Registration and Consent

New Patient Registration
Patient Name *

First Name Last Name
Gender *
Date of Birth *

Month Day Year
Phone Number *

Area Code Phone Number
Phone Type *

Mobile Home
Preferred Method of Contact *

SMS TEXT E-Mail Phone
Address *

Street Address

Street Address Line 2

City State

Zip Code
Email
example@example.com
Emergency Contact Name

First Name Last Name
Emergency Contact Phone

Area Code Phone Number
Emergency Contact Relationship
How do you pay for healthcare costs? *

Health Insurance A Healthshare program Self payment
Name of Primary Policy Holder *

First Name Last Name
Primary Policy Holder's DOB *

Month Day Year
Date
Social security number required (if you don't have traditional insurance): *
Please Upload Photo ID *

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Driver's license preferred Cancel of
Please Upload FRONT of Insurance Cards

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Cancel of
Please Upload BACK of Insurance Cards

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Cancel of

Consent for Treatment

This consent is required by the Health Insurance Portability and Accountability Act of 1996 to inform you of your rights for privacy with respect to your health care information.
Consent Related to Privacy Notice:
I have had a chance to review the Practice Privacy Notice as part of this registration process. I understand that the terms of the Privacy Notice may change and I may obtain these revised notices by contacting the practice by phone or in writing. I have had a chance to review the Health Information Exchange Notice and understand that Maready Medical participates in the statewide Health Information Exchange program. I understand that I have the right to request how my protected health information (PHI) has been disclosed and have the right to restrict how this information is disclosed. My request must be submitted in writing to the practice, but the practice is not required to agree to my restrictions. If it does agree to my restrictions on PHI use, it will be bound by that agreement. A copy, electronic copy, image or facsimile of this authorization is as valid as the original.

Consent for Care:
I, with my signature, authorize Maready Medical, and any employee working under the direction of the clinicians, to provide medical care for me, or to this patient for which I am the legal guardian. This medical care may include services and supplies related to my health (or the identified person) and may include, but not limited to, preventive, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body and the sale or dispensing of drugs, devices, equipment or other items required and in accordance with a prescription. This consent includes contact and discussion with other health care professionals for care and treatment, though state and federal laws may restrict redisclosure of HIV/AIDS information, mental health information, drug/alcohol conditions, or genetic information.

Consent for Release of Information and Assignment of Benefits:
I also authorize this practice to furnish information to the identified insurance carrier(s) for any and all payment activities. I consent to assign all payments for services directly to this practice. I further consent to the use for any practice operational needs as identified in the Practice Privacy Notice.
Select this if you want to authorize others to receive Protected Health Information (PHI) on your behalf
I give authorization to Maready Medical to disclose my Protected Health Information (PHI) to the following individuals, all of whom are involved in my care for any purpose related to my treatment or the payment of my care:
Names of individuals authorized to receive PHI
Information not authorized to share with these individuals:
Specify if there is any information that you always want kept confidential
Select this if a Guardian or Power of Attorney will be signing and will be responsible for healthcare decisions
Name of Guardian or Power of Attorney

First Name Last Name
Relationship to patient
Your signature below confirms that you have read and understand the Consent for Treatment Policy as stated above.
Signature *

Signature (Patient or Responsible Party) Clear

Financial Policy
We will adhere to these policies and would like assurance that you are in agreement before establishing care with us.
- You, the patient, are responsible for all co-payments, amounts applied to deductibles, and other amounts that may be deemed your responsibility by the payment sources, as required by your contract with your insurance plan and state regulations.
- If you have an insurance co-payment, you are expected to make payment for that at the time of that service.
- Your insurance entity may or may not cover some services. All insurance policies are not the same. Maready Medical is not responsible or able to know every policy available. You accept responsibility to verify applicable coverage prior to receiving the services. If you seek care outside of your insurance contract terms, you will be responsible for all charges that are incurred.
  Services may be requested and provided outside of the typical office visit. This may happen through telemedicine, a phone call, electronic messaging, provider review of medical records, provider consultation with other providers or healthcare facilities, or other methods. Care in these settings may be initiated by you, the patient, but may also be initiated by Maready Medical as deemed medically necessary. Bills may be submitted for these services within guidelines of existing billing rules. You agree to accept responsibility for these charges.
- A $25.00 fee may be applied for appointment cancellations if the office is not notified at least one business day prior to the scheduled appointment time.
- Unpaid balances due will be sent to collections. If this happens, you agree to pay any fees associated with this.
We want you to understand how billing for preventive visits work. We feel this is a very valuable resource, as these services are often available to you with no co payment or effect on your deductible.
- With commercial insurance, the preventive visit includes a review of medical history, ongoing medical condition management, physical examination, and preventive counseling. If you have a new symptom that needs to be evaluated or an ongoing medical problem that needs a significant change, we can provide this additional service, but we may apply a separate charge. In this case, you will receive a bill for the preventive service and a separate bill for the additional service.
- Annual Wellness Visits (AWV--a Medicare benefit): This service is completely covered by Medicare, without a co-pay or deductible and includes review of your medical history and counseling on appropriate preventive measures. Medicare specifically excludes coverage for a physical exam or management of any medical conditions. To adapt to this, we provide the AWV in conjunction with the medical management service, unless there are no active medical conditions to discuss. A co-pay and deductible may apply.
For any of our services, you agree to be responsible for any charges not covered by your insurance.

Thank you for your understanding and cooperation with this policy. We consider it a privilege to provide your medical care.
Your signature below indicates that you have read and understand this Financial Policy and agree to accept full responsibility as described.
Signature *

Signature (Patient or Responsible Party) Clear
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New Patient Registration

Consent for Treatment

Financial Policy