Patient registration

I hereby authorize my insurance benefits be paid directly to the provider and I am financially responsible for non-covered services. I also authorize the provider to release any information required in the processing of this claim and all future claims. If my account is sent to a collection agency, I agree to pay all collection and attorney fees.

DATES OF SERVICE

I understand that:

• once “this facility” discloses my health information by my request, it cannot guarantee that Recipient will not re-disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state laws governing the use and disclosure of my health information.
• I may make a request in writing at any time to inspect and/or obtain a copy of my health information maintained at this facility as provided in the Federal Privacy Rule 45 CFR (164.524)
• my records are protected and cannot be disclosed without written permission
• this Authorization will remain in effect for one year or I provide a written notice of revocation to the Medical Record Department.

IF SIGNED BY LEGAL REPRESENTATIVE, RELATIONSHIP TO PATIENT

OTHER:

FAMILY HISTORY –

Surgical history:

Please list any hospitalizations, surgeries, fractures or major illnesses you have had.

Medications:

List any medications you are currently taking (please include over the counter medications)

PLEASE PRINT LEGIBLY – NO CURSIVE PLEASE