PATIENT REGISTRATION

Transcripción

1 PATIENT REGISTRATION Date / Fecha Patient Information / Información del Paciente Check here if the patient is the guarantor First / Nombre Middle / Segundo Nombre Last / Apellido Suffix/ Sufijo Primary Mailing Address / Dirección de correo City / Ciudad State / Estado Zip Code / Codigo Postal Alternate - Physical Address / Dirección de domicilio City / Ciudad State / Estado Zip Code / Codigo Postal Homeless/ Sin hogar? Date became homeless/ Fecha en que quedo sin hogar Homeless Status/ Estatus sin hogar (Choose one if homeless/escoja uno si no tiene hogar): Homeless Shelter/Refugio Transitional/ Transición Doubling Up/Vive con otros On the Street/En la calle Other/Otro Unknown/ Desconocido Phone 1/ Telefono 1: Type (Choose One/Escoja uno): Home/Casa Mobile/ Móvil Work/Trabajo Pager No Phone/No tiene telefono Refused/Negado Phone 2/ Telefono 2: Type (Choose One/Escoja uno): Home/Casa Mobile/ Móvil Work/Trabajo Pager No Phone/No tiene telefono Refused/Negado DOB/Fecha de Nacimiento Social Security # /Numero de Seguro Social Marital Status / Estado Civil Single/Soltero Married/Casado Divorced/Divorciado Widowed/ Enviudado Separated/Separado Unknown/Desconocido Other/Otro (Choose One/Escoja uno) Male/Masculino Female/Femenino Family Size / Cuantos miembros en la familia? Montly income /Ingresos Mensual Primary language spoken by patient /Idioma primario hablado por Paciente? Agriculture Work Status/ Estatus de Trabajo de agricultura (Choose One/Escoja uno) Non-agricultural worker/ Trabajador no agrícola Seasonal/ Temporal Migrant/ Emigrante Employed Year Round/ Empleado año completo Retired Farm Worker/Jornalero jubilado Race / Raza Asian Native Hawaiian Other Pacific Islander Black/African American American Indian Alaska Native White More than one Race Refuse to report Ethinicity/Grupo Etnico Hispanic Non-Hispanic Employment Status/ Estatus de empleo (Choose One/Escoja uno): Employed /Empleado Part-Time Student/Estudia Medio Tiempo Full Time Student /Estudia Tiempo Completo Other / Otro: Employer / Empleador Work Phone # / Telefono del trabajo Employer Address / Dirección de Empleador City / Ciudad State / Estado Zip Code / Codigo Postal Are you, the patient, a veteran of a branch of military service? No Yes Usted el paciente es veterano de guerra o de alguna rama del servicio militar? No Yes Highest Level of Education/ Nivel más alto de Educación How did you hear about our center?/ Cómo se enteró usted de nuestro centro? address/correo Electronico PATIENT REGISTRATION HEALTHCARE NETWORK FORM# 1000 Rev. 11/2013

2 Guarantor Information / Información de Garante (Guarantor 1) First, MI,Last Name/ Suffix/ Primer Nombre, Segundo Nombre, Apellido Sufijo DOB / Fecha de Nacimiento / / Social Security # / Numero de Seguro Social Male/Masculino Female/Femenino Address / Dirección City / Ciudad State / Estado Zip Code / Codigo Postal Alternate Phone 1 / Teléfono Alternativo 1 Alternate Phone 2 / Teléfono Alternativo 2 (Guarantor 2) First, MI,Last Name/ Primer Nombre, Segundo Nombre, Apellido Suffix/ Sufijo DOB / Fecha de Nacimiento / / Social Security # / Numero de Seguro Social Male/Masculino Female/Femenino Address / Dirección City / Ciudad State / Estado Zip Code / Codigo Postal Alternate Phone 1 / Teléfono Alternativo 1 Alternate Phone 2 / Teléfono Alternativo 2 Emergency Contact Name/ Nombre de Contacto de emergencia: Relationship to Patient / La relación al Paciente: Emergency Contact Address / Dirección de Empleador City / Ciudad State / Estado Zip Code / Codigo Postal Emergency Contact Phone/ Numero de Telefono de Contacto de Emergenica: Does this person know that you are a patient?/ Esta persona sabe que es un paciente? Yes/Si NO Insurance Information ( Policy Holder is the one responsible for the ins. premium. E.G. self, parent, spouse)/ Información de Seguro Medico ("Poseedor de Polísa" es el responsable de prima de suguro. Por ejemplo usted mismo,pariente, cónyuge) Primary Insurance/Aseguransa Primaria Insured ID # / Núm. de Identificación# (como aparece en la tarjeta) Plan # / Numero del Plan de Seguro Insurance Plan Name / Nombre de Plan de Seguro DOB / Fecha de Nacimiento Social Security # /Numero de Seguro Social Insured Employer Secondary Insurance/Aseguransa Secundaria Insured ID # / Núm. de Identificación# (como aparece en la tarjeta) Plan # / Numero del Plan de Seguro Insurance Plan Name / Nombre de Plan de Seguro Insured Employer DOB / Fecha de Nacimiento Social Security # /Numero de Seguro Social Completed by: Date: PATIENT REGISTRATION HEALTHCARE NETWORK FORM# 1000 Rev. 11/2013

