Red Hook Family Practice Registration Form

Patient Information
Name*

First NameLast Name
Preferred:

Mr.Ms.MissDr.
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleOther
Social Security Number:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:*
Language preference*
Home Phone:
Cell:
Work:
Extension:
Emergency Contact 1:*
Phone Number:*
Relationship to Patient:*
Emergency Contact 2:
Phone Number:
Relation to Patient:
Please upload a valid photo ID*

If patient is a minor please upload the Parent or Guardians photo ID.
Cancelof

Financial Account
Relationship to Responsible Party:*

SelfSpouseChildOther
Name of Responsible Party:*
Responsible Party DOB:*

MonthDayYear
Date
Responsible Party Phone Number:*
Please enter a valid phone number.
Responsible Party Email:*
example@example.com
Account Type*

InsuranceSelf PayThird Party

CONSENT FOR TREATMENT
I hereby consent to the performance of medical treatment and/or diagnostic procedures as deemed necessary oradvisable by my physician(s) at Red Hook Family Practice PC. I also understand I have the right to be informed about all treatments given to me and the right to decline any specific treatment should I choose. I hereby consent to the performance of all nursing and technical procedures and tests as directed by my physician's. Further, I understand that should any medical personnel, physician, or otherperson(s) be exposed, or report an exposure to, my blood or body fluids, my blood will be tested for blood borneinfections including Hepatitis Band C as well as HIV/AIDS. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me as a result of treatments or examination at Red Hook Family Practice PC.
PATIENT HIPAA AWARENESS
With my permission, Red Hook Family Practice PC, which consists of Red Hook Family Practice, Yacht Haven Family Practice, and Cruz Bay Family Practice, may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to Red Hook Family Practice PC Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have reviewed the Notice of Privacy Practices prior to signing this consent. Red Hook Family Practice PC reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the Privacy Officer.

With my permission, Red Hook Family Practice PC may call my home or other designated location that was provided on the registration form and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others. If any contact information changes, it is my responsibility to complete a new registration form.

With my permission, the office of Red Hook Family Practice PC may mail to my home or other designated location that was provided on the registration form any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and or Confidential.

With my permission, the office of Red Hook Family Practice PC may e-mail to my email address that was provided during registration any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request in writing that Red Hook Family Practice PC restrict how it uses or discloses my PHI to carry out TPO.

By signing this, I am allowing Red Hook Family Practice PC to use and disclosure my PHI for TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If any change in demographics or insurance information is made, it is my responsibility to inform Red Hook Family Practice PC and complete a new registration form.
Insurance Policy
We submit claims to only Insurance Companies that are part of the VI Equicare Network. As a service to you, our office has agreed to bill your insurance company for the payment of your office visits. The patient is responsible for all copayment and deductibles specified by the insurance company at the time of the visit. Insurance companies do not always cover –immunizations, laboratory testing, surgical supplies, and trays. We may request payment for additional services to be paid when services are rendered. Most insurance companies DO NOT COVER the charge for the Sterile Instrument tray. If one is required for your procedure, the charge is $60 and is due upon services being rendered. Our physicians find it medically necessary to use these Sterile Instrument Trays to reduce the chance of infection.

Non-Participating Insurance: If Your Insurance Company is not in the VI Equicare Network, payment is due in full at the time of service, and we will gladly supply you with a claim form so that you may submit directly to your Insurance Company for reimbursement.

I consent to electronic visits by audio, audio-visual, and/or portal messaging.

It is my responsibility to provide RHFMG with a current, valid insurance card at each visit.
By signing below, I agree that the information I have provided is true and accurate to the best of my knowledge.

By signing below, I understand and agree to the stated policies above.
Signature of patient or person acting on behalf of patient*

Clear
Date*

MonthDayYear
Date

Should be Empty:

Patient Information

Financial Account

Insurance Information

CONSENT FOR TREATMENT

PATIENT HIPAA AWARENESS

Insurance Policy