New Patient Registration & Consent Form

New Patient Registration & Consent Form
Patient Information

Please complete the following patient information.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Preferred Contact Method
Sex

MaleFemale
Date of Birth

MonthDayYear
Date
Current Age
Social Security Number
Marital Status

SingleMarriedWidowedDivorcedSeparated
Race
Ethnicity
Language
Preferred Pharmacy
Are you a current LWC patient?

YesNo
Please list any other names or aliases that you may be listed under:
Employment Status

Full-TimePart-TimeUnemployedOther
Employer Name
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number
Please enter a valid phone number.
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Primary Insurance Information

Please provide the following information about your primary insurance provider.
Primary Insurance Provider
Primary Insurance ID #
Primary Insurance Group #
Subscriber Name
Subscriber Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber Date of Birth

MonthDayYear
Date
Subscriber Social Security Number
Subscriber Relationship to Patient
Secondary Insurance Information

Please provide the following information about your secondary insurance provider.
Secondary Insurance Provider
Secondary Insurance ID #
Secondary Group #
Subscriber Name

First NameLast Name
Subscriber Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber Date of Birth

MonthDayYear
Date
Subscriber Social Security Number
Subscriber Relationship to Patient
Consent Form

I hereby give my consent to be treated and accept the following terms:
Please confirm you accept the following terms and conditions:*

I am requesting the services of London Women’s Care rural health clinic.I understand that this is a clinic. I understand that the clinic employs independent advanced practitioners (Certified Nurse-Midwives, Certified Nurse Practitioners, or Physician Assistants), who practice under physician approved guidelines.I hereby give permission for my chart to be copied for the use of transfer of record information to another health care provider upon written request from that provider, or upon transfer of patient care or referral from my provider.I am aware that health care is dependent upon the responsibility of the patient to follow the guidance of the health care provider and includes cooperation by the patient. I know I am responsible for my actions and their effect on my body.I hereby consent for treatment of medical conditions as necessary, including the use of oral medications, injections, diet counseling, blood withdrawal, and other treatment which shall be fully explained, prior to treatment, by nurse or provider.
Individual Document Acknowledgement
I acknowledge that I have received a copy of London Women's Care notice of privacy practices (dated April 14, 2003).

Yes, I confirm I have received a copy of LWC privacy practices
Please issue a password that can be used to access your medical records.
Would you like to allow another person to access your medical records? They must know the password provided above.

YesNo
Release of Information, Benefit Assignment, Payment Authorization, Full Disclosure Statement and Agreement to Pay For Services

I hereby authorize London Women's Care (LWC) to release any information necessary to process my insurance/Medicare claim, acquired in the course of my examination or treatment; to allow a photocopy of my signature to be used to process my insurance/Medicare claim for the period of LIFETIME. I claim any insurance benefits due me for services rendered by LWC and authorize and direct my carrier to issue payment check(s) directly to LWC. Regardless of my insurance benefits, if any, I understand that I am fully financially responsible for any and all fees incurred, and I agree to pay such fees in full. The insurance information furnished here represents a full disclosure of the insurance/third party benefits to which I am entitled. I understand that failure to disclose pre-certification/second opinion requirements for any and all plans to which I subscribe, may cause me to incur full liability for professional charges, as a result of non-payment by any carrier.
Date Signed

MonthDayYear
Date
Patient / Responsible Party Signature

Clear
Do you have an Advanced Directive (Living Will)?

YesNo
Would you like more information on Advanced Directives (Living Wills)?

YesNo
Should be Empty: