Registration Form

Please fill out the Patient Registration Form

If you would like to download, print and fill it out, please click the button and the PDF version will open in a new tab. Otherwise, fill out the online registration form below.

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Online Patient Registration Form

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Patient Information

Patient's Full Legal Name

First MI Last

Birth Date

MM slash DD slash YYYY

SSN#

Gender

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Mobile Phone

May we leave a message regarding your care?

Yes

Marital Status

Occupation

Work Phone

Emergency Contact Name

First Last

Emergency Contact Phone

Emergency Contact Relationship to patient

HIPAA

Yes

HIPAA is a Document that allows an, appointed person or Party to share specific Health Information with another person.

Primary Care Physician Name

First Last

Reason For Today's Visit

How did you hear about us?

Existing Patient/Friend

Internet

Phonebook

Relative

Road Signs

Billboard on Hwy 484

Billboard on I-75

Drive By

llnsurance

Pharmacy

Dr. Referral-

Hotel

RV Park

Summer Glen

Absolute Health

Medical History Information

Please list any MEDICATION that you are currently taking with Dosage and Frequency

Medication

Dose/Strength

Times a Day

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Do you have any known ALLERGIES TO MEDICATION? If yes, please liet them below

Medication

Rash? or Other

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Preferred Pharmacy

Do you have any of the following conditions

Diabetes

HighBlood Pressure

High Cholesterol

Other

If yes, Please list other medical conditions

Are you currently a Smoker?

Yes

If yes, for how many years?

How much per day?

Do you drink Alcohol?

Yes

Frequency?

Please list any past surgeries and year

Surgery

Year

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Family History

Does Anyone in your Immediate Family

Mother

High Blood Pressure

Diabetes

High Cholesterol

Father

High Blood Pressure

Diabetes

High Cholesterol

Siblings

High Blood Pressure

Diabetes

High Cholesterol

Authorization and Release for All Treatment at this Facility

Authorization For Treatment: I voluntarily consent to the administration and cost of medical and surgical procedures, x-ray, and medication for myself and my dependents.

Assignment of Insurance Benefits: Iauthorize payment directly to Absolute Quick Care for all benefits and the release of medical information for all services and payments otherwise payable to me.

Guarantee of Payment: Iunderstand that Ia m financially responsible and agree to pay all of the charges that are not paid or billed to insurance or any other third-party payer. Iunderstand that Imust pay in full today for all services rendered unless my insurance is accepted. Ialso understand that if my insurance is accepted, I must pay all applicable insurance copays, coinsurances, and deductibles today. fI you are unable to verify my insurance at time of service, Iwill pay in full for all services.

Release of Records: | authorize Absolute Quick Care to release (verbal or in writing) confidential medical information to any person or entity including my insurance carrier, employer if treatment is related to employment purposes, or other healthcare operations, which may be liable to me or practitioners) for charges for this treatment and for quality management, utilization review, transter, and follow-up purposes.

Receipt of Privacy Practices: Iacknowledge that Ihave received and read the Absolute Quick Care Notice of Privacy Practices.

I understand that a copy of this agreement may be used with the same effectiveness as the original.

Patient Signature

Responsible Party Signature

Date

MM slash DD slash YYYY

Policyholder Information

Note: Please complete this section if the patient is NOT an insurance policy holder or is under 18 years of age.

Guarantor Name

First Last

Relationship

Guarantor Address

Street Address Address Line 2 City State ZIP Code

Guarantor Phone

Guarantor Birth Date

MM slash DD slash YYYY

Guarantor SSN#

Guarantor Employer

Guarantor Gender

Radiology

I understand that if my treatment requires radiology procedures (x-ray), it is my responsibility to inform the medical staff if Ia m pregnant or think Imay b e pregnant.

Iunderstand that if symptoms persist, Ishould seek additional medical care.

Signature

Date

MM slash DD slash YYYY

Absolute Quick Care - Notice Of Privacy Practices

This Notice Describes HowMedical Information About You May Be Used And Disclosed And How You can Get Access To This Information. Please review It Carefully.

This notice of privacy practicesdescribes how Absolute Quick Care (we) may use and disclose your "protected health information" (PHI) to carry out treatment, payment and/or healthcare operations and for other purposes that are permitted or required by law. tI describes your right to access and control your protected health information. Protected health information is information about you, including demographic information that may identify you and that relates to your past, present or future physical or mental health condition and related healthcare services.

We arerequired to maintain the privacy of your health information and toprovideyou witha notice as toour legal duties andprivacy practiceswith respect to information collected and maintained about you. We are required to abide by the terms of the Notice of Privacy Practices. We may c h a n g e the terms of our notice at any time. any new notice will be given to you upon your reguest a n d will be effective for all PHI we maintain at that time.

How We May Use Or disclose Your Protected Health Information

The following categories describe ways we may use or disclose your protected health information. There are explanations of what we mean for each category of uses and disclosures.

*Treatment, payment and healthcare operations Federal law permits Absolute Quick Care to use and disclose your PHI without your authorization or consent for the purposes of treatment, payment and healthcare operations.
*Treatment Wemay disclose PHI to other healthcare providers who are responsible for your medical treatment. For example, we may provide other physicians, upon request, copies of various information to assist him/her in treating you.
*Payment We may use or disclose information about you to determine coverage eligibility for insurance plan benefits, obtain copayment/coinsurance amounts and to facilitate payment for the treatment/services you receive from our healthcare providers.
*Healthcare Operations Healthcare operations refer to business functions undertaken by Absolute Quick Care. operations may include referral/specialist, recommending treatment alternatives and or providing information regarding services that may be of interest to the individual. Information may be disclosed for purposes of medical review, legal services, audit services, and fraudabuse detection programs. We will share your protected health information for purposes of claim administration on behalf of your medical insurance plan.

Other uses and disclosures permitted without authorization. Federal lawa l l o w sAbsolute Quick Care to disclose PHIwithout your authorization or consent in the following ways: *To you or a personal representative designated by you or desianated by law to act for you. *To the secretary of Health and Human Services or any employee of HHS as part of an investigation to determine our compliance with Federal Privacy laws. *To the State Medical Review Board torespond to inquiries/ investigations of our practiceor request audit. *In response to a court order, subpoena, discovery requestsor other lawful judicial or administrative proceeding. *As required for law enforcement purposes. For example, to notify authorities of a criminal act. *As required by law *As required to complywith Worker's compensation a n dor other similar programs established by law.

Right to Request Restrictionson Uses and Disclosures You have the right to request Absolute Quick Care to limit its uses and disclosures of PHI in relation to treatment, payment or healthcareoperations. You also have the right to restrict the disclosure of PHI tofamily members or personal representatives. Any such request must be in writing and must state the specific restriction and to whom it applies.

I WISH TO DISCLOSE MY PROTECTED MEDICAL INFORMATION TO

Name

Relationship

Click the plus sign to add another row / person

Right to Access Your Protected Health information You have the right to copies of your PHI following the procedure of Absolute Quick Care. Federal law prohibits you from having access to psychotherapy notes: information for use in a civil, criminalor administrative action or proceeding. fI your request for access si denied you may file a written complaint to:
US Department of Health and Human Services 200 Independence Ave. Sw Washington, DC 20201

Federal law indicates you read and sign this Notice as notification of your right to an accounting a n ddisclosure rights pertaining to Private Health Information after April 14, 2003.

Patient(Parent/Guardian) Signature

Date

MM slash DD slash YYYY

Comments

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