Patient Form

Patient registration form

First Name

Last Name

Date of Birth

Email

1st Phone #

2nd Phone #

Steet Address

Apt #

Floor / Suit #

City

State

Zip Code

height

Weight

INSURANCE INFORMATION

Primary Insurance Name

Member ID

Patient covered by another insurance:

Yes

No

Additional Insurance

Member ID

Referring Physician

Primary Care Physician

Phone #

Pharmacy Information

Name

Phone

Assignment and Release

I the undersigned certify that I or my dependent have insurance coverage with and assign directly to DR , under my insurance benefits: if any, otherwise payable to me for service rendered. I understand that i am financially responsible for all charge whether or not paid by my insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on file for insurance submissions.

Signature

Relationship

Today's Date

Are you taking any medication:

Yes

No

Please list the name of medication you are currently taking.

Medication #1

Dose

Medication #2

Dose

Medication #3

Dose

Medication #4

Dose

Medication #5

Dose

Medication #6

Dose

Please provide details regarding any allergies to medications you may have

Medication Allergies

Did you have any surgeries in the past:

Yes

No

Chewing Tobacco?

Yes

No

Medical History-Please Check that apply

Family history of any disease-Please Check

I (do or do not) give permission for any staff member of Atlantic Cardiovascular Associates to speak with a family member or individual regarding appointments, prescriptions, test results, or pick up films on my behalf. Please list individuals that we may speak with:

Full Name

Relationship

Telephone no. / fax no.

Full Name

Relationship

Telephone no. / fax no.

Full Name

Relationship

Telephone no. / fax no.

Patient Name

Practice Requirements

The Practice:

Is required by federal law to maintain the privacy of you PHI and to provide you with this Privacy Notice detailing the practice's legal duties and privacy practices with respect to your PHI.
Under the Privacy Rule, may be required by State law to grant greater access or maintain greater restrictions on the use or release of your PHI than that which is provided for under federal law.
You have the right to be treated with dignity and respect
You have the right to appropriate services in the least restrictive settings available that meets your needs
Is required to abide by the terms of this Privacy Notice
Reserves the right to change the term of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains.
Will distribute any revised Privacy Notice to your prior implementation.
Will not retaliate against you for filing a complaint

Patient Acknowledgement

By subscibing my (missing) below, I acknowledge receipt of a copy of a this Notice, and my understanding and my understanding and my agreement to its terms.

Patient Signature

(Guardian’s Signature if Patient is under 18)

Today's Date