immediate care patient registration

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immediate care patient registration
IMMEDIATE CARE PATIENT REGISTRATION
Today’s Date: _____________________ Arrival Time: ______________ (PAYMENT IS DUE AT THE TIME OF SERVICE)
WHAT IS THE REASON FOR YOUR VISIT HERE TODAY? ________________________________________
DATE OF ONSET OF SYMPTOMS, OR DATE OF ACCIDENT OR INJURY: ___________________________
If you are here for an injury, is it:  Work Related?  Auto Related?
Ethnicity:  Hispanic or Latino  Non-Hispanic or Latino  Unknown or Not Reported  Refused or Undetermined
Race:  American Indian or Alaskan Native  Asian  Black or African American  Multiracial
 Native Hawaiian or Other Pacific Islander
 Refused or Undetermined
 White
PATIENT INFORMATION
Patient’s Full Name: _______________________________________________________
Sex:  Male  Female
FIRST, MIDDLE, LAST
Date of Birth: _____________________ Age: _______________ Social Security Number: ________________________
(If 18 years of age or older.)
Street Address: _______________________________________ Primary Language Spoken: ______________________
City: __________________________________________
State: ___________________ Zip: ________________
Home: __________________________ Work: ______________________________ Cell: _______________________
Primary Care Physician: ____________________________________ Phone Number: __________________________
PATIENT EMPLOYER INFORMATION
Employer Name: _______________________________________ Employer Phone Number: _____________________
Employer Address: ________________________________________________________________________________
ADULT ACCOMPANYING PATIENT IF PATIENT IS UNDER 18
Full Name: _______________________________________________ Relationship to Patient: ____________________
FIRST, MIDDLE, LAST
Date of Birth: ______________________ Social Security Number: ________________________ Sex:  Male  Female
Street Address: ___________________________________________________________________________________
City: _________________________________________
State: ____________________ Zip: ______________
Home: __________________________ Work: ______________________________ Cell: _______________________
INSURANCE INFORMATION
PRIMARY INSURANCE:
SECONDARY INSURANCE:
ID#:
ID#:
GROUP#:
COPAY:
PATIENT RELATIONSHIP TO THE SUBSCRIBER:
 Self  Spouse  Child  Other ________________
GROUP#:
COPAY:
PATIENT RELATIONSHIP TO THE SUBSCRIBER:
 Self  Spouse  Child  Other ________________
SUBSCRIBER INFORMATION/POLICY HOLDER
(if different than patient)
NAME:
_______________________________________
SUBSCRIBER INFORMATION/POLICY HOLDER
NAME:
ADDRESS: _______________________________________
ADDRESS: _______________________________________
PHONE:
_______________________________________
PHONE:
_______________________________________
SS#:
_______________________________________
SS#:
_______________________________________
DOB:
_______________________________________
DOB:
_______________________________________
_______________________________________
** PLEASE SEE REVERSE SIDE **
FMH IMMEDIATE CARE PATIENT REGISTRATION
Release of Information and Medical Consent
I understand that I am under the supervision of my attending and/or treating physicians. I consent to any medical procedure,
treatment/exam, or services rendered to me under the general and special instructions of my physicians. I authorize FMH to disclose all
or any part of my medical records to any insurance company, third party payor, community service agency, nursing facility or to any
representative or agent of such insurance company or third party-payor for the purpose of obtaining payment or relevant to my
continuum of care for services provided to me. I intend this authorization and consent to apply to information relative to chemical
dependency and/or mental health diagnosis and/or treatment, to the extent and only in such amount as is necessary to allow for the
purpose described above.
Patient Signature: _________________________________________________ Date: __________________________
Patient Representative: _____________________________________________ Date: __________________________
Assignment of Benefits/Financial Agreement
I hereby authorize payment of health insurance benefits directly to FMH Immediate Care, not to exceed the balance due of the Provider’s
customary charges for the services rendered. I understand that I will be responsible for all fees and charges deemed as my
responsibility according to FMH Immediate Care and my health plan. I understand that if I do not provide a VALID insurance card before
services are provided, I will be held financially responsible for all services. I further agree that I will pay any outstanding amounts in
accordance with FMH Immediate Care’s rate and terms. Should the account be referred to an attorney for collection, I will pay
reasonable attorney’s fees and collection expenses, and I understand that all delinquent accounts bear interest at the legal rate. I also
understand that it is my responsibility to determine which laboratory participates with my insurance plan. Errors in this determination
may result in denial of payment by the insurance company, in which case the financial responsibility will be my own.
I CERTIFY THAT I HAVE READ THE FOREGOING AND THAT I AM THE PATIENT OR DULY AUTHORIZED TO ACT ON BEHALF OF
THE PATIENT. I AGREE TO THE TERMS STATED ABOVE.
Patient Signature: _________________________________________________ Date: __________________________
Patient Representative: _____________________________________________ Date: __________________________
Acknowledgement of Receipt of Privacy Notice
I acknowledge that I have been given the opportunity to read the Privacy Policy for FMH Immediate Care, and understand my rights
according to this policy. I understand that the HIPAA law grants FMH Immediate Care Providers authorization to use and disclose my
medical information for the purpose of treatment and payment operations.
Patient Signature: _________________________________________________ Date: __________________________
Patient Representative: _____________________________________________ Date: __________________________
Communications Authorization
If representatives of FMH Immediate Care are unable to reach me regarding lab results, I authorize them to leave messages regarding
those results at my  HOME /  CELL phone number (please check boxes).
Patient Signature: _________________________________________________ Date: __________________________
Patient Representative: _____________________________________________ Date: __________________________
Release of Information (If 18 years of age or older)
I understand that because I am 18 years or older, FMH Immediate Care and its representatives are not authorized to share my medical
information with anyone other than staff members directly involved in my care (including spouses). Because of this, I would like to
authorize the following person(s) to access my medical records:
Name: ______________________________________________
Relationship: ______________________________
Name: ______________________________________________
Relationship: ______________________________
I understand that this authorization can be cancelled at any time through a written request.
Patient Name: ____________________________________________________ Date: __________________________
Patient Signature: _________________________________________________ Date: __________________________

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