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CONFIDENTIAL PATIENT ADMISSION ADMISION DEL PACIENTE PATIENT NAME:___________________________________ Date of Birth:_______________ Sex: Male € Female Nombre Y Apellidos Fecha de Nacimiento Sexo: € M F Marital Status: Single € Married Divorced € Widowed Social Security Number:_______________________ Estado Civil: Soltero € Casado Divorciado €Viudo (Required. If presenting Insurance-Medicare- Medicaid) Mailing Address: ____________________________________________________________________________ Dirección Postal: City:_____________________________________ State:_________________ Zip Code:___________________ E-Mail:_______________________________________________________________________(Make it legible) Mobile #:_________________________________ Day Time Telephone Number: ________________________ Person to notify in case of emergency: __________________________________Tel:_________________________ Nombre de Persona para notificar por emergencias Relationship/parentesco con el paciente:___________________________________________________________ Your prefer language is /Lenguaje De Preferencia es : □ English □ Spanish □ Other:______________________ Select your prefer communication method: □Mobile □ E mail □ US Mail □ Home/Work Tel:__________________ INSURANCE INFORMATION IT IS MANDATORY TO PRESENT INSURANCE ID CARD AND PHOTO ID Primary Insurance:___________________________ MEMBER ID #:____________________________________ Nombre de Seguro Primario Group # IF ANY:__________________________________ Principal Name:______________________________________________________________________________ Nombre del Asegurado Principal Relationship to Patient:____________________________________________ Relación o Parentesco con el paciente: Date of Birth of Policyholder/Fecha de Nacimiento:_______________________________________________ Secondary Insurance: □ Yes □ No Secondary Insurance Name:______________________ID No:__________________________Group#____________ RELEASE OF INFORMATION FOR PATIENTS WITH INSURANCE Lifetime Medicare Part B and Commercial Insurance Signature Authorization for services starting on:____________________(Today’s Date) Spanish: Autorizacion para los servicios de Medicare Parte B y Seguros. I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers, or to the billing agent of The Medical Centre of Lehigh Acres, any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original and request payment of all medical insurance benefits either to myself or to the party who accepts assignment. I authorize the release of medical information necessary to process this claim. I authorize payment of medical benefits t The Medical Centre of Lehigh Acres for services rendered. Signature of Patient or Legal representative:x_______________________________________________________ Firma de Paciente o de Tutor o Representante Legal 2017

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Page 1: ADMISION DEL PACIENTE 2017 M F Widowed Social ......CONFIDENTIAL PATIENT ADMISSION ADMISION DEL PACIENTE PATIENT NAME:_____ Date of Birth:_____ Sex: Male € Female Nombre Y Apellidos

CONFIDENTIALPATIENTADMISSIONADMISIONDELPACIENTE

PATIENTNAME:___________________________________DateofBirth:_______________Sex:Male€ FemaleNombre YApellidos FechadeNacimientoSexo:€ M FMaritalStatus: Single€ Married Divorced€WidowedSocialSecurityNumber:_______________________ EstadoCivil:Soltero€CasadoDivorciado€Viudo(Required.IfpresentingInsurance-Medicare-Medicaid)MailingAddress:____________________________________________________________________________DirecciónPostal:City:_____________________________________State:_________________ZipCode:___________________E-Mail:_______________________________________________________________________(Makeitlegible)Mobile#:_________________________________DayTimeTelephoneNumber:________________________Persontonotifyincaseofemergency:__________________________________Tel:_________________________ NombredePersonaparanotificarporemergenciasRelationship/parentescoconelpaciente:___________________________________________________________

Yourpreferlanguageis/LenguajeDePreferenciaes:□English□Spanish□Other:______________________Selectyourprefercommunicationmethod:□Mobile□Email□USMail□Home/WorkTel:__________________

INSURANCEINFORMATION ITISMANDATORYTOPRESENTINSURANCEIDCARDANDPHOTOIDPrimaryInsurance:___________________________MEMBERID#:____________________________________NombredeSeguroPrimario Group#IFANY:__________________________________ PrincipalName:______________________________________________________________________________NombredelAseguradoPrincipalRelationshiptoPatient:____________________________________________ RelaciónoParentescoconelpaciente: DateofBirthofPolicyholder/FechadeNacimiento:_______________________________________________SecondaryInsurance:□Yes□NoSecondaryInsuranceName:______________________IDNo:__________________________Group#____________

