New Patient Registration Form for Savannah Clinic

26795 US-380, STE 100

Aubrey TX, 76227

Phone: 972-347-5761 Fax: 972-347-5786

Email: savannahclinic380@gmail.com

First Name

Middle Name

Last Name

If Patient is a minor, name of parent/legal guardian:

Patient Date of Birth (mm/dd/yyyy)

Patient Age

Patient Social Security Number

Marital Status

Male or Female

Male
Female

Race

Ethnicity

Preferred Language

Billing Address

Address Line 1

Address Line 2

City

Country

Select

State/Province

Select

Zip Code

Phone

Preferred Contact Method

Phone
Text
Email

Occupation

Employer

Work Phone

Preferred Pharmacy Name/Location

Pharmacy Phone Number

Emergency Contact Name

Emergency Contact Phone Number

Relationship

INSURANCE INFORMATION

Primary Health Insurance

Insurance Carrier

Insurance ID

Group#

Policy Holder Name

Social Security Number of Policy Holder

Date of Birth of Policy Holder

Effective Insurance Date

The undersigned makes the following acknowledgments and agreements regarding treatment to be provided to the patient whose name appears above:

Consent to treatment: I consent to any medical or surgical treatment rendered to the patient under general or special instructions of the physician(s). I certify that no guarantee of assurance has been made to me as to the results which may be obtained.
Release of medical information: I authorize the release of any medical or other information from this provider(s) and other providers necessary to process a health insurance claim or to provide treatment.
Assignment of benefits: I authorize payment of medical benefits to Savannah Clinic Associates, LLC.

I certify that the information given at the time of registration is correct. I understand that I will be financially responsible for all charges in full at the time I am given treatment unless otherwise discussed before I am seen. I understand I am financially responsible to Savannah Clinic Associates, LLC for charges not covered or billed to my insurance.

The undersigned makes the following acknowledgments and agreements regarding treatment to be provided to the patient whose name appears above:

Consent to treatment: I consent to any medical or surgical treatment rendered to the patient under general or special instructions of the physician(s). I certify that no guarantee of assurance has been made to me as to the results which may be obtained.
Release of medical information: I authorize the release of any medical or other information from this provider(s) and other providers necessary to process a health insurance claim or to provide treatment.
Assignment of benefits: I authorize payment of medical benefits to Savannah Clinic Associates, LLC.

Signature of Patient/Guardian/Legal Representative

To accept these terms, type in your name below:

Date Signed

Please list all medications you are currently taking, over the counter medications, vitamins and herbs.


DRUG NAME	TABLET/CAPSULE/LIQUID	STRENGTH	DIRECTIONS

List your medications here:

Please list and describe allergic reactions you have had to medications, foods, insect stings, etc...


ALLERGY	REACTION

List all allergies here:

SOCIAL HISTORY

Do you exercise?

If so, how often and duration?

Minor Child: Extracurricular Activities

Current Tobacco Use - (Smoke, Chew, or Electronic and Average Use

Diet- (Regular, Diabetic, Low Fat, Low Sodium...Etc.)

History of Tobacco Use

Year Quit

Do you want to quit?

Alcohol Use

Daily
Occasional
Rarely
None

Average Daily Use

1-2
3-4
more than 6

Recreational Drug Use (If yes, what type of drug?)

PAST MEDICAL HISTORY

ADD or ADHD Diverticular Disease Joint Problems                Skin Problem
Abnormal Pap Smear, when? Drug Abuse                                Kidney Disease               Sleep Apnea
Alcoholism Ear Problem Kidney Stones STD
Allergies Eczema Liver Disease Stroke
Anemia Endometriosis Low Blood Pressure Thyroid, Low
Anorexia Erectile Dysfunction Lung Disease Thyroid, High
Anxiety Eye Problem Memory Problems Tuberculosis
Arthritis Fibromyalgia Migraines Vasculitis
Asthma Gall Stones Multiple Sclerosis
Autoimmune Disease Gastritis/Gastric Ulcer Muscle Problems
Back Pain, Chronic Genital Herpes Narcolepsy
Bipolar Disorder Glaucoma Obesity
Blood Disease Heart Attack Osteopenia
Bulimia Heart Disease Osteoporosis
Cancer Heart Murmur Pancreatitis
Clotting Disorder Heartburn/Reflux Parkinson's Disease
Colon Polyp Hemorrhoids Postmenopausal
COPD Hepatitis   A   B   C Prostate Enlargement
Coronary Artery Disease High Cholesterol Psychiatric Disorder
Depression, History of High Blood Pressure Restless Leg Syndrome
Depression, Current                     HIV/AIDS Rheumatoid Arthritis
Diabetes, Type 1 or 2 Irregular Heart Rhythm Scoliosis
Diabetes, Gestational Irritable Bowel Syndrome Seizure Disorder

List any of the above that apply, past or present:

PAST SURGICAL HISTORY

Appendectomy Ear Tubes Shoulder Surgery

Breast Augmentation Cholecystectomy Prostate Surgery

Breast Biopsy Hysterectomy, Total Thyroid Surgery

Breast Lumpectomy Hysterectomy, Partial Tonsillectomy

Breast Mastectomy Heart Bypass Tubal Ligation

C-Section Hernia Repair Vasectomy

Cataract Removal Knee Surgery Weight Loss Surgery

Coronary Artery Bypass Back Surgery Neck Surgery

# of Vessels

List any of the above that apply, past or present:

HEALTH MAINTENANCE

List the Month/Year of Last Screening/Evaluation

Bone Density

Last PAP

Mammogram

Colonoscopy

PSA

Eye Exam

FAMILY HISTORY

In the blank provided please list family members who have history of disease.

Heart Disease

High Blood Pressure

Diabetes

Stroke

Cancer

High Cholesterol

Dementia

Thyroid

List any other major medical family history here:

FINANCIAL RESPONSIBILITY FORM

Thank you for choosing us as your family health care provider. We are committed to providing you and your

family with the highest quality and affordable healthcare we can. This is our financial policy, please read it

and ask us any questions you may have. Attached is a signature page that once signed we will add to your

medical record. We will provide you with a copy of this document if you request one.

Your responsibility as a patient of this clinic:

We participate with many insurance plans. We recommend that you contact your insurance carrier and educate yourself on your

benefits and our participation with your insurance carrier. This will save you frustration if you seek treatment or procedures your

insurance carrier will not pay for or file toward your deductible. We are here to help in any way we can, please ask our advice

and we will point you in the best direction.

Proof of Insurance:

Every patient needs to complete a patient information and demographics packet prior to seeing one of our providers. We will need

a copy of your ID/Driver's License and your current and valid insurance ID card. If you cannot provide your insurance ID card or

information that we can use to verify insurance benefits at the time of your visit, your payment will be due in full at the time of your

appointment. Please bring these items with you each time you visit our clinic.

Payment Options:

Payments of co-pays, deductibles, co-insurance and past due balances must be paid at the time you are seen. For your convenience

we will accept the following payment types: Cash, Master Card, Visa, Discover and American Express. We do allow our

established patients to write a personal check – NOTICE: all returned checks will be subject to a $35 returned check fee.

Claims Submission:

As a courtesy we will submit your visit to your insurance carrier. Your insurance carrier may require additional information from

you in order to process your claim. If you fail to comply with their requests, you may have your claim denied in which case you

will be responsible for the full payment.

Non-Payment:

If your account remains unpaid for 90 (ninety) days, it may be referred to an outside collection agency. Depending on the

circumstances, you could be dismissed as a patient at this clinic.

“No Shows”:

If you have an appointment scheduled and confirmed and do not show up for your appointment or did not let us know as soon

as possible that you would not be able to attend your appointment, there will be a $35 “no-show” fee attached to your account.

You will need to bring your account to current prior to being seen the next time you schedule an appointment. A third “no-show”

could result in you being dismissed as a patient of this clinic.

Medical Record Request:

You may request a copy of your medical files using the “Medical Request” form. There will be a $35 per CD fee charged for

the copying of your medical history and chart.

Injections:

We can give injections here at Savannah Clinic to help our patients feel better faster. Please note that if you elect to have an

injection it will not be billed to your insurance. As the patient, you are responsible for the injection at the end of your visit.

Injection fees start at $25.

Patients Full Name

Date of Signing

Signature of Patient or Responsible Party

To accept these terms, type in your name below:

Patient Date of Birth

PATIENT HIPAA NOTIFICATION

For your protection 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

YOUR HEALTHCARE INFORMATION IS PRIVATE

We understand that information we collect about you and your health is personal. Keeping your healthcare information private is one

of our most important responsibilities. We are committed to protecting your healthcare information and following all laws regarding

the use of your healthcare information. You have the right to discuss with the compliance officer your concerns about how your

healthcare information is shared.

The law says:

We must keep your healthcare information from others who do not need it.
You may ask us not to share certain healthcare information. Sometimes, we may not be able to agree to your request.

WHO SEES AND SHARES MY HEALTH INFORMATION?

Your healthcare givers, such as our staff, may see, use and share your healthcare information to determine your plan of care. This

use may cover healthcare services you had before now or may have later. We review your healthcare information and bills (claims)

to make sure that you get quality care and that all laws about providing and paying for your healthcare are being followed. We may

also use your information to remind you about appointments or to tell you about treatment alternatives.

HOW IS PAYMENT MADE?

We may share your healthcare information with health plans, insurance companies, or government programs to help you get your

benefits and so that we can be paid or pay for your healthcare services.

MAY I SEE MY HEALTH INFORMATION?

In most cases, you may see your healthcare information. There may be legal reasons or safety concerns that may limit the amount

of information that you may see. If you think some of your healthcare information is wrong, you may ask in writing that we correct

or add to it. You may ask that the corrected or new information be sent to others who have received your healthcare information from

us. You may ask us for a list of where we sent your healthcare information.

WHAT IF MY HEALTHCARE INFORMATION NEEDS TO GO SOMEWHERE ELSE?

You may ask to have your healthcare information sent to others. You will be asked to sign a separate form, called an authorized form,

permitting your healthcare information to go to them. The authorization form tells us what, where, and to whom the information must

be sent. You can stop or limit the amount of information sent at any time by letting us know in writing. We may charge a small amount

for copying costs. Note: If you are younger than 18 years old and by law you are able to consent for your own healthcare, then your

healthcare information is kept private from others unless you sing an authorization form. We charge a $25 fee per CD of information

we process.

COULD MY HEALTH INFORMATION BE RELEASED WITHOUT MY AUTHORIZATION?

We follow laws that tell us when we have to share healthcare information, even if you do not sign an authorization form. We report:

Reportable infectious diseases and birth defects
Reactions to problems with medicines or defective medical equipment
To the police when required by law
When the court orders us to
To the government to review how our programs are working
To a provider or other insurance company who needs to know if you are enrolled in one of our programs
Birth, death and immunization information
To the federal government when they are investigating something important to protect our country, the government workers
Abuse, neglect and domestic violence, if related to child protection or vulnerable adults.
To Workers Compensation for work related injuries; We may also share healthcare information for permitted research purposes
and serious threats to public health or safety.

MAY I HAVE A COPY OF THIS NOTICE?

This notice is yours and you may ask for a copy at any time. If there are important changes to this notice we will get a new copy to you

on your next visit.

QUESTIONS OR COMPLAINTS?

If you have questions or complaints please see the office manager and allow that person to assist you in any way we may legally help.

If after speaking with our office staff you still feel your rights have been violated, here is the website where you may file a complaints

with the US Department of Health & Human Services.Http://www.hhs.gov/ocr/privacy/psa/complaint

Date

Patient's First Name

Patient's Last Name

I have read and understand my rights as pertains to HIPAA rules and regulations and the way in which Savannah Clinic Associates will adhere and enforce those rules and regulations. By signing this document I ascertain that

I have been informed of the HIPAA rules and regulations and the way in which Savannah Clinic Associates will adhere and enforce these rules and regulations.

Signature of Patient or Patient's Legal Guardian

To accept these terms, please type your name below

Signature of Staff Member

Disclosure of Protected Health Information

I understand that any and all care I receive at Savannah Clinic Associates will be treated with the utmost confidentiality. To facilitate my medical care I hereby authorize the following person to have access to my personal medical history information including treatment and medical conditions.

NAME

Date of Birth

Telephone Number

Relationship

NAME

Date of Birth

Telephone Number

Relationship

NAME

Date of Birth

Telephone Number

Relationship

NAME

Date of Birth

Telephone Number

Relationship

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New Patient Registration Form for Savannah Clinic

Thank you for registering online with Savannah Clinic!