raphlanmedical.com - Registration Form

Authorization for Release of Medical Records
Patient Name:

First NameLast Name
Birthdate:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Request Release From:
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Request Release To:
Raphael D. Lanadee, M.D.
Shallowford Commons
6106 Shallowford Road Suite 100
Chattanooga, TN 37421
Office Phone: 423-208-9377
Office Fax: 423-475-5143
I, Name , Authorize Type a label to release copies of my medical records, Labs, Imaging reports, medication list, and including at least the last 3 office notes, etc. to Dr. Raphlan D. Lanade, M.D for the purposes of follow up and necessary treatment.

This authorization expires in one year from the date below, and covers only treatment prior to that date. This above facility is authorized to furnish this information even though the confidentiality of information is protected by Federal and state laws, check the disclaimer listed at the bottom. This above facility is hereby released and discharged from any liability, and the undersigned will hold the facility harmless for complying with this authorization of their protected health information.
Signature:

Clear
Date:

MonthDayYear
Date
The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is Intended only for the use of the person(s) named above. If you are not the intended recipient; you are hereby notified that any, review, dissemination, distribution, or duplication of this communication is strictly prohibited. If you are not the intended recipient, please contact the sender by reply email if this was an email, or by fax and destroy all copies of the original message.

Assignment and Release
I certify that I and/or my dependent(s); have insurance coverage with Type a label to Dr. Raphael D. Lanade, M.D. for all insurance benefits; if any, and are assigned otherwise payable to.me for services rendered. I understand that I am financially responsible for all other charges not paid by my insurance. I authorize the use of my signature on all insurance submissions. The above named doctor may use my health care information and may disclose such information to the above named insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.

Should the account be referred to an attorney or collection agency for collection, the undersigned agrees to pay all cost of collection (including a reasonable attorney's fee, agency fee and other collection expenses).

By signing below, I authorize that I have read and received a copy of the Notice of Privacy Practice provided by Raphlan Medical Associates.
Signature of Patient, Parent, Guardian or Personal Representative

Clear
Date

MonthDayYear
Date

Patient Registration Form
Name

First NameMiddle NameLast Name
Sex:
Marital Status:
Date of Birth:

MonthDayYear
Date
Social Security Number:
Patient's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Mobile Phone:
Please enter a valid phone number.
Email Address:
example@example.com
Referred by:
Primary Care Physician:
Primary Care Physician Phone:
Please enter a valid phone number.
Pharmacy:
Pharmacy Phone Number:
Please enter a valid phone number.
Pharmacy Address:
Patient Employee/ School Information
Employer/ School:
Occupation:
Employer/ School Phone:
Please enter a valid phone number.
Employer/ School Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Information
Emergency Contact Name:
Emergency Contact Phone:
Please enter a valid phone number.
Relationship to Patient:
Billing and Insurance
Primary Health Insurance
Insurance Company
Plan
Plan Number
Group Number
Insured's Employer/ School
Insured's Name (as it appears on Insurance card or ID)
Relationship to Patient
Insured's Phone Number
Please enter a valid phone number.
Insured's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured's Social Security Number
Insured's Birthdate

MonthDayYear
Date
Secondary Health Insurance
Insurance Company
Plan
Plan Number
Group Number
Insured's Employer/ School
Insured's Name (as it appears on Insurance card or ID)
Relationship to Patient
Insured's Phone Number
Please enter a valid phone number.
Responsible Party
Billing Name (If other than patient)
Phone Number
Please enter a valid phone number.
Relation to Patient
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Authorization for Release of Medical Records

Request Release From:

Request Release To:

Assignment and Release

Patient Registration Form

Patient Employee/ School Information

Emergency Contact Information

Billing and Insurance

Primary Health Insurance

Secondary Health Insurance

Responsible Party