RELEASEOFINFORMATIONFORPATIENTSWITHINSURANCE

LifetimeMedicarePartBandCommercialInsuranceSignatureAuthorizationforservicesstartingon:____________________(Today’sDate)Spanish:AutorizacionparalosserviciosdeMedicareParteBySeguros.IauthorizeanyholderofmedicalorotherinformationaboutmetoreleasetotheSocialSecurityAdministrationandHealthCareFinancingAdministrationoritsintermediariesorcarriers,ortothebillingagentofTheMedicalCentreofLehighAcres,anyinformationneededforthisorarelatedMedicareclaim.Ipermitacopyofthisauthorizationtobeusedinplaceoftheoriginalandrequestpaymentofallmedicalinsurancebenefitseithertomyselfortothepartywhoacceptsassignment.Iauthorizethereleaseofmedicalinformationnecessarytoprocessthisclaim.IauthorizepaymentofmedicalbenefitstoTheMedicalCentreofLehighAcresforservicesrendered.SignatureofPatientorLegalrepresentative:x_______________________________________________________FirmadePacienteodeTutoroRepresentanteLegal

2017

Page 2: ADMISION DEL PACIENTE 2017 M F Widowed Social ......CONFIDENTIAL PATIENT ADMISSION ADMISION DEL PACIENTE PATIENT NAME:_____ Date of Birth:_____ Sex: Male € Female Nombre Y Apellidos

CONSENTTODISCLOSEMEDICALINFORMATIONConsentimientoparadivulgarsuinformacióndesalud

PatientName:_____________________________________________DateofBirth:________________________PleaseCHECKoneofthefollowing:Seleccioneunadelassiguientesopciones.DeseaotorgarpermisoalosfamiliaresquesunombreapareceenesteDocumento.Simarcalasegundaopción,noofreceremosinformaciónaningunaotrapersona.

€ IgivemypermissiontotheemployeesofTheMedicalCentreofLehighAcrestodisclosemyProtectedHealthInformationtomeANDthefollowingfriendsorfamily:Yoautorizoalosempleadosdeestecentromédicoabrindarinformaciónsobremiestadodesaludademásdeamilossiguientesmiembrosdemifamilia.NAME: RELATION: NAME: RELATION: OR

IrequestthatallmyProtectedHealthInformationbedisclosedONLYtomeandnootherfriendsorfamily.Noquieroquelebrindenmiinformaciónaningunaotrapersona.Solamenteami.

WHATTYPEOFMESSAGEMAYWELEAVEFORYOU?InanefforttoserveyoubetterTheMedicalCentreofLehighAcreswouldliketoknowwhattypeofmessagewemayleaveonyourvoicemailwhencontactingyou.ItisthepolicyofTheMedicalCentreofLehighAcrestocallyouatanyphonenumberyouprovidetous.Whenwecontactyoubycallingyouatanyphonenumberyouhaveprovidedus:Mayweleaveadetailedmessageonyouransweringmachine/voicemail?€YesNoIfno,wewillleaveamessagewithjustenoughinformationforyoutocallusback.****PleaseNote:Forappointmentreminders,wewillALWAYSleaveadetailedmessageonyouransweringmachine/voicemailorwithanyonewhoanswersyourphone.IunderstandthatImayrevokeorchangethisauthorizationatanytimebyfillingoutanotherConsenttoDiscloseMedicalInformation”form.IunderstandthatIwillnotbedeniedorrefusedtreatmentifIrefusetosignthisauthorization.IunderstandthattheinformationusedordisclosedpursuanttothisauthorizationmayberedisclosedbytherecipientandnolongerprotectedbyFederalandStateprivacylaws.IunderstandthatIhavearighttoreceiveacopyofthisauthorizationifIrequestone.Ialsounderstandthatthisauthorizationwillnotexpire.X_______________________________________________________________________________________SignatureofPatientorPersonalRepresentative Date_____________________________________________________________________________________________*PrintedNameifnotsignedbyPatient *Relationship/AuthoritytoActonbehalfofthepatientThisformandanypersonalrepresentativedocumentationmustbescannedintothepatient’smedicalrecord.

