New Patient Registration Packet 10.2021

Jon J Atiga MD Inc 25405 Hancock Ave Ste 108, Murrieta Ca 92562
Patient Name*
Date of Birth*

MonthDayYear
Date
Social Security Number: (if available)
Gender*
Address*

Address

Street Address Line 2

CityState / Province

Zip
Preferred Language*
Do you need language assistance*
Race*
Ethnicity*
Cell Phone*
Home Phone*
Email Address*
example@example.com
Preferred Method of contact*
PRIMARY INSURANCE*
Subscriber Name*
Date of Birth*

MonthDayYear
Date
Subscriber ID*
SECONDARY INSURANCE
Subscriber Name
Date of birth

MonthDayYear
Date
Subscriber ID
PARENT/LEGAL GUARDIAN NAME*
DOB*
Social Security #*
Driver's License #*
Phone Number*
Employer Name*
Employer Phone number*
PARENT/LEGAL GUARDIAN NAME*
DOB*
Social Security #*
Driver's License #*
Phone Number*
Employer Name*
Employer Phone number*
EMERGENCY CONTACT #1: (PARENT/GUARDIAN)
Name*
Phone Number*
EMERGENCY CONTACT #2: (OTHER THAN PARENT/GUARDIAN)
Name*
Phone Number*
Relationship to patient*
We currently participate in CAIR (a California Immunization registry), we are also currently participating in MEDEX (a universal medical record platform To opt out, please inform front office.
PHARMACY NAME*
Phone Number
Address
My initial here is to hereby authorize the practice to obtain my Rx History Consent: (Initials) external Prescription/Medication history through external sources.
Initials*

Clear
The above information is complete and correct. I hear by authorize release of information necessary to file a claim with the insurance company. I assign benefits otherwise payable to me to the practice. I understand that I am financially responsible for charges for medical services rendered regardless of insurance coverage. I also understand that I am responsible for any office visit copayment due at the end of the time of service and/or deductibles that may apply. If this account is assigned to an attorney for collection and/or suit, a copy of the signature is valid as the original. I authorize treatment for my child if I brought in by someone else. In such case that I am unable to bring my child in personally. I herby consent to and authorize the administration of all treatments that may be considered advisable and necessary. I hereby authorize payment directly to the physician of benefits otherwise payable to the physician of benefits otherwise payable by me for this service. Your patient bills/statements will be sent to your web portal. To opt out and receive paper statements, please inform front office.

We will be charging for NO SHOW visits of $25.00. Please call 24 hours in advance of your appointment, feel free to leave a cancelation on the voicemail.
SIGNATURE

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DATE

MonthDayYear
Date
JON J. ATIGA M.D. OFFICE FINANCIAL POLICY

We are committed to providing all our patients with the best possible medical care. If you have medical insurance, we are anxious to help you receive your maximum allowable benefit. In order to achieve these goals, we need your assistance and your understanding of our payment policy.

ALL PATIENTS: The patient is responsible for all services rendered regardless of insurance coverage. The full responsibility of payments rest with YOU.

CASH PATIENTS: All services are rendered on a cash basis and must be paid in full at the time of service. Financing and financial assistance is available.

PRIVATE INSURANCE: We must have a fully completed and signed insurance form at the time of service. If you cannot supply us with all the necessary billing information your account will be handled the same as a cash patient. Deductible and copays are due at the time of service.

PPO: We must have a copy of both sides of your insurance card on file. All co-payments are due at the time of

HMO: ALL HMO patients must be assigned to Jon J. Atiga M.D. under the medical group Vantage or Primecare or Alpha Medical group at the time of the visit. If you are not assigned to Jon J. Atiga at the time of visit you will be responsible for the charges should your insurance deny payment. Co-payment must be made at time of service.

Amounts which are over 60 days past due by an insurance company are immediately due from the patient. Amounts which are over 90 days past due are subject to collection procedures which could include small claims court or a 1- - 12 % service charge per month on the unpaid balance. Account sent to a collection agency will include an additional $10.00 transferring fee.

If at any time you should experience financial hardship, please make this office aware of the situation. We are willing to make special arrangements for those patients who need extra help. If you need to make arrangements, please ask to speak to the office manager,

I have read and understand all of the above.

