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PATIENT REGISTRATION FORM


* Indicates Requied Fields

PATIENT INFORMATION

Single Mar Div Sep Wid
Male Female
English Spanish Other
Hispanic or Latino Not Hispanic or Latino
American Indian or Alaska Native Black or African American Native Hawaiian or Other Pacific Islander White
Male Female Transgender Male Transgender Female Genderqueer Other Decline to Answer
Heterosexual Homosexual Bisexual Transgender Female Something else Don’t Know Decline

INSURANCE INFORMATION

(Please give your insurance card to the receptionist)

Name of secondary insurance (if applicable):

I, the undersigned authorize payment of medical benefits to Northstar Surgery Specialists, P.A. for any services furnished me by the physician. I understand that I am financially responsible for any amount not covered by my contract. I also authorize you to release to my insurance company or their agent information concerning health care, advice, treatment or supplies provided by me. This information will be used for the purpose of evaluating and administering claims of benefits.



ADDITIONAL INFORMATION

1. In case of an emergency, please notify:
Yes No
Yes No
2. Can confidential messages be left on your:
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
5. Pharmacy Information:

Acknowledgement of Notice of Privacy Practices & CANCELLATION POLICY


I have reviewed the Notice of Privacy Practices of NorthStar Surgery Specialists, P.A., which explains in plain language how my protected health information (PHI) will be used and disclosed, my individual rights, and the practice’s legal duties with respect to my PHI. I understand that I am entitled to receive a copy of this information upon request.

I also acknowledge the following cancellation/no show policy: New patients that no show to a scheduled appointment are subject to a $25 no show charge. Also, established/post-operative patients are subject to a cancellation/reschedule/no show charge of $25 if a 24 hour notice is not given.



Release of Medical Records


I am requesting that the medical information be transferred to Vineet Choudhry MD.

I understand that the information in my or my child’s health record may include information relating to STD, AIDS, or HIV. It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.