2017

Page 3: ADMISION DEL PACIENTE 2017 M F Widowed Social ......CONFIDENTIAL PATIENT ADMISSION ADMISION DEL PACIENTE PATIENT NAME:_____ Date of Birth:_____ Sex: Male € Female Nombre Y Apellidos

NOTICEOFPRIVACYPRACTICESACKNOWLEDGEMENTFORM

PatientName:_____________________________________________DateofBirth:________________________NombreyapellidosFechadenacimiento:IhavebeenpresentedwithacopyofTheMedicalCentreofLehighAcresNoticeofPrivacyPractices,detailinghowmyinformationmaybeusedanddisclosedaspermittedunderfederalandstatelaws.BysigningbelowIacknowledgethereceiptofTMCOLA’sNoticeofPrivacyPractices:Consufirmaustedreconocequeestárecibiendosusderechosasuprivacidad.X SignatureofPatientorPersonalRepresentative Date *PrintednameifnotsignedbyPatient*Relationship/AuthoritytoActonbehalfofthepatient*IfnotsignedbythepatientyoumustprovideTMCOLAwithacopyofthedocumentofauthoritythatmakesyouthepatient’spersonalrepresentative(i.e.HealthCarePowerofAttorney,HealthCareSurrogate,HealthCareProxy,Guardian,etc.)Wealsoneedacopyofyourdriver’slicense.

ForInternalUseOnly:Ifawrittenacknowledgementwasnotobtainedfromthepatientorthepatient’spersonalrepresentative,thepersonresponsibleforobtainingthewrittenacknowledgementmustdocumentthereasonforfailurebelow:Reason:______________________________________________________________________________________ EmployeeNameandTitle:_________________________________________________________________________Date:_____________________________

Thisformandanypersonalrepresentativedocumentationmustbescannedintothepatient’smedicalrecord.

Revised:01/03/2017

2017

Page 4: ADMISION DEL PACIENTE 2017 M F Widowed Social ......CONFIDENTIAL PATIENT ADMISSION ADMISION DEL PACIENTE PATIENT NAME:_____ Date of Birth:_____ Sex: Male € Female Nombre Y Apellidos

FINANCIAL POLICY ThisisanagreementbetweenTheMedicalCentreofLehighAcres,Inc(TMCOLA)andthePatientnamedonthisform.

Thewords“you”,“your”and“yours”,meanandreferto,thePatient.Theword“account”referstotheaccountthathasbeenestablishedinthePatient’snameinwhichchargesaremadeandpaymentsareapplied.Thewords“we”,“us”,and“our”refertoTMCOLA.

Asacourtesytoyou,wewillbillyourprimary insurancecompanyonyourbehalf.Wewillestimatewhatyour insurancecompanymaypay,butthis isnotaguaranteeofpayment.Your insurancecompanywillmakethefinaldeterminationofyoureligiblebenefits.Youacknowledgethatyouunderstandthatinsurancecoverageforbenefitsisanagreementbyandbetweenyouandyourinsurancecompany.Therefore,youareacceptingresponsibilityforthechargesthatyourinsurancecompanydoesnotpay.

Referra l/Authorizat ion: Your insurance company may require a referral and/or preauthorization of some medicalservices.Shouldyourinsurancecompanyrequireareferraland/orpreauthorizationforservices,itisyourresponsibilitytoobtainsaidreferraland/orpreauthorization.Byfailingtoobtaintheproperreferraland/orpreauthorization,theinsurancecompanymayreduceordenypaymentforservices.

Managed Care: All insurance companies require that Patient co-payments and deductibles are payable at time ofservice.Ifyouareunabletopayattimeofservice,anadditionalchargeof$25.00willbeassessedtothebalancetocovertheadditionalcollectioncosts.ThisservicefeeisPatientresponsibilityandcannotbebilledtoinsurance.