3 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I,, hereby acknowledge that I have received a copy of the Healthcare Network s Notice of Privacy Practices which summarizes the ways my identifiable health information may be used and disclosed by the Healthcare Network and states my rights with respect to my medical information. I understand the Healthcare Network has the right to revise these information practices and to amend the Notice of Privacy Practices. I have been informed that in the event the Healthcare Network revises its information practices, a revised Notice will be posted at the Healthcare Network and that I may obtain a current Notice of Privacy Practices upon request. Interpreted in: By: Date Signature of Patient/ Guardian/ Representative Date Signed If Guardian/ Representative, state Relationship to Patient Signature of Witness Date Signed ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES HEALTHCARE NETWORK FORM #1045 5/12

4 CONSENT FOR TREATMENT I,, hereby authorize Healthcare Network of Southwest Florida, its facilities or treatment centers, its affiliated physicians, dentists, surgeons, and other medical personnel in charge of my care, to administer examinations and treatments, as may be deemed medically necessary in the exercise of their professional judgment. Signature of Patient Date CONSIENTA PARA el TRATAMIENTO Yo,, por este medio autorizo Healthcare Network of Southwest Florida, sus centros de facilidades o tratamiento, sus médicos afiliados, los dentistas, los cirujanos, y otro personal médico a cargo de mi cuidado, para administrar exámenes y tratamientos, como ellos piensen que sea medicamente necesario en el ejercicio de su juicio profesional. Firma del Paciente Fecha CONSENTIR POUR LE TRAITEMENT Mwen,, otorize Healthcare Network of Southwest Florida, fasilite ou sant de sante, afilye ak fizisyan, dantis, chirijyen, e tout pesonel medical ki responsab de swen mwen, pou administer ezamen e tretman, ki kapab konsidere medikalman nesese nan exzesis jijman pesonel. Syiate Pasian Dat CONSENT FOR TREATMENT HEALTHCARE NETWORK FORM # /12

5 PATIENT FINANCIAL RESPONSIBILITY AGREEMENT Method of Payment (Check all that apply) Self-Pay Insurance Medicaid Medicare Other (please specify: ) I wish to be considered for sliding fee scale. I have no Health/Dental Insurance coverage of any kind or my Health/Dental Insurance does not recognize Healthcare Network as a participating provider. I shall authorize Healthcare Network to verify my income with my employer. I understand that written proof of income is required. In the event I am able to secure Health/Dental insurance coverage, I shall authorize the release of any medical/dental or other information necessary in order for Healthcare Network to process any insurance claims as a result of treatment. I will authorize payment of medical/dental benefits to Healthcare Network, for any services provided while a patient at Healthcare Network. I am currently covered by Health/Dental Insurance. I understand that if I am no longer covered by Health/Dental Insurance I may be considered for sliding fee scale. I authorize Healthcare Network to verify my income with my employer. I understand that written proof of income is required. I authorize the release of any medical/dental or other information necessary in order for Healthcare Network to process any insurance claims as a result of treatment. I authorize payment of medical/dental benefits to Healthcare Network for any services provided while a patient at Healthcare Network. I am currently covered by Medicaid. I understand that if I am no longer considered Medicaid eligible I may apply for sliding fee scale if I have no other Health/Dental Insurance. I authorize Healthcare Network to verify my income with my employer. I understand that written proof of income is required. I authorize the release of any medical/dental or other information necessary in order for Healthcare Network to process any insurance claims as a result of treatment. I authorize payment of medical/dental benefits to Healthcare Network for any services provided while a patient at Healthcare Network. I am currently on Medicare. If I currently do not have secondary coverage to Medicare I wish to be considered for sliding fee scale as a secondary. I authorize Healthcare Network to verify my income with my employer. I understand that written proof of income is required. I authorize the release of any medical/dental or other information necessary in order for Healthcare Network to process any insurance claims as a result of treatment. I authorize payment of medical/dental benefits to Healthcare Network for any services provided while a patient at Healthcare Network. I do not wish to be considered for the sliding fee scale. In the event I am able to secure Health/Dental insurance coverage, I shall authorize the release of any medical/dental or other information necessary in order for Healthcare Network to process any insurance claims as a result of treatment. I will authorize payment of medical/dental benefits to Healthcare Network for any services provided while a patient at Healthcare Network. I,, the guarantor, agree to be personally and fully responsible for the payment of any and all medical services, not covered by a federal, state or commercial benefit program, that are provided by Healthcare Network. I understand that I am personally and fully responsible for the payment of all applicable co-payments and deductible or, if applicable, the payment of the appropriate sliding fee. I understand that all applicable payments are due at the time of services. I understand that in the event that I am unable to pay at the time of service or in the event of an outstanding balance, I will be required to speak to a financial counselor prior to services being rendered. I further understand that in order to remain a patient(s) in good standing, I may be required to sign a payment agreement. Interpreted into: By: Signature of Patient/ Guarantor Date Signature of Witness Date PATIENT FINANCIAL RESPONSIBILITY AGREEMENT HEALTHCARE NETWORK FORM #1177 6/12