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PATIENT REGISTRATION FORMPATIENT INFORMATIONName_____________________________________________________ Driver’s license#_________________________Address____________________________________________City_______________ST___Zip____________________ Telephone (__)_____________________Cell (__)______________________Birthdate_____________________Email address_______________________________Pharmacy:____________________________________________Social security #________-________-_______SEX OF PATIENT: ( ) Male ( ) Female MARITAL STATUS: ( ) Single ( ) Married ( ) Divorced ( ) WidowedRACE: ( ) White ( ) Black ( ) Hispanic ( ) Other ETHNICITY: ( ) Hispanic ( ) Not of Hispanic originPREFERRED LANGUAGE: ( ) English ( ) Spanish ( ) French ( ) German ( ) OtherEDUCATION: ( ) High school ( ) 2yr College ( ) 4yr College ( ) Other_________________________________RESPONSIBLE PARTY INFORMATION (Fill this section out ONLY IF different from above information)Name_____________________________________________________________________________________Address___________________________________________ City, ST, Zip_____________________________Telephone (_____) _________________________________ Relationship to patient_____________________EMPLOYMENT INFORMATIONEmployer__________________________________________________________________________________Address__________________________________________ City, ST, Zip______________________________Telephone (_____) _________________________________ Occupation_______________________________EMERGENCY NOTIFICATION/ NEXT OF KIN (NOT living with you)Name______________________ Telephone (_____) ____________Relationship to patient________________MISCELLANEOUS INFORMATIONWhat other doctors have you seen in this area? __________________________________________________________Are you allergic to any medications that you are aware of? ( ) Yes ( ) No If so, please list them below:___________________________________________________________________________________________________RELEASE OF AUTHORIZATION / ASSIGNMENT OF BENEFITSI authorize the release of any medical information necessary to process my insurance claim(s). I authorize and request payment of medical benefits directly to Dr. P. Mora. I agree that this authorization will cover all medical services rendered by Dr. P. Mora until such authorization is revoked by me. I agree that a photocopy of this form may be used in place of the original. I hereby authorize direct payment for surgical benefits to Mora Surgical Clinic, P.C., for services rendered by Dr. P. Mora or under his supervision. I understand that I am financially responsible for any balance not covered by my insurance and collection fees that may occur._______________________________________________________________________________________Print Patient NameSigned (Patient or Patient’s representative/ legal guardian) Date: ____/____/_______HOW DID YOU FIND OUT ABOUT US? Advertisement (what kind? ______________________), phone book,Word-of-mouth, Other______________________________________MORA SURGICAL CLINIC, P.C.Notice of Privacy PracticesTHIS 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.If you have any questions about this Notice, please see the office manager or call us at (334) 361-6126This is a summary of our Notice of Privacy Practices which describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. We are required by law to maintain the privacy of your protected health information and to provide you with a notice of our legal duties and privacy practices with respect to protected health information.We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time, and reserve the right to do so. The new notice will be effective for all protected health information that we maintain at that time.We will use your protected health information as part of rendering patient care, including treatment, payment and healthcare operations.Other uses and disclosures of your protected healthcare information will be made only with your written authorization, unless permitted or required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.We may use or disclose your protected healthcare information in certain situations without your authorization or opportunity to agree or object.You have the right to request a restriction of your protected healthcare information.You have the right to request to receive confidential communications of your protected health information.You have the right to inspect and copy your protected healthcare information.You have the right to amend your protected health information.You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.You have the right to obtain a paper copy of this notice from us.You may complain to us or the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.For your convenience, The entire notice of our privacy practices is posted in our lobby beside the check-in window.I, ________________________________________, acknowledge that I reviewed a copy of the privacy practices and I am aware that there is a copy on the lobby wall.___________________________________________________________________________________Name of Patient or Personal Representative (please print!)Signature of Patient or Personal Representative___________________________________________________________________________________________DateRelationship to patient (if Personal Representative)Implemented 4/1/03PATIENT FINANCIAL RESPONSIBILITY AND MEDICAL RECORD INFO RELEASEMORA SURGICAL CLINIC, P.C.I, the undersigned, acknowledge that I am responsible for ALL charges billed for services rendered which are not covered by insurance or other third party payors. My responsibility includes, but is not limited to, deductibles, co-payments, co-insurance and/or another charges incurred but not covered by insurance or other third party payors.I hereby assign all benefits from any insurance coverage that will pay for this medical service, to Mora Surgical Clinic, P.C. I understand that Mora Surgical Clinic, P.C. will make reasonable efforts to collect on my assigned insurance, but that if my insurer has not paid within ninety (90) days of being billed, that payment of the billed charges will be my responsibility.I acknowledge and understand that if my account remains unpaid for a period of ninety (90) days and/or financial arrangements I make with Mora Surgical Clinic, P.C. are not met, my account will be referred to an outside collection agency and I will be responsible for an automatic collection fee of 30% of the total debt owed that will be added to the principal balance. Upon default, I agree to pay any and all fees, charges, or expenses incurred by Mora Surgical Clinic, P.C. in the process of collecting the amount owed or incurred while turning over the debt for collection.Due to federal privacy guidelines under HIPAA, we are required to have a medical release of information on file for each patient. This authorizes our office to release medical information to your designated family members, caregivers, and friends, as well as, pharmacists, hospitals, emergency medical personnel, and referral specialists about you or your minor (under 14 years of age) children’s PROTECTED HEALTH INFORMATION (PHI). Included would be all health and identifiable information. This authorizes us to share your health information, after proper identification, by verbal or written communication, telephone, answering machine, fax, mail or e-mail as needed for your care to only those that you have identified below.I ________________________________________ (name) __________________________ (date of birth), give my authorization to the following individual(s) listed below to discuss my medical care with you and/or your staff on my behalf. The information is private and confidential and will be placed in your medical record. This authorization will expire 12 months from the date signed.NAME, RELATIONSHIP, DATE OF BIRTH, AND PHONE NUMBERName: _________________________________ Relation: _______________________Number:_______________________________ DOB: __________________________Name: _________________________________ Relation: _______________________ Number:_______________________________ DOB: _________________________If there is any health information you DO NOT WISH to be given out, please list below.___________________________________________________________________________________DISCLAIMER (Check below ONLY if you want NO ONE else to have access to your information.)________ I DO NOT want you to discuss my medical care with anyone other than myself.________________________________________________________________________Witness Patient Signature________________________________________________________________________DateResponsible party/ Legal Guardian (if applicable)Patient Name:__________________________________ Date:___________________________Do you have a Primary Care doctor?:? Yes ? No Name of Doctor:______________________Doctor’s phone #:____________________ Date and Year last seen:_______________________Medical HistoryComplaint:_______________________________________________________________________History of present illness: (please circle each item that applies to YOU) AsthmaDepressionLung diseaseSeizure Esophageal refluxThyroid diseaseStrokeBlood transfusionHeart disease HepatitisHIV/AidsKidney/bladder disease OsteoarthritisUrinary incontinenceHigh blood pressure DiabetesSleep apnea Cancer of:____________________ Other:_____________________________Have you EVER had surgery? : (include year of the procedure)__________________________________________________________________________________________________________________________________________________________________________________________________________________Family history: (please circle each item that has occurred in YOUR PARENTS, CHILDREN, BROTHERS, SISTERS, GRANDPARENTS, UNCLES, AND AUNTS) High blood pressureLiver diseaseHeart diseaseUlcers DiabetesThyroid diseaseKidney disease Cancer of:_____________________Other:__________________________Autoimmune connective tissue disease HIV Systemic Lupus ErythematosusSclerodermaSocial history: (please fill in the information of all that are applicable) ? Currently smoke ( _____packs per day for _______ years) ??Former smoker ??Never smoked Alcohol________ use for ________ years Street drugs_________________use for _________yearsAllergies: Current medication:_____________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ _________________________________ _____________________________ ______________________________________________________________ ______________________________________________________________ _________________________________Patient Name_________________________________________ Date___________________PLEASE CIRCLE ALL THAT APPLY TO YOU GENERAL:Fatigue/WeaknessWeight lossFeverChillsSKIN:Change in size/color of molesRashEYES:Poor visionDouble visionBlurred visionEars, Nose:Sore throat DeafnessRinging in earsHoarsenessMouth, Sinus Drainage Nose bleedThroatCARDIAC:Difficulty breathing going up stairs (circle YES or NO). How many floors? 1 or 2High blood pressurePalpitations (heart racing/beating irregularly)Shortness of breath at restSwelling in feet/legsChest painLUNGS: Wheezing SnoringWaking up at night(not to urinate) Falling asleep in the day Coughing up blood Use oxygen at homeCough (Does anything come up? Circle YES or NO) Describe:_____________________DIGESTION:HeartburnPainful swallowingNauseaVomitingVomiting bloodIndigestionDiarrheaConstipationTarry stoolsYellow jaundiceBloody stoolsChange in bowel movementsURINARY:Kidney/bladder disease Unable to urinate Painful urinationKidney failure/dialysisBlood in urine Inability to control urine if straining/laughing/coughing Frequency/ UrgencyMUSCLE/:WeaknessTrauma Limited motionSKELETALBone/joint deformityswelling of joints Joint painBRAIN:ParalysisWeakness Seizure Fainting Headache Stroke/Mini-strokeMigraineIncoordination Head traumaNumbness/tingling in extremities PSYCH:AnxietyDepression Hallucinations ENDOCRINE: Change of appetite Excessive thirst/urination Goiter Diabetes/Diabetes problemsHEMATO:Swollen lymph nodesBleeding disordersIMMUNO:Immune disorders HIV Immunosuppressive medication Autoimmune connective tissue disease Systemic lupus erythematosus Scleroderma Symptoms of one of the above named diseasesFEMALES ONLYBREAST:LumpsPainNipple dischargeInfectionTraumaLast mammogram (date)_____________________GYN:Irregular periodsHormone therapyMenopauseLast pelvic exam (date)_________________ Last period date)________________Patient signature:_____________________________Date:______________________Physician signature:___________________________ ................
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