Print patient name: Print responsible party name:
Print patient name*
Print responsible party name*
Patient or responsible party signature

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What is your relationship to the patient?
Date*

MonthDayYear
Date
Communication Consent Agreement
MURRIETA, CA 92562
Your Name*
This form allows our physicians and office staff permission to speak with your family members or other individuals noted below.

understand that under Federal Law (HIPAA) this medical office may not release any medical information to any individual without my expressed written permission for my child

Law enforcement and court order are two exceptions to this requirement. I, therefore, give permission to Jon J. Atiga M.D. Inc., and staff to release medical information on my behalf to the following individuals. I understand that Dr. Atiga and staff can refuse to discuss private health information if believed that it is in the best interest of the patient. I understand that I will be required to fill out a complete medical release form for copies of records.
Name*
Relationship*
Phone Number
Date of Birth

MonthDayYear
Date
Name
Relationship
Phone Number
Date of Birth

MonthDayYear
Date
Name
Relationship
Phone Number
Date of Birth

MonthDayYear
Date
The authorization to release protected health information specifically to individuals named herein shall remain valid until revoked by a subsequent signed writing or unless a court order executed after this authorization prohibits the release of information.

Parent or legal Guardian Signature Printed Name:
Parent or legal Guardian Signature

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What is your relationship to the patient?
Printed Name
Date of Birth

MonthDayYear
Date
Signature Date

MonthDayYear
Date
PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM
You may refuse to sign this acknowledgement &. authorization. In refusing we may not be allowed to process your insurance claims.
AND CONSENT/LIMITED AUTHORIZATION & RELEASE FORM
Date*

MonthDayYear
Date
MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.
Please print name of Patient*
Please sign for Patient / Guardian of Patient*

Clear
Legal Representative / Guardian*
Relationship of Legal Representative / Guardian*
Your comments regarding Acknowledgements or Consents
HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM THE RECEPTION AREA?

First Name OnlyrProper SurnameOther
PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION

(This includes step parents, grandparents and any care takers who can have access to this patient's records): Name:Relationship
Name
Relationship
Name
Relationship
(This includes step parents, grandparents and any care takers who can have access to this patient's records): Name:Relationship

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize. that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. we, under current HIPAA Omoibus Rule, provide you this information with your knowledge and consent. Office Use Only AsPrivacy Offieer, I attempted to obtain the patient's (or representatives) signature on this Acknowledgement but did not because: If was emergency treatment Icould not communicate with the patient The patient refused to sign The patient was unable to sign because Olher (please describe) Signature of Privacy Officer
I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT & BILLING INFORMATION VÍA:*

Cell Phone ConfirmationText Message to my Cell Phone Email ConfirmationHome Phone ConfirmationEmail ConfirmationWork Phone ConfirmationAny of the Above
I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA:*

Cell Phone ConfirmationText Message to my Cell Phone Email ConfirmationHome Phone ConfirmationEmail ConfirmationWork Phone ConfirmationAny of the Above
I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS or NEW HEALTH INFO on behalf this Healthcare Facility via:*

Phone MessageText MessageEmail MessageNone of the AboveAll of the Above
In signing this HIPAA Patient Acknowledgement Form. you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third-party remuneration from these affiliated companies. We. under current HIPAA Omnibus Rule. provide you with this information with your knowledge and consent.
Signature*

Clear
Please print your name.
What is your relationship to the patient?
CHILD HEALTH HISTORY:
Patient Name*
Date of Birth*

MonthDayYear
Date
HISTORY OF PREGNANCY WITH THIS CHILD:
During which month of pregnancy did you first see the doctor?*
Where was the baby born?*
How long was your pregnancy in MONTHS?*
If baby was born at home, were blood tests for newborn screening done?*

YESNONot born at Home
Did you have any illnesses or problems (including sexually transmitted or other communicable diseases

YESNO
Did you use any non-prescribed drugs? (tobacco, alcohol, street drugs, over the counter or home remedies)?*

YESNO
Did you take any medications? prescribed by your doctor?*

YESNO
Did the baby go home with you from the hospital*

NOYES
Did you have a difficult/abnormal delivery/C section?*

YESNO
Was more than one baby born*

YESNO
Did the baby have any problems during the 1st week of life?*

YESNO
Did the baby receive the Hepatitis B vaccine?*

YESNO
CHILDS HISTORY*

MaleFemale
Birth Weight (pounds)*
Birth Weight (ounces)*
Length (inches)*
HAS YOUR CHILD EVER HAD: (PLEASE CHECK ALL THAT APPLY)*

