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

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

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

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

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