New Patient Form

Patient Registration Form

First Name:

Middle Name:

Last Name:

Address:

City/State:

Zip:

Phone Number:

Email:

Age:

Birthdate:

social security number:

Sex:

Male Female

Marital status:

Married Single Divorced Widowed

Ethnicity:

Language:

Employer:

Occupation:

Emergency Contact:

Relationship:

Primary Insurance:

Subscriber name/DOB:

Policy number:

Group number:

Pharmacy:

How did you hear about us:

Signature:

Date:

Emergency Information

Name:

Relationship:

Contact Number:

Financial Responsibility and Assignment of Insurance Benefits: I guarantee payment to Cochran Family Medical Center of all charges for services provided to the patient. I understand I am personally responsible for all charges not covered by insurance. I authorize payment of surgical and medical benefits to Cochran Family Medical Center for all services rendered. I certify that the information provided by me in regards to my insurance coverage is correct. I will be prepared to present my correct insurance information at every visit.

Consent for Healthcare and Release of Medical Information: I voluntarily consent to healthcare treatment from the physicians and staff at Cochran Family Medical Center. I am aware that the practice of medicine is not an exact science. No guarantees have been made to me regarding the result of treatments or examinations. I consent to the use and disclosure of protected health information about me for treatment, payment and healthcare operations. I have read this form. I have had the opportunity to ask questions and my questions have been answered.

Acknowledgement of Notice of Privacy Practices: I have been offered and/or received a copy of the Cochran Family Medical Center Notice of Privacy Practices. I am aware that the Notice may be changed at any time. I may obtain a revised or additional copy at anytime by writing the office, downloading from the website or requesting one from a Cochran Family Medical employee.

Acknowledgement of Patient Rights and Responsibilities: I have been offered and/or received a copy of the Cochran Family Medical Center Patient Rights and Responsibilities. I am aware that the document may be changed at any time. I may obtain a revised or additional copy at anytime by writing the office, downloading from the website or requesting one from a Cochran Family Medical employee.

Signature:

Date:

Divorce, Separation, and Custody Agreement

At Cochran Family Medical Center, we understand that issues related to divorce are very difficult for the entire family. However, we will not be party to custodial, separation or financial disputes relating to individuals and/or minor children to whom services are provided. All copays, co-insurance and deductibles will be collected at the time of service.

Both parents have access to the minor child's medical records unless we are provided a copy of a court order that mandates otherwise.

We maintain that divorce, separation and custody agreements should not take precedence over the provision of medical care; such matters should remain between the individuals..

Printed Name:

Signature:

Date:

Financial Obligation

Please initial by each statement and sign and date at the bottom...

I understand that I am ultimately responsible for all charges incurred on my behalf, who is seeking medical care.. Any co-pays, deductibles, or charges which are denied coverage from my commercial insurance company are my responsibility and will be paid.

I hereby authorize the release of any medical information necessary to process insurance claims or any medical information that is required for any health care related utilization review or quality assurance activities.

I hereby assign and authorize payment to Cochran Family Medical Center of all medical/surgical/major medical benefits to which I am entitled under any insurance policy or policies, under any self-insurance program or under any other benefit plan.

I understand and acknowledge that this assignment of benefits does not relieve me of my financial responsibility, including, but not limited to, payment of those fees and charges not directly reimbursed to Cochran Family Medical Center by any insurance policy, self-insurance plan, or other benefit plan.

This authorization shall remain in effect until revoked by me in writing. A photocopy of this authorization shall be considered as effective and valid as the original. I understand that I have the right to receive a copy of this authorization.

Printed Name:

Signature:

Date:

Late/ No Show Policy

The following is our office policy when arriving late and missing appointments. If you have questions, please ask one of our front staff for clarification.

If a NEW patient appointment is missed, the account will be inhibited until someone can explain our no show policy. If two new patient appointments are missed, the patient will not be allowed to come to our practice.

We attempt to confirm appointments, but for various reasons we are not always successful in reaching someone. It is your responsibility to arrive for your appointments on time, even if a call is not made. If you are 10 minutes late for your appointment you may have to be rescheduled to a later time or date.

When two appointments are missed (no-shows), you may receive a letter stating the policy again. A third missed appointment (no-show) is grounds for dismissal from our practice. If you cannot make an appointment, please call.

Printed Name:

Signature:

Date:

Cochran Family Medical Center

Patient Registration Form

Emergency Information

Divorce, Separation, and Custody Agreement

Financial Obligation

Late/ No Show Policy

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