Pa ent's Name (First, Middle Ini al, Last)

Address:

City: State: Zip:

Home Phone: __________________________

Emergency Phone: ______________________

Date of Birth: ____/____/_____ Sex: Male Female

Marital Status: ______ Married _____ Single _____ Divorced _____ Widowed _____ Unknown

Social Security Number: ___________________ E-mail: _______________________________________

Race: Ethnicity:

____White/Caucasian ____ Non-Hispanic/Non-La no

____ Black/African American ____ Hispanic/La no

INFORMATION ON THE PERSON BEING SEEN TODAY

Patient Registration Form

Employer Phone: Employer Name:

Date: ___________________________ How did you hear about TLC? ___________________________

Mobile Phone:

Emergency contact (Rela onship)___________________

____ Asian ____ Unknown

____ Other (explain)_____________________________ ____ Declined

____Declined

Preferred Language: ____ English ____ Spanish ____ Other______________________

Responsible Person's Name (First, Middle Ini al, Last):

Address:

City: State: Zip:

Home Phone: __________________________ Mobile Phone:

Emergency Phone: ______________________ Emergency contact (Rela onship):__________________

Date of Birth: ____/____/____ Sex: Male Female

Social Security Number: E-mail:

INFORMATION ON THE PERSON RESPONSIBLE FOR PATIENT

Preferred Method of Communica on: ___ Le er Phone Number:________________ E-mail address:______________________________

INSURANCE INFORMATION:

PLEASE NOTE: It is the policy of The Longstreet Clinic that we collect full payment at the me ofyour visit. If you have a policy with a company with which we have a contract, we will gladly fileyour claim for you. Please understand that if you are not with a contracted carrier, you mustpay for your visit at me of service. If you have a concern about your ability to pay for the services in full, please speak with the recep onist at me of service.

PRIMARY INSURANCE CARRIER:

Name of Policyholder: Policyholder's DOB: / /

Policyholder's Employer: Policyholder's SS#:

Policyholder's Rela onship to pa ent: __________________________________________________

SECONDARY INSURANCE CARRIER:

***** Please allow the recep onist to make copies of your insurance cards*****

Patient Registration Form

Name of Policyholder: Policyholder's DOB: / /

Policyholder's s'redlohyciloP:reyolpmE SS#:

Policyholder's Rela onship to pa ent: __________________________________________________

I authorize The Longstreet Clinic, P.C . to release to my insurance company any informa onrequired for services provided. I authorize payment of Medical Benefits to

Signature:

I understand that I remain responsible to The Longstreet Clinic, P.C . for any and all charges.

Signature:

Revised: 08/30/11

h:\FORMS\Pa ent Registra on Form ALL

The Longstreet Clinic, P.C.

2EMG

Name: Referring MD:Date: Primary Care MD:

Please answer Yes NoAre you allergic to latex?Do you take Coumadin (Wafarin)?Do you drink alcohol?Do you have diabetes?

Review of SystemsReview of SystemsReview of SystemsReview of SystemsNeurologyNeurology weakness loss of cons.

numbness paralysis tremormemory loss headaches weakness

MusculoskeletalMusculoskeletal joint swelling crampsjoint pain muscle pain neck painback pain limb pain

Signed: Date: Rev: 1/31/2012

The Longstreet Clinic, P. C.

(A copy of this signed form will be provided to the individual and/or the individual’s legal representative) PF004 Revised 12/2010

AUTHORIZATION TO USE AND/OR DISCLOSE HEALTH INFORMATION Fax # 770-297-5634 _____________________________________________________ ________________________ ____________________ Patient Name (Please Print) Date of Birth IDX # _______________________________________________________________________________ ____________________________________ Home Address, City, State, Zip Physician

I hereby authorize the use/disclosure of my protected health information as described below.

1. The information that may be used or disclosed is the following (check one):

____All of my protected health information including privileged information (privileged information may include, but is not limited to,

information concerning HIV/AIDS illness, infection and related testing, mental illness and psychiatric, drug/alcohol treatment, as well as

communicable disease and genetic testing)

____All of my protected health information excluding privileged information

____Other (describe in a specific and meaningful fashion): ____________________________________________________________

2. The information will be used or disclosed for the following purposes: (i.e., continuing care, treatment, etc.)

____ As requested by me ____ Other (describe): ___________________________________________________________________

3. Persons/organizations authorized to use or disclose (release) the information (check one):

____ The Longstreet Clinic (identify physician)____________________ ____ Other (identify and give address) _______________

Street Address:___________________________________________City: ____________________State:___________ Zip:_________

Telephone #:_______________________________________ Fax #:_____________________________________________________

4. Persons/organizations authorized to receive the information:

____________________________________________________________________________________________________________

Street Address:___________________________________________City:_____________________State:___________ Zip :________

Telephone #:_________________________________________ Fax#:____________________________________________________

5. This authorization will expire (check one):

____90 days from the date of signing

____ When I revoke this authorization in writing as described below

____ Other expiration event that relates to you or the purpose of the use/disclosure:

____________________________________________________________________________________________________________

____Other (specify date) ________________________________________________________________________________________

I understand that any information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be pro

by federal privacy regulations. I understand that I may revoke this authorization in writing at any time by sending the revocation to the TLC Medi

Records Department, except to the extent that action has been taken in reliance on this authorization. Aside from this I understand that upon expiration

of the authorization, no further use or disclosure of the information may be made. I understand that I may be declined treatment if I refuse to sign this

authorization only when: (1) the treatment is for the sole purpose of creating protected health information for disclosure to a third party pursuant to thi

authorization; or (2) the treatment is related to a research project and this authorization is for the use/disclosure of information for such research. I

understand that I may inspect or copy the information used/disclosed.

tected

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s

________________________________________________ ___________________________________________ Signature of Individual or Individual’s Legal Representative Date ________________________________________________ ___________________________________________ Print Name of Legal Representative (if applicable) Relationship of Legal Representative to Individual