test form

New Patient Registration (1)

Patient Information
Signature
First Name
Middle Name
Last Name
SSN#
Birth Date
MM
DD
YYYY
Language
Sex
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Work Phone
Cell Phone
Email
Ethnicity
Race
Primary Care Physician
Referring Physician
Pharmacy Name
City
State
Do we have your permission to confirm your appointment?
If Yes, at which number do you permit us to contact you at to confirm?
Responsible Party Information
(If different than above)
Name
First Middle Last
SSN#
Birth Date
MM
DD
YYYY
Language
Sex
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Work Phone
Cell Phone
Email
Relationship to Patient
Primary Insurance
Name of Insurance Company
Policy #
Group #
Name of Insured
Date of Birth
Relationship to Patient
Secondary Insurance (if applicable)
Name of Insurance Company
Policy #
Group #
Name of Insured
Date of Birth
Relationship to Patient
Emergency Contact
In Case of Emergency, please contact
Relationship to Patient
Home Phone
Work Phone
Cell Phone
Name
First Last
Birth Date
Do you have a Living Will or Advanced Directive?
If No, would you like more information on one?
HOW DID YOU HEAR ABOUT OUR PRACTICE?
- My Primary Physician
- My Specialty Physician (i.e. Gastro, Endo, OB/GYN)
- Insurance Company
- Internet Search
- Other
Please Check One.
ACKNOWLEDGE RECEIPT
I acknowledge receipt of Patient Bill of Rights.
Enter Initials
I acknowledge receipt of Notice of Privacy Practices.
Enter Initials
AUTHORIZATION FOR DISCLOSURE OF PHI
I hereby authorize Adult & Pediatric Urology of Hunterdon to verbally disclose my medical information, including but not limited to: lab test results, imaging test results, billing/claim/insurance information, making and confirming appointments with the following individuals:
Name
Relationship to Patient
Name
Relationship to Patient
Name
Relationship to Patient
I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the Privacy Officer at Adult & Pediatric Urology of Hunterdon to 5 Walter Foran Blvd, Suite 4001 Flemington, NJ 08822. I understand that a revocation is not effective to the extent that action has already been taken prior to date of notification. I understand that certain information cannot be released without specific authorization as required by state and federal law. By initialing the lines below I authorize the release of the following protected or sensitive information to the above named individuals:
Information regarding diagnosis and treatment for HIV/AIDS and other communicable disease
Enter Initials
Information regarding mental health/behavioral health/pyschiatric care
Enter Initials
Information regarding mental health/behavioral health/pyschiatric care
Enter Initials
Information regarding alcohol and/or drug use and/or treatment
Enter Initials
Signature
Signature
Date
Date Format: MM slash DD slash YYYY
I DO NOT authorize Adult & Pediatric Urology of Hunterdon to release any or all information concerning my medical care to any individual except in the event of OR a critical episode or if I am unable to give my authorization due to the severity of my medical condition.
- I DO NOT authorize
- I DO authorize
Date
Date Format: MM slash DD slash YYYY
Assignment / Release / Consent to Treat
Permission is hereby granted to healthcare providers within this practice to administer such testing, examinations, treatment and procedures as are deemed necessary in the course of my care. Information about me necessary to substantiate my insurance claims may be released by the healthcare provider involved in my care. I authorize payment directly to the provider's office of all insurance benefits otherwise payable to me for services rendered. I understand I am financially responsible for all charges whether or not paid by my insurance, for all services rendered on my behalf or on my dependents behalf.
Signature
Date
Date Format: MM slash DD slash YYYY

New Patient Registration (1)

Patient Information

Responsible Party Information

Primary Insurance

Secondary Insurance (if applicable)

Emergency Contact

ACKNOWLEDGE RECEIPT

AUTHORIZATION FOR DISCLOSURE OF PHI

Assignment / Release / Consent to Treat

Contact Us

Please feel welcome to contact our office with any questions or concerns you may have about your care.

Adult & Pediatric Urology of Hunterdon

Office Hours