Form to Request Restrictions on Use and Disclosure of PHI.
ASSIGNMENT OF BENEFITS:I authorize payments for services be made directly to SAMA which may otherwise be payable to me from all sources including, but not limited to, my medical insurance company, my employer’s workman compensation carrier, or other parties for surgical or medical benefits with whom I have contracted. Such benefits shall not exceed SAMA’s billed charges for these services. I understand that I am financially responsible to SAMA for charges not covered by this assignment and will adhere to the financial policies of SAMA in the collection of these charges. I accept full responsibility for providing SAMA accurate and complete information needed for their assisting me in processing my claims for reimbursement of medical services. I authorize the refund of overpaid insurance benefits where my coverage is subject to coordination of benefits.
SAMA Healthcare Services PA complies with applicable Federal civil rights law and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
GUARANTEE OF ACCOUNT: For services furnished by and through SAMA, I personally guarantee payment of all my accounts for services rendered to me, to my dependents, and/or on my account. For payment of said accounts for services, I waive all claims of exemption under the state of Arkansas and agree to pay all costs of collection, including attorney and court fees.
SAMA Healthcare sometimes communicates via text messaging, if you choose to opt out, please let our office staff know.

New patients, patients not seen at SAMA during the past three years, and patients that have had a change in billing, employment, or contact information are required to complete the following.

Insurance Information:

Insurance Subscriber Information: If someone other than you is the Insurance Subscriber, please complete the following.

Guarantor of account: A copy and/or evidence of insurance coverage, payment of past due balances, the insured’s estimated portion of the charges, the required co-payment, and/or the estimated payment in full will be required each visit before services are provided.
If the Guarantor is NOT the patient listed above, and the relationship to the patient is spouse, parent/guardian,child, or other - please complete the following.

The guarantor is the guardian/parent that is claiming financial and medical responsiblity for the patient above.

To the best of my knowledge and ability, the information provided herein is accurate and complete. By my signature here, I confirm I have read and agree to the conditions and my responsibilities as outlined above.

Please list other guardian(s):