Patient Registration Form

Patient Information

Patient Name

Date of Birth

Social Security No.

Address

City

State

Zip

Gender
Male
Female

Home Phone

Cell

Work

Employer Name

Employer Address

City

State

Zip

Primary Care Physician

Referred by

Communication preference - please check at least one
Home Phone
Cell Phone
Email

Medical information may be given to
Mother
Father
Other

Emergency Contact

Relationship

Phone

Primary Caregiver (for child or elderly)

Primary Caregiver contact numbers

Home phone

Cell phone

Patient Demographics

Student
Yes
No

Status
Full time
Part time

Retired
Yes
No

Veteran/Current Military
Yes
No

Ethnicity
Hispanic/Latino
Non-Hispanic/Latino
Unknown
Declined

Preferred spoken language

Do you smoke or use tobacco products
Yes
No

Revised July 2012 - Thank you for your assistance with government regulations

**PLEASE NOTE THAT ALL CO-PAYS ARE DUE AT TIME OF SERVICE, THANK YOU**

Insurance Information

Do you have healthcare insurance
Yes
No

Primary Insurance Company Name

Policy /ID Number

Name of Policyholder

Group Number

Policyholder Relationship to Patient

Copay Amount

Insurance Co. Address

City

State

Zip

Effective Date

Expiration Date

Do you have secondary insurance
Yes
No

PLEASE UPLOAD A COPY OF INSURANCE CARD - IF NO COPY IS AVAILABLE THE ACCOUNT WILL BE CONSIDERED "SELF-PAY"

Please attach a scan or photo of the front of your insurance card

Please attach a scan or photo of the back of your insurance card

Medical Authorization: The undersigned permits the physicians and all other personnel caring for the patient to examine, recommend treatment, and explain any associated risk involved. The undersigned also understands that this care may include diagnostic testing, examinations, or surgical treatment and no guarantees have been made regarding the outcome of this care.

Financial Agreement: I, the undersigned agree to be responsible for the balance of my account. Although an insurance claim (if applicable) will be filed with my insurance company by Northland Family Care on my behalf, negotiating payments through my insurance company is ultimately my obligation. I understand that payment will be made at the time of services rendered unless financial arrangements have been made PRIOR to the services. A statement will be mailed to me showing the balance due from me and will be considered past due after 30 days. If I am unable to make payment in full, I understand that I should contact the business office immediately to set up a payment arrangement. I understand that if no payment has been received or financial arrangements made on my balance, my account may be sent to collections. If my account is referred for collections, I understand that I will be responsible for the balance as well as any fees associated with the collection process.

Patient or Representative Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

signature

Date

Medical Information Release Form

(HIPAA Release Form)

Name

Date of Birth

Address

City

State

Zip

Please communicate my healthcare information in the following manner (check all that apply):

Home Telephone

Cell Telephone

Work Telephone

Notice of Privacy Practices
I was offered and made available, but I am electing not to receive a copy of the Notice of Privacy Practices
I acknowledge receiving a copy of the Notice of Privacy Practices

Release of Information

Release Authorization
I authorize the release of information including the diagnosis, records; examination rendered to me and claims information.
Information is not to be released to anyone.

This Release of Information will remain in effect until terminated by me in writing or three (3) years after the date signed, whichever is first.

Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Financial Policy

We value our relationship with our patients. To make sure there are no misunderstandings, our office policies regarding financial responsibilities for services provided are outlined below. Please review these policies and ask us if you have any questions.

Current state issued picture ID and current insurance card need to be presented at the time of your appointment. If you have an insurance with a designated Primary Care Physician, please make sure you have selected a physician in our office
Copays and balances are due and payable at the time of your appointment. If we are contracted with your insurance, you will be billed any remainder after we receive a response from them. We accept cash, checks, Visa, MasterCard and Discover. If you do not pay your copay at the time of your appointment you will be charged a $25 administration fee.
Any balance is your responsibility after insurance processes your claim. Please be aware that some, and perhaps all, of the services provided may not be covered services, and not considered reasonable and necessary under the Medicare program and/or other medical insurance. In this case, the balance is your responsibility. If you have a question about your benefits, please call your insurance company prior to your office visit and check your benefits.
Responsibility for payment for services rendered to the child/children of divorced or separated parents’ rests with the parent who seeks treatment. Any court-ordered judgement must be between the individuals involved, without including our facility or providers.
Accounts become past due after 30 days. We reserve the right to send an account to collections if not paid in full. If you cannot pay your balance in full please contact our billing department at 816-897-5810 to make appropriate arrangements. Any account sent to collections will be considered self-pay, and no appointment may be scheduled until all current and prior balances are satisfied. Any balance sent to collections may be subject to the 25% fee charged to NFC.
All returned checks must be paid with cash or money order within 5 working days or they will be turned over to the prosecuting attorney’s office. A fee of $35 will be charged on all returned checks.
Notify us at least 24 hours in advance if you cannot keep your appointment. Failure to do so will result in a $40 charge.
We do not bill workers’ compensation insurance. We do not treat conditions from open workers’ compensation claims.
All auto accidents will be self-pay appointments. We do not file insurance for auto accident claims, and we do not accept responsibility for collecting or negotiating insurance settlements. Treatment resulting from auto accident will be considered self-pay.
The fee for completion of FMLA forms, disability forms, etc. is $35.00 per form.

I agree to abide by the terms of the above financial policy and accept responsibility for any balance not covered by my insurance. I authorize my insurance company to pay directly to Northland Family Care, and/or provide any information regarding the payment of my bill. If my account becomes delinquent, I agree to pay all costs incurred in collecting the account, including a reasonable attorney’s fee if applicable.

Patient Signature (if the patient is a minor, responsible party please sign) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Name

Patient Date of Birth

Responsible Party Printed Name (if other than the patient)

Date

Medical Record Release Authorization

Patient Name

Maiden Name

SSN

Date of Birth

Home Phone

Cell Phone

Work Phone

Address

City

State

Zip

A) I hereby authorize records FROM:

Name *

Address

City *

State

Zip

Phone

Fax

B) I hereby authorize records TO:

Name

Address

City

State

Zip

Phone

Fax

C) This request is being made for the following purpose(s):

Date Range
to or

last 3 years or
last 2 years or
last 1 year

Physicians’ Office Notes
Operative/Procedure Reports
Cardiology/EKG Reports
Radiology/XRay/MRI Reports
Lab/Path Reports
Other

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that any disclosure of information carries with it the potential for an authorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure.

I understand that the information in my medical record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Medical Records Department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

I have read the information provided on this release form and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.

*Subject to Fees - see below

*PLEASE READ Fee Information: Northland Family Care will provide all medical records requested from our office. We reserve the right to charge the fee schedule as set by the State of Missouri. A $22.82 handling fee, $0.53 cents per page and postage may be invoiced to you from Northland Family Care with all of the necessary directions to receive your records. By signing this authorization, you are agreeing to pay Northland Family Care for your records. In the case of continuity of care, we may transfer a minimal portion of your records directly to a physician as a courtesy.

This authorization will expire one year from the below date unless I specify an expiration date

Patient/Parent/Guardian or Authorized Representative Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.

Date

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