Gibson OP

PATIENT REGISTRATION
DATE

MonthDayYear
Date
LAST NAME*
LAST NAME*
LAST NAME*
FIRST*
FIRST*
FIRST*
M
Address*

Street Address

Street Address Line 2

CityState

Zip Code
SSN
DOB*

MonthDayYear
Date
DOB*

MonthDayYear
Date
PRIMARY PHONE NUMBER*
PHONE TYPE*
IS INJURY RELATED TO:*

WORKAUTOOTHER
IS PATIENT RECEIVING SERVICES FROM A HOME HEALTH AGENCY OR SKILLED NURSING FACILITY?*

YESNO
HAVE YOU HAD ANY THERAPY SERVICES IN THE LAST 12 MONTHS?*

YESNO
EMERGENCY CONTACT NAME*
RELATIONSHIP*
PHONE NUMBER*
IS SOMEBODY OTHER THAN THE PATIENT FILLING OUT THIS FORM

YESNO
NAME OF PERSON COMPLETING PAPER WORK:*

RESPONSIBLE PARTY ( IF OTHER THAN PATIENT)
NAME ( PARENT/ GUARDIAN/ OTHER, WHO BROUGHT MINOR FOR THERAPY)*

First NameLast Name
RELATIONSHIP TO PATIENT*
RELATIONSHIP TO PATIENT*
SSN
DOB*

MonthDayYear
Date
PRIMARY PHONE NUMBER*
PHONE TYPE*
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Are you a self pay patient?*

YesNo

MEDICAL INSURANCE INFORMATION
IS THE PATIENT THE SUBSCRIBER?

YESNO
POLICY HOLDER NAME*
SUBSCRIBER DOB*

MonthDayYear
Date
SUBSCRIBER/POLICYHOLDER ADDRESS IF OTHER THAN PATIENT
DO YOU HAVE MEDICARE?*

YESNO
INSURANCE NAME*
MEMBER ID/POLICY #*
GROUP #
EFFECTIVE DATE*

MonthDayYear
Date

AUTO INSURACE INFORMATION
INSURANCE NAME*
DATE OF ACCIDENT*

MonthDayYear
Date
POLICY #*
CLAIM #
ADJUSTOR/AGENT*
AGENT PHONE #*
ACCEDENT OCCURRED IN WHICH STATE?*
CHECK ALL THAT APPLY

PASSENGERDRIVEROTHER

WORK RELATED INJURY
EMPLOYER NAME*
EMPLOYER ADDRESS*
CASE MANAGER NAME*
CASE MANAGER PHONE #*
EMPLOYER LIABILITY CARRIER*
LIABILITY CARRIER ADDRESS
DATE OF INJURY*

MonthDayYear
Date
NUMBER OF VISITS APPROVED

	Yes
Cancer
Broken Bones/fractures
Heart Disease
High Blood Pressure
Head Injury
Blood Disorder
Stroke
Lung Problems
Allergies
Circulation Problems
Seizure Disorder or Epilepsy
Thyroid Problems
Osteoporosis
Repeated Infections
Diabetes/High Blood Sugar
Arthritis
Ulcers/Stomach Problems
Developmental/Growth Problems
Infectious Disease (ie. Hepatitis)
Headaches Frequent/Severe
Vision Difficulties
Numbness or Tingling
Dizziness
Weakness
Depression
Hearing Problems
Kidney Problems
Multiple Sclerosis
Muscular Dystrophy
Parkinson Disease
Bowel/Bladder Dysfunction
Skin Disease
Low Blood Sugar/Hypoglycemia
Chemical/Substance Dependency

FINANCIAL RESPONSIBILITY
FINANCIAL RESPONSIBILITY
Thank you for choosing Deaconess. Our goal is to provide you with quality medical services. Your clear understanding of our financial policy is important to our professional relationship. Please understand that payment of your bill is vital to our ability to continue to provide medical care within the community. We accept Cash, Check, Visa, MasterCard and Discover.

ALL ACCOUNTS

In consideration of a Deaconess Health System, Inc. affiliate, including but not limited to Deaconess Hospital, Inc., Deaconess Clinic, Inc., Methodist Health, Inc. d/b/a Deaconess Henderson Hospital and d/b/a Deaconess Union County Hospital, and Gibson General Hospital, Inc. d/b/a Deaconess Gibson Hospital (collectively “Deaconess”), rendering services for the above named patient, I/we, the undersigned, and each of us, agree to be jointly and severally responsible for payment for these services and any other account that the patient had at any time in the past, at the present, or may have in the future with Deaconess. I/we agree that the charges for which I/we are responsible will be calculated according to Deaconess’s Chargemaster and I/we agree to pay those Chargemaster rates. All accounts are due and payable at the time of the patient’s discharge. Any credit will be applied to outstanding balances prior to being refunded. Please contact the Deaconess Financial Counseling Services at 812-450-6815 if you need assistance. Past due patient accounts that do not have agreed upon financial arrangements with Deaconess will be submitted to a collection agency or attorney for collection. I/we agree that I/we will pay all attorney fees and court costs incurred by Deaconess in the collection of all sums due Deaconess.

COMMUNICATIONS

If I/we provide Deaconess or its agents with our cell phone number, I/we authorize Deaconess or it agents to contact us at that cell phone number by calling or text messages, which could result in charges to me. I/we authorize Deaconess to contact us on our cell phone number by using pre-recorded artificial voice messages and/or use of an automatic dialing device. I/we understand that any e-mail address I/we provide is our personal e-mail address and I/we authorize Deaconess or its agents to contact us via that e-mail address.

WORKER’S COMP / LIABILITY / AUTO ACCIDENT

If the reason for your visit is related to a workers comp claim, liability claim, or auto accident, you are responsible for providing Deaconess with complete billing information, including police report, claim number, etc. as appropriate, within seven (7) business days. You should be aware that if you do not provide this information or these claims are denied, the balances then become the patient’s responsibility.

INSURANCE

If the patient has active insurance coverage, we will bill the patient’s insurance company. It is the patient’s responsibility to understand his/her insurance coverage. Payment of deductibles, non-covered services and co-payments are your responsibility.

ASSIGNMENT OF INSURANCE BENEFITS

I/we assign insurance payments to be made directly to Deaconess for services rendered. I/we have read, understand and agree to the terms listed above.

NOTICE OF NONDISCRIMINATION

I have received a Notice of Nondiscrimination.
Date

MonthDayYear
Date
PRINTED NAME*
SIGNATURE OF PATIENT/GUARDIAN*

Clear

CANCELLATION / NO-SHOW POLICY
We strive to provide not simply good, but absolutely the best care to our clients. We schedule our clients according to care plans that optimize their wellness outcomes. Making your appointment as scheduled is very important, not just for us, but for you. We are convinced that if you make your wellness a life priority, you will achieve not only a higher level of function, but a greater degree of happiness.

We have the most highly trained and experienced clinicians in the region. You are working with the best. Their services and time are in high demand, with waiting lists for many of their services. As you know, we attempt to schedule all new clients within 24-48 hours of their initial request for service. Thus, appointment time is a valuable commodity for both you and us.

If negative circumstances require you to cancel a scheduled appointment, we request that you do so at least 48 hours in advance. If you must cancel within 24 hours of your appointment or fail to show up for your appointment, a $20 fee will be applied to your account, which will be patient responsibility and is not billable to insurance. This facility also reserves the right to cease rescheduling new appointments due to habitual no shows or cancellations and reserves the right to discharge any patient who fails to give proper notice three consecutive times.
While we are not fond of the negative connotation of any cancellation policy, we believe such a policy is in the best interest of accommodating all of our clients who are dedicated to improving their wellbeing. When an appointment is made, it takes an available slot away from another client. No-shows and late-cancellations prohibit us from offering that slot to another client. We understand that situations such as medical emergencies occasionally arise when an appointment cannot be kept and adequate notice is not possible. These situations will be considered on a case by case basis. Thank you for your consideration.

I acknowledge that I have read and understand the Cancellation / No-Show Policy.
Date

MonthDayYear
Date
PRINTED NAME*
SIGNATURE OF PATIENT/GUARDIAN*

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PAYMENT AT TIME OF SERVICE
As a standard practice, Deaconess Gibson Hospital collects all expenses that are the responsibility of the patient at the time of service. This request for payment will include any deductible, co-pay and coinsurance amounts that
apply to my visit. I understand that as a courtesy Deaconess Gibson Hospital will bill my insurance directly for the services I receive, but this is not a guarantee that my insurance will pay for services rendered or materials received.
It is my responsibility to know my insurance benefits and coverage.

In some cases, the amount of charges is an estimate based upon information provided directly by my insurance company regarding my particular plan and eligibility and the procedures performed. However, the exact amount of
all charges may not be known at the time of service as my insurance may process differently than anticipated. It is possible that additional expenses that are my responsibility may be reflected on my final statement. In such a case,
the payment collected at the time of service serves as a deposit towards my final balance. Additionally, any overpayment will be promptly refunded to me after all claims have been processed by all applicable payers.

In the event that there is a past due balance on my account, it will be submitted to a collection agency, and I agree to pay all attorneys’ fees and court costs incurred by Deaconess Gibson Hospital in the collection of my account.

I understand that if I anticipate problems paying my portion of my bill, I should let the front office know as soon as possible, so that payment alternatives may be discussed, should I qualify.

I authorize Deaconess Gibson Hospital or its agents to contact me via manual or auto-dial telephone call in order to collect any amounts I may owe, including calls to my cell phone number, if I have provided that number. I also agree that any email address I have provided is my personal email address and I authorize Deaconess Gibson Hospital or its agents to contact me via that email address.

I acknowledge that I have read, understand, and agree to all of the terms above.
Signature

Clear
Printed Name
Date

MonthDayYear
Date

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
Click here for the Notice of Privacy and Practices
I have received a Notice of Privacy Practices from Deacones Gibson Hospital.
Date

MonthDayYear
Date
Signature*

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Should be Empty:

PATIENT REGISTRATION

RESPONSIBLE PARTY ( IF OTHER THAN PATIENT)

MEDICAL INSURANCE INFORMATION

AUTO INSURACE INFORMATION

WORK RELATED INJURY

MEDICAL HISTORY QUESTIONNAIRE (PLEASE PRINT)

OTHER CLINICAL TESTS OR IMAGING

CONSENT FOR TREATMENT

AUTHORIZATION FOR DISCLOSURE

APPOINTMENT REMINDER CONSENT

FINANCIAL RESPONSIBILITY

FINANCIAL RESPONSIBILITY

CANCELLATION / NO-SHOW POLICY

PAYMENT AT TIME OF SERVICE

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT