Insurance cards copied
Date: 

Patient Registration
Information

Please PRINT AND Complete ALL Sections Below!

PATIENT'S PERSONAL INFORMATION
Martial Status : Single  Married  Divorced  Widowed   Sex: Male  Female
Last name:  First name:  Initial: 
Street Address:  (Apt #  ) City:
State:  Zip:
Home Phone:(  )  Work phone:(  ) 
Social Security #  --
Date of Birth:  Month  / Day  / Year 
Driver's License: (State & Number) 
Employer / Name of School 
Spouse's/Parent's Name: Last Name:  First Name: Initial:
Spouse's/Parent's Work Phone: (  ) 
How do you wish to be addressed? 
PATIENT'S / RESPONSIBLE PARTY INFORMATION
Responsible Party:  
Date of Birth: 
Relationship to Patient: Self Spouse Other 
Social Security # 
Responsible Party's Home Phone: (  ) 
Work Phone:(  ) 
Address:  (Apt #  ) City: 
State: Zip:  


PATIENT'S INSURANCE INFORMATION  Please Present Insurance Cards to Receptionist.
PRIMARY insurance company's name: 
Insurance Address:  City: 
State:  Zip:  
Name of Insured:  Date of Birth: 
Relationship to insured: Self  Spouse Child Other
Insurance ID Number:  Group number: 


SECONDARY Insurance Company's Name:
Insurance Address:  City: 
State:  Zip:  
Name of Insured:  Date of Birth: 
Relationship to Insured: Self  Spouse Other Child
Insurance ID Number:  Group Number:
PATIENT'S REFERRAL INFORMATION
Referred by: 
If referred by a friend may we thank her or him?   YES  NO
Name(s) of Other Physician(s) Who Care for You:
EMERGENCY CONTACT
Name of Person not Living with You:
Relationship:
Address:  City: 
State:   Zip:  
Phone number ( home ) : (  )
Phone number ( work ) : (  ) 

Assignment of Benefits · Financial Agreement
I hereby give lifetime authorization for payment of insurance benefits to be made directly
to   ,and any assisting physicians,for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collection,and reasonable attorney's fees. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits.
I futher agree that a photocopy of this agreement shall be as valid as the original.

Date:  Your Signature:  









HEALTH HISTORY
DATE:  
Name:  Last: First:  MI: Age:  
Birth Date:  /  /  Sex: Male Female
Highest Grade Completed:  
Place of Employment:  How Long?:  Occupation:  
Single    Married      Separated     Divorced     Widowed

Others Who Live With You Relationship Age Received Care Here (Yes/No)
          yes  no
          yes  no
          yes  no
          yes  no
          yes  no

Do You Have any Special Spiritual, Religious, or Cultural Needs?
Yes  No  Explain:
ALLERGIES:Any Allergies or Reactions to any Medications.
X-ray Dyes, Foods, Environmental or Other substances? Yes  No
(please list)
1. 2.
3. 4. 
PAST MEDICAL HISTORY AND REVIEW OF SYSTEMS:
Please Circle If You Have Had Problems with or are Presently Complaining of any of the following:
 1. High Blood
Pressure 		 13. Pneumonia  25. Hemorrhoids  37. Blood Disorder
 2. Diabetes  14. Persistent Cough  26. Gallbladder
Disease 		 38. Sickle Cell
 3. Cancer  15. Tuberculosis(TB)  27. Hepatitis or Liver
Disease		  39. Blood Clots
 4. Heart Disease  16. Asthma  28. Thyroid Disease  40. Anemia
 5. Chest
Pain/discomfort		  17. Hayfever  29. Seizures  41. Anxiety
 6. Shortness
of Breath		  18. Indigestion/heartburn  30. Headaches  42. Depression
 7. Swollen Ankles  19. Abdominal Discomfort  31. Incontinence  43. Skin Diseases
 8. Palpitations  20. Change in Appetite  32. Kidney Diseases  44. Hearing Difficulty
 9. Lightheadedness  21. Constipation
or Diarrhea		  33. Kidney Stones  45. Gout
 10. Stroke  22. Unexplained
Wt Gain/Loss		  34. Difficulty Urinating  46. Low Back
Problems
 11. High cholesterol  23. Blood in Stool  35. Urine Infections  47. Glasses
or Contacts
 12. Fever,
chills,sweats		  24. Ulcers  36. Arthritis  48. Glaucoma
/Cataracts

Any Problems Not Listed Above:   
Are You on a Special Diet?   No  Yes Type:  
Do You Use any Community Resources? (i.e Home Health, etc.)   No  Yes
Which?:  

FEMALE HEALTH HISTORY: MALE HEALTH HISTORY:
Age of Start of Periods:  Years Old Testicular masses: No  Yes
Frequency:   Length of Period:  Days Discharge from the penis:  No  Yes
Pregnancies:  Sexually Transmitted Disease: No  Yes
Births:  Miscarriages:  Problems with Erections: No  Yes
Method of Birth Control:  Difficulty Urinating: No  Yes
Prolonged or Abnormal Bleeding:  No  Yes
Leakage of Urine:  No  Yes
Pelvic Pain:  No  Yes
Abnormal Discharge:  No  Yes
History of Abnormal Pap Smear:  No  Yes
Sexually Transmitted Disease:  No  Yes


Hania Alaidroos, M. D. / Arbor Green Family Medicine Clinic
Pre-Treatment Notification

Some health plans require that we inform you in advance that they may deny payment for services not covered and for services not deemed by the health plan to be reasonable and customary or medically necessary. Hania Alaidroos, M. D. renders only services that, in her professional judgment, are needed to provide quality medical care for you. In order for us to collect from you for our services when payment is denied by your health plan, your health requires that you sign the following agreement.


Agreement: I have been notified by the physician that payment may be denied for "services not covered" or for "deemed by the health plan to be reasonable and customary or medically necessary" or that have been specifically requested by me, the patient. If payment is denied, I agree to be personally and fully responsible for payment.

Signature  Date  

YOUR HEALTH PLAN COVERAGE

Hania Alaidroos, M. D. is committed to providing you with the best possible care and helping you to receive maximum allowable benefits under your health plan. In order to achieve these goals, we need your assistance.

REGARDING OFFICE VISITS, LAB WORK & X-RAYS

1.     Co-payments are due at the time of the visit.
2.     A valid, current card mast be presented at each office visit.
3.     If the service is not a covered benefit or if your health plan tells us you are not covered, payment in full for all services are due when rendered. If your insurance company subsequently makes payment, any overpayment will be refunded to you.

REGARDING YOUR HEALTH PLAN

1.     Your insurance is a contract between you, your employer and the insurance company. We are not party to that contract. While we may have an agreement with many of the health plans to provide services, any questions regarding coverage must be resolved by you with the insurance company.
2.     Not all services are a covered benefit with all contracts. Some health plans select certain services which they will not cover. By signing below, I acknowledge that I have read this information and understand all of the above.

Signature  Date 
Witness  Date  

Hania Alaidroos, M. D. / Arbor Green Family Medicine Clinic
Patient Consent and Acknowledgement of receipt of Privacy Notice

I understand that as part of the provision of healthcare services, Hania Alaidroos, M. D. creates and maintains health records and other information describing among other things, my health history, symptoms, examination, and test results, diagnoses, treatment, and any plan future care or treatment.

I have been provided with a Notice of Privacy Practices that provides a more complete description of the uses and disclosures of certain health information. I understand that I have the right to review the notice prior to signing this consent. I understand that organization reserves the right to change their Notice and practices and prior to implementation will mail a copy of any revised notice to the address I have provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations (quality assessment and improvement activities, and auditing functions, etc.) and that the organization is not required to agree to the restrictions requested.

By signing this form, I consent to the use and disclosure of protected health information about me for the purposes of treatment, payment and healthcare operations. I have the right to revoke this consent, in writing, except where disclosures have already made in reliance on my prior consent.


This consent is given freely with the understanding that:

1.     Any and all records, whether written or in electronic format, are confidential and cannot be disclosed for reasons outside of treatment, payment or health care operations without my prior written authorization, except as otherwise provided by law.
2.     A photocopy or fax of this consent is as this original.
3.     I have the right to request that the use of my Protected Health Information, which is used or disclosed for the purposes of treatment, payment, or healthcare operations, be restricted. I also understand that the Practice and I must agree to any restrictions in writing that I request on the use and disclosure of my Protected Health Information; and agree to terminate any restrictions in writing on the used and disclosure of my Protected Health Information which have been previously agreed upon.





 
Patient’s Name Printed		  
Date
 
Patient’s Signature (Or Guardian, if a Minor)		  
Social Security Number (For I.D. Purposes)
 
Witness (Optional) 		 
Date