Patient Registration Packet

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Patient Registration Packet

Patient Registration Packet

First Name
Last Name
Email
Date
Date Format: MM slash DD slash YYYY
DOB
Date Format: MM slash DD slash YYYY
SSN
Sex
- Male
- Female
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work Phone
Cell Phone
Which would you prefer we call:
- Home
- Cell
- Work
Email
Employer
Preferred Language
Race
Ethnicity
The following is authorized to receive medical information
Untitled
Please do not disclose information to anyone else
Emergency Contact Name
Phone
Relationship
Insurance Company
Provider ID
Group #
Insurance Company
Provider ID
Group #
Policy Holder Name (If different from patient):
Name
DOB
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Phone Number
Relationship to Patient
Signature
Gender
- Male
- Female
For females, check if applicable
- Pregnant
- Breastfeeding
Reason for Visit
When did this start?
List all your current medications, including over the-counter medications + supplements:
Check here if no meds (If you have a medication list please provide it to the receptionist so we may scan it into your chart,
- No
Check here if no known allergies
- No
Past Medical History
- Allergies
- Anxiety
- Asthma
- Arthritis
- Cancer (Type)
- Depression
Past Medical History
- Diabetes/Emphysema/COPD
- Epilepsy/ Seizure Disorder
- Headaches
- Heart Disease
- High Blood Pressure
Past Medical History
- High Cholesterol Kidney Disease
- Liver Disease
- Stroke
- Thyroid Disease
- Other (specify):
Hospitalization & Surgery
- Appendix
- Adenoids
- Back
- Bzeaet
Hospitalization & Surgery
- Heart
- Hernia
- Hysterectomy
- Tonsiltectozny
Hospitalization & Surgery
- Tribal Ligation
- Vasectomy
- C-Section
- Other (specify)
Social History
- Single
- Married
- Divorced
- Widowed
For the MINOR patient: Child lives with:
- Parents
- Grandparents
- Other
Do you use any recreational drugs or medications not prescribed to you?
- Yes
- No
Primary Care Provider:
Pharmacy:
Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information. There are certain circumstances that require us to use or disclose your health information. Some of these circumstances are: to public heath authorities, lawsuits law enforcement officials, federal officials, correctional institutions, military officials (for members of the military only), Workers Compensation Health Insurance programs.

You have rights regarding your health care information. These rights include and/or but are not limited to: communication regarding your healthcare, inspection of any health information or medical records (including billing records but not including psychotherapy notes), requesting amendments to health information, filing complaints against privacy, written consent and authorization to disclose any health or personal information to certain individuals. If you have any questions regarding this notice or our health information privacy policies please contact a member of our staff.

* A full copy of our privacy policy is provided upon request.

I have read and understand the copy of Privacy Policies provided.
Signature
Date
Date Format: MM slash DD slash YYYY
• We respect the privacy of your personal medical records and will do all we can to secure and protect that privacy.

• When it is appropriate and necessary, we provide the minimum necessary information to only those individuals required by law or who feel are in need of your health care information and information about treatment, payment or health care, operations in order to provide health care that is in your best interest.

• You may refuse consent to use or disclose your personal health information, but this must be in writing.

• You have the right and we agree to provide you with access to your medical records in accordance all State and Federal laws.

* All full copy of our HIPAA policy is provided upon request.

I have read and understand the copy of HIPAA Policies provided.
Signature
Date
Date Format: MM slash DD slash YYYY
If you have any questions regarding this content, please speak with a member of our staff
Name (Please Print)
DOB
Date Format: MM slash DD slash YYYY
Date
Date Format: MM slash DD slash YYYY
1. Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan we participate in, payment in full is expected at each visit. If you are insured by a plan we participate in but do not have a current insurance card, payment in full for each visit is required until we can verify your coverage. When insurance is involved, we can file claims on your behalf in most cases.

At times however, a portion of care is paid by the patient based on your specific plan. We will bill the responsible party for those services clearly outlined by the insurance plan that are the patient's responsibility.

Knowing your insurance benefits is your right and responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

2. Co-Payments. All co-payments must be paid at the time of service. This arrangement is part of our contract with your insurance company. Failure on our part to collect co-payments from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit.

3. Non-Covered Services. Please be aware that some, and perhaps all, of the services you receive may be non-covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full whether at the time of your visit or hereafter.

4. Proof of Insurance. All patients must complete our patient information forms before seeing the provider.

We must obtain a copy of your photo ID and a valid current insurance card to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of your claim.

5. Claims Submission. We will submit your claims and assist you in any reasonable way to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their requests. The amount owed to the office as outlined in your insurance contract is your responsibility.

6. Coverage Changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.

7. Financial Policy. We are committed to providing you with the best possible care. In order to achieve this goal, we need your assistance and understanding of our payment policy. Co-payments and fees that you are responsible for are due in full at time of service. Should the account become delinquent, your account may be referred to a collections agency and you will be responsible for those fees. If your account is delinquent, you may be asked to seek treatment elsewhere until your account is paid. Acceptable forms of payment are cash, check (only established patients), Visa, MasterCard, Discover, American Express, and Apple Pay.

By signing below you agree that you have read and understand the above information and will comply with these policies.
Signature of Patient or Representative:
Date
Date Format: MM slash DD slash YYYY
Locations:*
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240 East St, Plainville, CT 06062
7 Mill Pond Rd. Granby, CT 06035

(860) 747 - 4541 (860) 653 -2382

Drstreatment@gmail.com
Dtcgranby@gmail.com

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