Medicare: Weparticipate inMedicarePartB andwewill bill all serviceson yourbehalf. You are responsible for yourannualMedicaredeductibleandthe20%Patientresponsibility.YouareresponsibleforanyservicesthatMedicaredoesnotcover.Wewillbillyoursecondaryinsuranceonyourbehalf.

Self-Pay: Ifyouarepayingforservicesyourself(self-pay),thenallpaymentsfortheservicesrenderedaredueatthetimeofservice.Ifyouareunabletopayattimeofserviceforcertainservices,anyremainingbalancewillbebilledtoyouuponpriorapprovalfromthebillingdepartment.

Worker’s Compensat ion: At this timewearenotaffiliated,norarewecontractedwithanyworker’scompensationcarriers.

Personal In jury Cases/Motor Vehic le Accidents: At this timewe are not accepting patients involved in autoaccidents or slip and fall occurrences. If amedical evaluation is necessarywewill not billed your insurance companyoracceptletterofprotection.Youthepatientmustpay(self-pay)forthemedicalevaluation.

Patient Balances: IfyouhaveaPatientBalanceonyouraccount,youwillbebilledfortheentireamountdue.Yourbillwillshowseparatelyanypreviousbalance,anynewchargesonyouraccount,andanypaymentsorcreditsappliedtoyouraccountduring thatbillingcycle.Yourbillmayalsoshowpendingpayments fromyour insurancecompany, ifapplicable.ThePatientBalancewillbeclearlyindicated.

CONTINUETOREADANDSIGNINTHELASTPAGEPROCEDAALEERYFIRMARLAPROXIMAPÁGINA

2017

Page 5: ADMISION DEL PACIENTE 2017 M F Widowed Social ......CONFIDENTIAL PATIENT ADMISSION ADMISION DEL PACIENTE PATIENT NAME:_____ Date of Birth:_____ Sex: Male € Female Nombre Y Apellidos

FINANCIAL POLICY UnlessyouhavemadeotherarrangementsforpaymentofthePatientBalanceapprovedbyTMCOLA’sBillingOfficewriting,theamountindicatedasPatientBalanceisdueuponreceipt.Yourbalancewillbepastdueifpaymentisnotreceivedwithin30daysfromtheissuedateprintedonthestatement.TMCOLAreservestherighttoaddanyfeesincurredforadditionalbillingand/orcollectionservices.Foryourconvenience,weacceptpaymentviaallmajorcreditcards,includingbankdebitcards.

Ifnecessary,TMCOLABillingServicesmaysetuparegularpaymentscheduleforyou.TMCOLAreservestherighttoreportyouraccounttocreditreportingagenciesifyourbalancegoesintoapastduestatus.NonpaymentofpastduePatientBalancemayresultinTMCOLAinabilitytoprovideyouwithcontinuedcare.

Youunderstandthatifyouraccountissubmittedtoanattorney,collectionagency,involvedincourtlitigation,orreportedtoacreditreportingagency,thefactthatyoureceivedtreatment/servicesatourofficemaybecomeamatterofpublicrecord.

TransferringofmedicalrecordsmustberequestedinwritingalongwithaMedicalRecordsReleaseform.

By signing below, you acknowledge and agree that:

YouunderstandthatitisyourresponsibilitytoprovideTMCOLAwithcurrentandaccuratebillinginformationatthetimeofserviceandyouwillnotifyTMCOLAimmediatelyifthereareanychangestothisinformation.

Youagreetothetermsandconditionscontainedherein.Youunderstandthatanychargesnotcoveredbyyourinsurancecompanyalongwithanyco-paymentsanddeductibles,areyourresponsibility.

YouauthorizeyourinsurancebenefitstobepaiddirectlytoTMCOLAforservicesrendered.

Agreementiseffectiveondateagreementissignedbelow.

PATIENT NAME:

Signature of Responsible Party:X

Responsible Party/Relat ionship: ( I f other than the pat ient. ) FIRMA DE GARANTE DE LA CUENTA Y SI NO ES EL PACIENTE INDIQUE EL PARENTESCO

Date:

Thisformandanypersonalrepresentativedocumentationmustbescannedintothepatient’smedicalrecord.

Revised:01/03/2017

2017


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