NEW PATIENT REGISTRATION UNIVERSITY FAMILY HEALTHCARE, PA

PLEASE FILL THIS (2) PAGE FORM OUT COMPLETELY AND SIGN WHERE INDICATED PRIOR TO APPOINTMENT:

PATIENT

NAME: / / __Male __Female

LAST TITLE, FIRST MIDDLE NAME DATE OF BIRTH

SSN: - - ___ _ __Married __Single __Widowed __Divorced

DRIVERS LICENSE NUMBER STATE OF ISSUE

STREET ADDRESS:

CITY: STATE: ZIP CODE:

HOME PHONE: WORK PHONE: CELL#

OTHER PHONE: EMAIL ADDRESS:

MAILING ADDRESS or OUT OF STATE ADDRESS: (IF DIFFERENT FROM ABOVE)

STREET _________________________________________________________________________

CITY: STATE: ZIP CODE:

EMPLOYER: PHONE:

CITY: STATE: ZIP _________________

IN CASE OF EMERGENCY NOTIFY: ____

RELATIONSHIP: PHONE:

CREDIT REFERENCES:

Please Circle:

BANK NAME: ________________________________________ CREDIT CARD: VISA MC OTHER: _____

PRIMARY INSURANCE COMPANY: ___________________________ INSURANCE ID NUMBER: ___________________________

Please Circle:

PPO HMO OTHER: ________________________ GROUP NUMBER: ___________________________________

IF THE PATIENT IS A MINOR or DEPENDANT we MUST have the FOLLOWING:

NAME OF PERSON Social Date of

ON INSURANCE CARD: Security #: _ Birth: ___

Minor or Dependant’s

Relationship to PERSON ON CARD: ______________________ Sex of Person on Card: M F Sex of Minor or Dependant: M F

PREVIOUS PHYSICIAN: __________________________________________ PHONE: _____________________

ARE YOU TRANSFERRING TO US? Y N

Is this a WORKER’S COMPENSATION INJURY? Y N DATE /TIME of INJURY: ______________/_______________

NAME OF W/C GUARANTOR: ______________________________________________________

I CERTIFY THAT THE ABOVE INFORMATION IS TRUE TO MY KNOWLEDGE:

ALL PATIENTS or GUARDIANS

MUST SIGN HERE: DATE: ____________________

MEDICARE PATIENTS

MEDICARE NUMBER: __________________________

MEDICARE DISCLAIMER

I FULLY UNDERSTAND AND AGREE that if MEDICARE SHOULD DENY PAYMENT for ANY NON-APPROVED SERVICE RENDERED, that I WILL BE FINANCIALLY RESPONSIBLE for ANY REMAINING BALANCE except for that portion that is designated to be “assignment” by Medicare.

ONLY MEDICARE PATIENT’S SIGNATURE__________________________________________________

I HEREBY AUTHORIZE MY INSURANCE BENEFITS TO BE PAID DIRECTLY TO:

UNIVERSITY FAMILY HEALTHCARE, P.A.

for any and all claims submitted to a third party due to the practice of medicine by Dr. LOREN CARLSON

(My Physician) and/ or his employees AND I ALSO REALIZE THAT I WILL BE FINANCIALLY RESPONSIBLE

TO PAY IN FULL FOR ANY CHARGES NOT COVERED BY MY INSURANCE PLAN.

I HEREBY AUTHORIZE THE AUTOMATIC RELEASE OF MEDICAL INFORMATION TO:

MY INSURANCE COMPANY, MY PHYSICIAN, AND ANY PHYSICIAN TO WHOM I MAY BE REFERRED by Dr. Carlson and/or his designated employees.

SIGNATURE:

ALL PATIENTS or GUARDIANS MUST SIGN HERE

APPOINTMENT POLICY

This office operates BY APPOINTMENTS ONLY. Effective January 2, 2003, any person who fails to keep an appointment, whether set by this office or at a patient’s request, may be charged a $50.00 MISSED APPOINTMENT FEE. If you are unable to keep your appointment, YOU MUST NOTIFY THIS OFFICE PRIOR TO YOUR SCHEDULED APPOINTMENT and the $50.00 fee will be waived. We will gladly set a new appointment at that time if you still desire one. If we are notified in advance, another patient could be scheduled during the appointment that is missed. Please be courteous.

ACKNOWLEDGEMENT AND CONSENT TO TREAT:

I consent to any or all treatment as deemed necessary or desirable for the care of myself, the patient, or my minor child or dependant, named above, including but not restricted to whatever drugs, performance of surgical procedures, laboratory testing, X-rays or other studies or procedures may be used or recommended by Dr. Loren Carlson, and/or his Nurse Practitioner, Physician’s Assistant, qualified medical assistant, or other designate. (If the patient is a minor or a dependant, Guardian must sign below)

ALL PATIENTS

or GUARDIANS

MUST sign here: DATE: ____________________

Circle relationship to PATIENT: SELF GUARDIAN