Measles, Mumps, Rubella, Chicken Pox Thyroid problemsThyroid ProblemsTuberculosis or positive TB testTonsilitis / Sore throatProblems with Eyes / visitonProblems with Ears / HearingDifficulty breathing / snoring at nightHeart ProblemsAsthma, bronchitis, pneumoniaAllergiesSerious Illness or AccidentSurgery or HospitalizationAnemia, bleeding problems, blood transfusionStomach AchesDiarrhea, soiling self with stoolBladder, kidney problemsConstipationVomiting after eating, refusing to eatMuscle, bone, or joint problemsSkin ProblemsHeadaches or dizzinessConvulsions, Seizures, EpilepsyDiabetesDevelopmental or school problemsGIRLS: are there problems with her periods?GIRLS: has started her periods
FAMILY HISTORY

*If marked YES, please notate on the blank area provided, which family member was diagnosed:
Diabetes

YESNO
Family Member (Mother, Father, Sister, Brother, Aunt, Uncle, Grandma, Grandpa
Epilepsy or Convulsions

YESNO
Family Member (Mother, Father, Sister, Brother, Aunt, Uncle, Grandma, Grandpa
Mental Retardation

YESNO
Family Member (Mother, Father, Sister, Brother, Aunt, Uncle, Grandma, Grandpa
Heart Disease

YESNO
Family Member (Mother, Father, Sister, Brother, Aunt, Uncle, Grandma, Grandpa
Cancer

YESNO
Family Member (Mother, Father, Sister, Brother, Aunt, Uncle, Grandma, Grandpa
Kidney or Urinary Disease

YESNO
Family Member (Mother, Father, Sister, Brother, Aunt, Uncle, Grandma, Grandpa
Bone or Joint Problems

YESNO
Family Member (Mother, Father, Sister, Brother, Aunt, Uncle, Grandma, Grandpa
High Blood Pressure

YESNO
Family Member (Mother, Father, Sister, Brother, Aunt, Uncle, Grandma, Grandpa
Bleeding Disorder

YESNO
Family Member (Mother, Father, Sister, Brother, Aunt, Uncle, Grandma, Grandpa
Tuburculosis

YESNO
Family Member (Mother, Father, Sister, Brother, Aunt, Uncle, Grandma, Grandpa
Allergies

YESNO
Family Member (Mother, Father, Sister, Brother, Aunt, Uncle, Grandma, Grandpa
Lung or Breathing Problems

YESNO
Family Member (Mother, Father, Sister, Brother, Aunt, Uncle, Grandma, Grandpa
Eye Disorder

YESNO
Family Member (Mother, Father, Sister, Brother, Aunt, Uncle, Grandma, Grandpa
Ear Disorder

YESNO
Family Member (Mother, Father, Sister, Brother, Aunt, Uncle, Grandma, Grandpa
PARENT INFORMATION
MOTHER: age*
MOTHER: height*
MOTHER: Occupation*
FATHER: age*
FATHER: height*
FATHER: occupation*
HOUSEHOLD INFORMATION
Number of People in the home*
Are both parents living in the home?*

YESNO
Does anyone in the home smoke, do drugs, or drink alcohol?*

YESNO
Language(s) spoken in the home*
Do you live in an:*

ApartmentHomeMobile HomeShelterHomeless
Signature*

Clear
Please print your name.
Date*

MonthDayYear
Date
Relationship to child
Authorization to Provide Information to Child Care Provider or School Health Officer
Patient Name*
Date of Birth*
I give authorization for Dr. Atiga’s staff to provide any information ( written of verbal) regarding services rendered to my child care provider or school health office upon their request.
Please specify any restriction:
Parent / Legal Guardian Signature

Clear
Please print your name.
What is your relationship to the patient?
Date

MonthDayYear
Date
About Telemedicine
WHAT IS TELEMEDICINE?
Telemedicine (also sometimes called telehealth) services are a way to deliver healthcare services locally to a patient when the healthcare provider is located at a distant site. Telemedicine is generally defined as the use of electronic information and communications technology to exchange medical information from one site to another site to provide medical or surgical treatment to a patient and/or to participate in the medical diagnosis of, or medical opinion or medical advice to, a patient.

When a healthcare provider believes a patient may benefit from the use of telemedicine services, telemedicine can maintain a continuity of care with the provider and facilitate patient self- management and caregiver support of the patient. Telemedicine services often provides a broader access to medical care, eliminates transportation concerns, and increases comfort and familiarity for patients and their families when located in their own homes or other local environments.

However, telemedicine uses new communications technology for which there is little research supporting its effectiveness. For example, telemedicine services may not be as complete as in- person healthcare services because the healthcare provider will not always be able to observe subtle non-verbal communications such as a patient's posture, facial expression, gestures, and tone of voice.

