southernentandsinus.com - New Patient Form

New Patient Form
Patient Name
Social Security #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Telephone #
Please enter a valid phone number.
Cell Phone #
Please enter a valid phone number.
Work Phone #
Please enter a valid phone number.
Patient’s Birth Date

MonthDayYear
Date
Sex

MaleFemale
Marital Status
Patient’s Employer
Responsible Party
Social Security #
Address:
Daytime Telephone
Please enter a valid phone number.
Responsible Party’s Employer
Person to contact in case of emergency
Phone #
Please enter a valid phone number.
Primary Insurance
Contract Holder
Policy / Contract #
Contract Holder Birthdate

MonthDayYear
Date
Secondary Insurance
Contract Holder
Policy / Contract #
Contract Holder Birthdate

MonthDayYear
Date
Referring or Primary Care Doctor
The patient/responsible party agree(s) to pay in full all charges submitted by Southern ENT & Sinus Center, P.C. during patients treatment, including treatment rendered during hospitalization, unless P.C. is legally obligated to accept payment for those charges solely from a third party. The patient/responsible party agrees to be fully financially responsible to the PC, even though there may be insurance or other third party coverage, HMO, or other third parties requiring specific referral authorization prior to making payment. Party acknowledges and agrees that for any service rendered without prior authorization, the patient/responsible party will be solely responsible for payment. Patient/responsible party acknowledges that payment is due at the date of service.

AGGREEMENT TO PAY: I, the undersigned, accept the fee charged as a legal and lawful debt and agree to pay said fee, including any/all Collection Agency Fee, (33.33%), attorney fees and court costs, if such be necessary. I waive now and forever my right of exemption under the laws of the constitution of the State of Alabama and any other State.

EXPRESS PRIOR CONSENT TO CONTACT CONSUMER BY CELL PHONE: I, the undersigned, give Southern ENT & Sinus Center, P.C., its employees and/or agents “express prior consent” to contact me any any/all phone numbers, including cell phone numbers (by phone call or text message), for the purpose of treatment, insurance or payment. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, as applicable.
Signature of Patient / Responsible Party

Clear
Date

MonthDayYear
Date
Signature of Witness

Clear
Date

MonthDayYear
Date

Certain in office surgical procedures (Video Stroboscopy, nasal endoscopy, etc), imaging studies (CT) and audiology services may be subject to an individual’s deductible, based on their insurance policy.

It is the responsibility of the patient to know their insurance policy.

By signing this document, I acknowledge I am responsible for the cost if not covered by insurance.
Patient Signature

Clear
Date

MonthDayYear
Date

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT
I, Name , acknowledge I have received a copy of the Notice of Privacy Practices.
Signature of Patient / Parent / Guardian

Clear
Date

MonthDayYear
Date
Relationship to patient
AUTHORIZATION TO RELEASE MEDICAL RECORDS AND RELATED TEST RESULTS
I, hereby authorize the physicians and/or staff of SOUTHERN ENT AND SINUS CENTER, P.C., to discuss my medical condition and to release my lab/pathology reports to:

Only to myselfLeave lab/pathology results on answering machineAny member of my familyOnly to the following family members
Please list the family member(s):
Signature of (Patient/Parent/Guardian)

Clear
Date

MonthDayYear
Date

AUTHORIZATION FOR TEXT MESSAGING/EMAIL
I consent to receive appointment reminders and other healthcare communications/information via text message/email from Southern ENT & Sinus Center. This is to remind you of an appointment and to provide general health reminders/information.
Cell Phone Number authorized to receive text messages
Please enter a valid phone number.
Carrier
(Example: Verizon, AT&T, Sprint, T-Mobile)
Email
example@example.com
I understand Southern ENT & Sinus Center is not responsible for any overages or text messaging charges. Your standard text messaging rates will apply.

This request to receive text messages will apply to all future appointment reminders/health information unless I request a change in writing.
Print Name
Patient’s Signature

Clear
Date

MonthDayYear
Date

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions about this Notice please contact our Privacy Officer at (205) 838-3755.

This is a summary of our Notice of Privacy Practices which describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information.

We are required by law to maintain the privacy of your protected health information and to provide you with a notice of our legal duties and privacy practices with respect to protected health information. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time, and reserve the right to do so. The new notice will be effective for all protected health information that we maintain at that time.

We will use your protected health information as part of rendering patient care, including treatment, payment and healthcare operations.

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken action in reliance on the use or disclosure indicated in the authorization.

We may use or disclose your protected health information in certain situations without your authorization or opportunity to agree or object.

You have the right to request a restriction of your protected health information.
You have the right to request to receive confidential communications of your protected health information.
You have the right to inspect and copy your protected health information.
You have the right to amend your protected health information.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.
You have the right to obtain a paper copy of this notice from us.

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us.
You may file a complaint with us by notifying our privacy officer of your complaint. We will not retaliate against you for filing a complaint.

This summary was published along with the Notice of Privacy Practices.
Should be Empty:

	Yes	No
Heart problems
High blood pressure
Stroke
Cardiac stents
Seizures
Meningitis
Asthma
Emphysema
Severe heartburn
Hiatal/Umbilical hernia
Anesthesia problems
Sleep apnea
Use CPap or BiPap
Stomach Ulcers
Hepatitis
HIV/AIDS
Kidney failure
Thyroid problems
Diabetes
Arthritis
Unexplained weight loss
Enlarged lymph nodes
Free bleeding
History of tuberculosis

	Yes	No
Penicillin
Codeine
Sulfa
Tetanus
“Mycins”
Demerol
Aspirin
Tetracycline
Latex

New Patient Form

Medical Information Form

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT

AUTHORIZATION TO RELEASE MEDICAL RECORDS AND RELATED TEST RESULTS

AUTHORIZATION FOR TEXT MESSAGING/EMAIL