|
Thank you for choosing Mid Coast Medical Clinic for your next medical visit. By completing this pre-registration form, you can receive peace of mind that we have your medical information for your upcoming services. Pre-Registration not available for weekend appointments. |
Complete the following information as accurately as possible. This form should take 4 or 5 minutes to complete. To submit your information simply click the "Submit Form" button to complete your pre-registration process. (*) Required information is necessary. Pre-registration not available for weekend appointments. |
* |
LOCATION Please select clinic location. |
|
|
PATIENT INFORMATION |
* |
Patient's Name First Name, Middle Initial, Last Name (Required) |
|
* |
Patient’s Street Address (Required) |
|
* |
City (Required) |
|
* |
State (Required) |
|
* |
Zip Code 5 Digit Zip Code (Required) |
|
* |
Home Phone Number Area Code and 7 Digit Number (Required) |
|
* |
Alternate/Cell Phone Number Area Code and 7 Digit Number |
|
|
E-mail Address |
|
* |
Date of Birth (Required) |
|
* |
Race (Required) |
African American Caucasian Asian Hispanic Other |
* |
Age |
|
* |
Sex (Required) |
Male Female |
* |
Last 4 Digits of Social Security Number Last 4 Digits of Social Security Number |
|
* |
Driver’s License Number |
|
* |
Marital Status (Required) |
Single Married Divorced Other |
|
Patient’s Employer If you are employed please list your employer's business name. |
|
|
Occupation |
|
|
Work Telephone Number Area Code Plus 7 Digit Number |
|
|
Employer's Street Address |
|
|
City |
|
|
State |
|
|
Zip Code 5 Digit Zip Code |
|
|
Spouse’s Name |
|
|
Date of Birth |
|
|
Last 4 Digits of Social Security Number Last 4 Digits of Social Security Number |
|
|
Driver’s License Number |
|
|
Work Telephone Number Area Code and 7 Digit Number |
|
|
Spouse’s Employer |
|
|
Employer’s Address |
|
|
City |
|
|
State |
|
|
Zip Code 5 Digit Zip Code |
|
|
INSURANCE INFORMATION - Please present your insurance card to the front desk |
|
Primary Insurance Company |
|
|
Policyholder |
|
|
Certificate Number |
|
|
Group Number |
|
|
Secondary Insurance Company |
|
|
Policyholder |
|
|
Certificate Number |
|
|
Group Number |
|
|
EMERGENCY CONTACT INFORMATION |
|
Nearest Local Relative Not Living With You |
|
|
Street Address |
|
|
City |
|
|
State |
|
|
Zip Code 5 Digit Zip Code |
|
|
Telephone Number Area Code and 7 Digit Number |
|
|
IF A PATIENT IS A MINOR OR A STUDENT |
|
Father’s Name |
|
|
Street Address |
|
|
City |
|
|
State |
|
|
Zip Code 5 Digit Zip Code |
|
|
Home Telephone Number Area Code and 7 Digit Number |
|
|
Father’s Employer |
|
|
Work Telephone Area Code and 7 Digit Number |
|
|
Last 4 Digits of Social Security Number Last 4 Digits of Social Security Number |
|
|
Driver’s License Number |
|
|
Date of Birth |
|
|
Mother’s Name |
|
|
Street Address |
|
|
City |
|
|
State |
|
|
Zip Code 5 Digit Zip Code |
|
|
Home Telephone Number Area Code and 7 Digit Number |
|
|
Mother’s Employer |
|
|
Work Telephone Area Code and 7 Digit Number |
|
|
Last 4 Digits of Social Security Number Last 4 Digits of Social Security Number |
|
|
Driver’s License Number |
|
|
Date of Birth |
|
|
I hereby authorize Mid Coast Medical Clinic Physicians, Physician Assistants and/or staff to discuss my protected health information with: |
|
Name |
|
|
Relationship |
|
|
Telephone Number Area Code and 7 Digit Number |
|
|
AUTHORIZATION FOR TREATMENT AND/OR SURGERY The patient and others whose signatures are attached below do hereby consent to any and all medical surgical treatments, including
anesthetics and operations, which may be deemed advisable by his or her physicians or physician assistant/nurse practitioner serving on the
staff of Mid Coast Medical Clinic, the intention hereof being to grant authority to administer and to perform all and singular any
examinations, treatments, anesthetics, operations and diagnostic procedures which may now or during the course of the patient’s care be
deemed advisable or necessary. |
|
ASSIGNMENT OF BENEFITS I/We hereby transfer, assign and convey all my/our rights, title and interest in and all benefits due me/us, if any, by reason of services
described in the statements rendered, and as provided for in any contract or policy of insurance under which I/we may be an insured or
beneficiary and I direct said insurance company(s) and Medicare to pay directly to Mid Coast Medical Clinic, all of such benefits. I/we also
assign my/our causes of action against any and all third parties who may be responsible or liable for the injuries requiring admission to or
treatment by Mid Coast Medical Clinic, up to but not to exceed the amount of charges described in the statements rendered. I agree to pay
Mid Coast Medical Clinic any remaining balance after insurance payment or denial of coverage under this assignment of benefits. I also
authorize the release of any information required in the processing of my healthcare claims. |
|
AUTHORIZATION/PRECERTIFICATION If my group or private insurance policy requires prior certification, authorization, second opinions, or any other type of utilization review
function, I understand that I am responsible for compliance with these and all other terms of my policy. |
|
PATIENT FINANCIAL RESPONSIBILITY Mid Coast Medical Clinic’s election to pursue one or more forms of collection shall not constitute a waiver of its right to pursue other
collection measures it deems advisable or necessary. All such remedies shall be cumulative in nature. Venue for collection shall be Wharton
County, Texas This agreement shall not require payment by any person in contravention of any state or federal statute, rule or regulation. |
|
ADVANCE DIRECTIVE ACKNOWLEDGMENT |
* |
Do you have a living will? |
|
* |
Would you like information on a living will? |
|
|
CONSENT TO TESTING AFTER BLOOD OR BODY FLUID EXCHANGE I understand, agree, and authorize that in the event a health care worker is exposed to my blood or body fluids, my blood will be tested at no
cost to me.
The undersigned certifies that he/she has read this entire document and is the patient, or is duly authorized by the patient or by the law to
execute the above agreement and accepts and understands its terms. |
|
MID-LEVEL PRACTITIONER ACKNOWLEDGEMENT I acknowledge that it is the policy of Mid Coast Medical Clinic to delegate healthcare tasks or general medical services to a qualified
physician assistant or nurse practitioner. This allows for more effective utilization of the skills of the physicians. Delegation of such duties is
consistent with due regard for the health and safety of our patients and in keeping with sound medical practice.
I fully understand that the physician assistant or nurse practitioner is NOT A PHYSICIAN, and that I have the right to insist at any time on
seeing any licensed physician providing services at this clinic.
I further acknowledge that the general medical services provided my by a physician assistant or nurse practitioner are the responsibility of the
physicians providing services at this clinic both professionally and legally, for the acts of such allied health personnel rendered during the
care and treatment of his/her patients.
I have read the above in its entirety and fully understand the Mid Coast Medical Clinic’s policy regarding physician assistants and/or nurse
practitioners and do hereby consent to receiving general medical services from a physician assistant or nurse practitioner as may be assigned. |
|
Signature of Patient or Legally Authorized Representative |
|
|
Today's Date |
|
|