Telemedicine may transfer medical information through the use of interactive, real-time audio/visual technology (for example, video conferencing) or electronic data interchange (for example, computer-to-computer exchanges), or it may transfer medical information through the use of store-and-forward technology (for example, emails While precautions are taken to secure the confidentiality of telemedicine services, the electronic transmission of medical information can be incomplete, lost or otherwise disrupted by technical failures. Additionally, despite such measures, the transmission and storage of medical information can be accessed by unauthorized persons, causing a breach of the patient's privacy.

I read and understand the information provided in this document. I discussed any question I had with my doctor and all of my questions were answered to my satisfaction.
Date*

MonthDayYear
Date
Patient's Signature*

Clear
CONSENT TO USE TELEMEDICINE
Patient's Name*
My Doctor's Name*
I am physically located in California. At the beginning of each telemedicine session, I will help my doctor to complete a check-in to assess the suitability of using telemedicine services by verifying my full name, my current location, my readiness to proceed, and whether I am in a situation conducive to private, uninterrupted communication. By signing this consent, I understand and agree:

1. My doctor is located in and licensed by the State of California. My doctor may not be able to prescribe medications for me and/or may not be able to assist me in an emergency situation when I am located in any other state or country. If I require medication, I may contact my doctor. If I require emergency care, I may call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for free 24-hour hotline support.

2. I submit to the exclusive jurisdiction of the California state superior courts and agree that any claim, lawsuit, or other legal proceeding arising out of or relating to the telemedicine services provided by my doctor and my doctor's staff will be brought solely and exclusively in California state superior courts. I also agree that the interpretation of this consent will be exclusively governed by and construed in accordance with the laws of

3. My doctor believes that telemedicine services are appropriate for my medical condition and that I would benefit from its use despite its risks and limitations. While I may expect anticipated benefits from the use of telemedicine, no specific results can be guaranteed or

4. If my doctor believes at any time that another form of services (for example, a traditional in-person consultation) would be appropriate, my doctor may discontinue telemedicine services and schedule an in-person consultation with my doctor or refer me to a healthcare provider in my area who can provide such services.

5. I have the right to withdraw consent to the use of telemedicine services at any time and receive inperson healthcare services with my doctor.
6. I received an explanation of how the electronic communications technology will be used for the telemedicine services. I am comfortable with using electronic communications technology to communicate with my doctor and understand there are limitations to the technology which may require an in-person consultation.

7. I agree to have the necessary computer, equipment and internet access for my telemedicine communications. I also agree to arrange for a location with sufficient lighting and privacy and is free from distractions and intrusions during my telemedicine

8. The laws that protect privacy and the confidentiality of my medical information also apply to telemedicine. The medical information that is transmitted electronically by my doctor to me will be encrypted during transmission and will be stored only by my doctor or a service provider selected by my doctor. I understand the dissemination of any personally-identifiable images or information from the telemedicine communication to researchers or other healthcare providers will not occur except as required by federal or California state law.

9. I understand my risks of a privacy violation increase substantially when I enter information on a public access computer, use a computer that is on a shared network, allow a computer to "autoremember" usernames and passwords, or use my work computer for personal communications. I also understand it is my responsibility to encrypt medical information I transmit electronically to my doctor and my failure to use technical safeguards, such as encryption, increases my risks of a privacy violation.

10. [I agree to be videotaped and recorded during the telemedicine services. I understand the resulting images and audio will become part of my medical record. OR [No part of the encounter will be recorded without my written consent.]

11. I have the right to access my medical information and obtain copies of my medical

records in accordance with California law.

12. I understand that the telemedicine services provided to me will be billed to my health insurance company and that I will be billed for any patient responsibility as per my

I read and understand the information provided in this Consent to Use of Telemedicine. I discussed any questions I had with my doctor and all of my questions were answered to my
Date*

MonthDayYear
Date
Patient's Signature*

Clear
Please Upload Driver's License / ID card

Cancelof
Please upload your Insurance Card

Cancelof
Should be Empty:

EMERGENCY CONTACT #1: (PARENT/GUARDIAN)

EMERGENCY CONTACT #2: (OTHER THAN PARENT/GUARDIAN)

MURRIETA, CA 92562

AND CONSENT/LIMITED AUTHORIZATION & RELEASE FORM

CHILD HEALTH HISTORY:

HISTORY OF PREGNANCY WITH THIS CHILD: