New Patient Registration Form for Savannah Clinic

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INSURANCE INFORMATION

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

  1. 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.
  2. 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.
  3. 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:

  1. 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.
  2. 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.
  3. 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.


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

 
DRUG NAME TABLET/CAPSULE/LIQUID STRENGTH

DIRECTIONS

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

 
ALLERGY REACTION

SOCIAL HISTORY

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             


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


HEALTH MAINTENANCE
List the Month/Year of Last Screening/Evaluation

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

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 $30 “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.

 


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:

  1. We must keep your healthcare information from others who do not need it.
  2. 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:

  1. Reportable infectious diseases and birth defects
  2. Reactions to problems with medicines or defective medical equipment
  3. To the police when required by law
  4. When the court orders us to
  5. To the government to review how our programs are working
  6. To a provider or other insurance company who needs to know if you are enrolled in one of our programs
  7. Birth, death and immunization information
  8. To the federal government when they are investigating something important to protect our country, the government workers
  9. Abuse, neglect and domestic violence, if related to child protection or vulnerable adults.
  10. To Workers Compensation for work related injuries; We may also share healthcare information for permitted research purposes 
  11. 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

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.


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.

Thank you for registering online with Savannah Clinic!

We have received your registration form and will contact you shortly with any questions! 

Thank you again for using our ONLINE DIGITAL FORM. 

Warm regards,

Savannah Staff