Patient Registration Form

For your convenience, our patient registration form is provided below for you to fill in your information and submit for your first appointment. Having this form completed upon your arrival to our office will ensure a fast and easy first time visit!

 

Patient Information

Name: *
Address: *
City: *
State: *
Zip: *
Home Phone: *
Work/Cell: *
Birth Date: *
Sex: *
Marital Status: *
Primary Physician: *
Who Referred You?
Emergency Contact: *
Emergency Phone: *
Preferred Pharmacy Location: *
Special Needs:
   
 

Responsible Party

Party Responsible for Payment: *
   
 

Insured Party (Primary Card Holder)

Name: *
Birth Date:*
Are You Interested In Being Contacted about Participation in Research Studies?  Yes No
   
How Did You Hear About Us?: *
   
   
Credit Policy: *  
Wake Internal Medicine will be happy to file claims to your insurance company as a courtesy to you. However, seeing that your account is paid is your responsibility. We do expect timely settlement of your account, and payment at the time of service is expected. Any delinquent accounts may be reported to the Credit Bureau.
   
Assignment and Release: *  
I, the undersigned, understand that I am financially responsible for all charges whether or not paid by my insurance. I hereby authorize Wake Internal Medicine Consultants, Inc. to release all information necessary to facilitate the processing of all claims related to my care. I authorize use of this signature on all my insurance submissions.
   
Medicare Patients Only  
I acknowledge that I have been informed of Wake Internal Medicine Consultants non-participation with the Medicare Program and acknowledge that benefits will be paid to me unless otherwise prohibited by Medicare regulations. I authorize any holder of medical information about me to release to the Center for Medicare and Medicaid Services and its agents any information needed to determine these benefits or benefits payable for related services. I understand my signature requests payment be made and authorizes release of medical information necessary to pay the claim. If 'OTHER HEALTH INSURANCE' is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. I acknowledge my responsibility to pay the amount determinded by Medicare to be my responsibility to Wake Internal Medicine Consultants, Inc. in full on the date the services is rendered or as soon there after as can be arranged by mutual consent.
   
Privacy Policy: *  
I hereby acknowledge receipt, before any medical services were provided, of a 'Notice of Privacy Practices of Wake Internal Medicine Consultants, Inc.' for protected health information. I acknowledge that I have been given the opportunity to ask any questions that I may have regarding such policy. I understand WIMC may use or disclose personal health information relating to me for purposes of treatment, payment, and health operations as disclosed in the notice.
   
No Show/Late Cancellation
Policy: *
 
I acknowledge that Wake Internal Medicine reserves the right to charge a fee for missed appointments or procedures. A missed appointment is defined as failure to show for your scheduled appointment or a cancellation/reschedule within less than 24 hours of the appointment time slot (48 hours for procedures). No Show/Late Cancellation Fees: Internist: $25, Specialist: $50, Procedures: $250.
   
   
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