Registration Form

PATIENT INFORMATION

Today's Date:

Patient's Name:

E-mail Address:

Home Phone:

Business Phone:

Cell Phone:

DEMOGRAPHICS

Address:

SS #:

DOB:

Gender:

Marital:

Spouse Name:

Spouse Phone #:

Occupation:

Employer:

Primary Care Physician:

Primary Care Phys. Phone #:

Emergency Contact:

Emergency Contact Phone #:

Relationship to Patient:

INSURANCE INFORMATION

Primary Insurance

Policy Holder Name:

Phone #:

ID #:

Group #:

Secondary Insurance

Policy Holder Name:

Phone #:

ID #:

Group #:

Signature of Patient:

Date:

INDIVIDUALS WITH WHOM YOU MAY DISCUSS MY TREATMENT AND BILL

LIST OF INDIVIDUALS WITH WHOM YOU MAY DISCUSS MY TREATMENT AND BILL

First Name:

Last Name:

Relationship:

Signature of Patient or Patient's Representative:

Printed Name of Patient or Patient's Representative:

Date:

MEDICATION LIST

Patient's Name:

DOB:

Pharmacy Name:

Pharmacy Number:

Medication List:

Medication Name:

Dose:

Frequency:

Do you have an allergy to iodine?

Yes

No

PLEASE SEND MY FOLLOW-UP INFORMATION TO THE FOLLOWING PHYSICIANS:

Physicians List

MD Name:

Phone #:

Fax #:

Speciality:

Signature of Patient or Patient's Representative:

Printed Name of Patient or Patient's Representative:

Date:

To our patients:

I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plan for future care or treatment.

I understand that this information serves as:

- A basis for planning my care and treatment.
- A means of communication among the many healthcare professionals who contribute to my care.
- A source of information for applying my diagnosis and surgical information to my bill.
- A means by which a third-party payer can verify that services billed were provided.
- A tool for routine healthcare operations such as assessing care quality and reviewing the competence of healthcare professionals.
- A means of investigation for improving the quality of patient care which may be conferred among healthcare professionals or used educationally.

I understand that I have the right:

- To object the use of my health information for directory purposes.
- To request restrictions as to how health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested.
- To revoke this consent in writing, except to the extent that the organization has already acted in reliance thereon.

In general, the HIPPA privacy rule gives individuals the right to request a restriction on uses and disclosure of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to an address other than your home address.

Our physicians and staff of South Florida Therapy Institute respect your privacy and wish to make all reasonable attempts to respect your wishes regaring your confidential information.

Sincerely,
SFPTI Team

Signature of Patient or Patient's Representative:

Printed Name of Patient or Patient's Representative:

Date: