Patient Registration MRN__________________________________
Patient Information
First Name
Last Name
MI
Date of Birth
Address
City
State
Zip
Please check Primary
phone
Home Phone
Work Phone
Other Name(s) Used
E-mail Address
Gender
SSN
Preferred Language
Driver’s License
M F
Marital Status
Preferred Contact
Ethnicity
Race
Married
Single
Divorced
Separated
Widowed
Life Partner
Mail
Home Phone
Day Phone
Cell Phone
Patient Portal
(MyChart)
Cambodian
Filipino
Hispanic/Latino
Non-Hispanic
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian/Other Pacific Islander
White
Other
Primary Care Provider
Referring Provider
Responsible Party (Guarantor) Same as patient
First Name
Last Name
MI
Date of Birth
Address
City
State
Zip
Please check Primary
Phone
Home Phone
Work Phone
SSN
Relationship to Patient
Preferred Language
Driver’s License
Emergency Contact (for minor child, this section may be used for other parent)
First Name
Last Name
MI
Date of Birth
Address
City
State
Zip
Please check Primary
Phone
Home Phone
Work Phone
I/We do hereby consent to and authorize the performance of all treatments, surgeries and medical services deemed advisable by the
physicians and staff of the MemorialCare Medical Foundation affiliated medical groups to me or to the above-named minor of whom I
am the parent or legal guardian. I hereby certify that, to the best of my knowledge, all statements contained hereon are true. I
understand that I am directly responsible for all charges incurred for medical services for myself and my dependents regardless of
insurance coverage, excluding only authorized services provided under a valid prepaid HMO contract. I furthermore agree to pay legal
interest, collection expenses, and attorneys’ fees incurred to collect any amount I may owe. I also hereby authorize my MemorialCare
Medical Foundation affiliated medical group to release information requested by insurance company and/or its representatives. I fully
understand this agreement and consent will continue until cancelled by me in writing.
Signature of Patient/Responsible Party
Date
Name of Patient/Responsible Party (Please Print)
Relationship to Patient
3/18/2014
Nonbinary
How did you hear about us?
click to sign
signature
click to edit
Patient Registration MRN__________________________________
Pharmacy Information
Preferred Pharmacy
Secondary Pharmacy
Name
Name
Address
Address
Phone
Phone
Fax
Fax
Advanced Directives
None Do Not Resuscitate Durable Power of Attorney Living Will HC Proxy
Date Reviewed:
Medications List all medications you take, prescription and non-prescription, and the dosage
I do not take any medications
Medication Name
Dosage
Medication and Food Allergies List all known allergies (drugs, food, animals, etc.)
No Known Allergies
Medical History Check if you have ever experienced the following conditions, and year of onset.
Condition
Year
Condition
Year
None
Gallbladder Disease
Allergies
GERD (Reflux)
Anemia
Hepatitis C
Angina
Hyperlipidemia
Anxiety
Hypertension
Arthritis
Irritable Bowel Disease
Asthma
Liver Disease
Atrial Fibrillation
Migraine Headaches
Benign Prostatic Hypertrophy
Myocardial Infarction
Blood Clots
Osteoarthritis
Cancer Type
Osteoporosis
Cerebrovascular Accident
Peptic Ulcer Disease
Coronary Artery Disease
Renal Disease
COPD (Emphysema)
Seizure Disorder
Crohn’s Disease
Thyroid Disease
Depression
Other
Diabetes
Other
3/18/2014 2
Patient Registration MRN__________________________________
Surgical History Check if you have received the following procedures, and year performed.
Surgical Procedure
Year
Surgical Procedures
Year
None
Male Only
Angioplasty
Prostate Biopsy
Angioplasty w/Stent
TURP
(Trans-urethral resection of Prostate)
Appendectomy
Arthroscopy Knee
Vasectomy
Back Surgery
Other
CABG (heart bypass)
Other
Carpal Tunnel Release
Cataract Extraction
Female Only
Cholecystectomy
Augmentation Mammoplasty
Colectomy
Bilateral Tubal Ligation
Colostomy
Breast Biopsy
Gastric Bypass
Cesarean Section
Hernia Repair
D and C
Hip Replacement
Hysterectomy
Knee Replacement
Mastectomy
LASIK
Myomectomy
Liver Biopsy
Reduction Mammoplasty
Pacemaker
TAH/BSO
Small Bowel Resection
Vaginal Hysterectomy
Thyroidectomy
Other
Tonsillectomy
Other
Health Maintenance Check if you have received the following, and date of most recent exam.
Exam
Date
Exam
Date
None
GYN Exam
Breast Exam
Influenza Vaccine
Cardiac Stress Test
Lipid Panel
Colonoscopy
Mammogram
DEXA Scan
PAP Test
Echocardiogram
Physical Exam
EKG
Pneumococcal Vaccine
Eye Exam
Pulmonary Function Test
FOBT (stool card for hidden blood)
Sigmoidoscopy
Foot Exam
Tetanus Vaccine
Family History Check if any family member(s) has had any of the following conditions.
Adopted
Diagnosis
Mother
Father
Brother
Sister
Other
Other
Other
Alcoholism
Allergies
Alzheimer’s Disease
Asthma
Blood Disease
CAD (Heart Attack)
Cancer Type:
CVA (Stroke)
Depression
Developmental Delay
Diabetes
3/18/2014 3
Patient Registration MRN__________________________________
Family History continued
Diagnosis
Mother
Father
Brother
Sister
Other
Other
Other
Eczema
Hearing Deficiency
Hyperlipidemia (High Cholesterol)
Hypertension (High Blood Pressure)
Irritable Bowel Disease
Learning Disability
Mental Illness
Tuberculosis
Obesity
Osteoarthritis
Osteoporosis
PVD
Renal Disease
Other
Other
Social History for Adult Patient
Occupation
Employer
Do you have children? Yes No
Female(s)
Male(s)
Tobacco Use
No
Daily Weekly Less
Former/Year quit:
Chewing Pipe
Cigar Cigarette
Smokeless Brand:
Alcohol Use
No
Daily Weekly Less
Former/Year quit:
Beer Wine
Liquor Other:
Exercise Activity
Moderate Vigorous Sedentary
Days/Week:
Sleep Pattern:
Changes No Changes
Caffeine Use
No
Daily Weekly Less
Former/Year quit:
Chocolate Coffee
Soda Tea
Tablets Other:
For Pediatric Patient
Patient Reside
with:
Primary
Mother
Father
Both Parents
Other:
Secondary
Mother
Father
Other:
Mother’s Occupation
Father’s Occupation
Parents Relationship
Childcare
Married Single
Divorced Separated
Widowed
Mother Grandparent
Father Nanny
Sibling Daycare
Tobacco Exposure: Yes No
Smokers at home: Yes No
Patient is current smoker? Yes No
3/18/2014 4
ACKNOWLEDGEMENT OF RECEIPT
Joint Notice of Privacy Practices
1004909 (11/06) 3016855 Conditions of Admission
3043218 (7/31/13)
Your name and signature on this form indicates that you have received a copy of MemorialCare’s
Joint Notice of Privacy Practices on the date and time indicated below.
If you have any questions regarding the information contained in MemorialCare’s Joint Notice
of Privacy Practices, please contact MemorialCare’s Chief Compliance Officer at (714) 377-3218.
Printed Name: _______________________________________________
Signature: _______________________________________
_____
_______
Relationship to Patient: __________________________
_________
____
Date Received: ______________________ Time Received: _________
FOR FACILITY USE ONLY
We attempted to obtain written acknowledgement of patient’s receipt of our Joint Notice
of Privacy Practices, but acknowledgement could not be obtained from the patient for the
following reason:
n
Individual Refused to Sign
n
Emergency Situation Prevented Signature
n
Patient Requested Above Individual Sign on His / Her Behalf
n
Other (please specify) _______________________________________________________________
Registration Representative Signature: _________________________________ Date: ___________
ACKNOWLEDGEMENT OF RECEIPT
Joint Notice of Privacy Practices
Page 1 of 7
JOINT NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Who Will Follow This Notice
MemorialCare (“MemorialCare” or “we”), through its afliated hospitals and facilities (“MemorialCare Facility”) and the
employees and staff of each MemorialCare Facility, provide healthcare to patients, together with other healthcare providers
and other organizations. This Notice applies to the following persons and entities, who have agreed to be bound by this
Notice:
Each MemorialCare Facility, as well as all MemorialCare employees, staff and other personnel, who may need to
access your information to perform their job functions.
Members of the medical staff of each MemorialCare Facility, as well as other health care professionals who provide
health care services at a MemorialCare Facility.
Any member of a volunteer group we allow to help you while you are receiving care.
This Notice applies to all of the records related to your health care provided to you in a MemorialCare Facility and generated
by the applicable MemorialCare Facility, whether made by MemorialCare personnel or your personal healthcare provider.
Your personal healthcare provider may have different policies or notices regarding the use and disclosure of your medical
information created or maintained in the healthcare provider’s ofce or clinic. You should review your healthcare provider’s
notice for information on how your healthcare provider will handle your medical information outside of MemorialCare
Facilities.
Our Pledge Regarding Medical Information
We understand that medical information about you and your health is personal. Protecting medical information about you
is important. We create a record of the care and services you receive while in our care. We need this record to provide you
with quality care and to comply with certain regulatory requirements. This Notice will tell you about the ways in which we
may use and disclose medical information about you. This Notice also describes your rights, and certain obligations we have
regarding the use and disclosure of your medical information. We are required by law to:
Keep medical information that identies you private;
Give you this Notice of our legal duties and privacy practices with respect to medical information about you; and
Follow the terms of the Notice that is currently in effect.
2027569 (11/15/17) 3017479
Page 2 of 7
How We May Use And Disclose Medical Information About You
The following categories describe different ways that we use and disclose medical information. For each category of uses
or disclosures, we will explain what we mean and try to give some examples. Not every use or disclosure in a category will
be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose
medical information about you to healthcare providers who are involved in taking care of you. For example, a doctor treating
you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the
doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. Different healthcare
professionals within a MemorialCare Facility also may share medical information about you in order to coordinate the
different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you
outside the MemorialCare Facility that treated you to people who may be involved in your medical care after you leave a
MemorialCare Facility.
Payment. We may use and disclose medical information about you so that the treatment and services you receive may
be billed to, and payment may be collected from, you, an insurance company or a third party. For example, we may need
to give your health plan information about surgery you received at a MemorialCare Facility so your health plan will pay us
or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to
obtain prior approval or to determine whether your insurance will cover the treatment.
Health Care Operations. We may use and disclose medical information about you for our health care operations. These
uses and disclosures are necessary to make sure that all of our patients receive quality care and to run each MemorialCare
Facility. For example, we may use medical information to review our treatment and services and to evaluate the performance
of our staff in caring for you. We may also disclose information to doctors, nurses, technicians, medical students, and
other personnel for review and learning purposes. We may also combine the medical information we have with medical
information from other facilities to compare how we are doing and see where we can make improvements in the care and
services we offer. We may remove information that identies you from this set of medical information so others may use it
to study health care and health care delivery without knowing the identities of the specic patients. We may disclose your
medical information to another health care professional that you have seen so they may improve their quality or costs of
care.
Health Information Exchange (HIE). MemorialCare may make your individual medical information available to a local,
regional and/or national Health Information Exchange (“HIE”) including, but not limited to, the National Health Information
Network (“NHIN”). An HIE is a state and/or federal government sponsored initiative that provides a mechanism for healthcare
providers in our community to share information electronically, all with a common goal of improving the quality of care for
our patients while protecting the privacy and security of your medical information. For example, if you received treatment in
a MemorialCare hospital’s emergency department over the weekend and you were following up with your regular physician
in their ofce that next week, the physician would be able to access and review your emergency department record
during your ofce visit. This type of access provides your physician with the most current information about your care and
treatment.
MemorialCare will only transmit your medical information to an HIE for the purposes of treatment, payment, or healthcare
operations, or as required by law. Individual health information that currently by law requires an additional signed
authorization for release WILL NOT be transmitted to an HIE without your consent, or as otherwise mandated by law or
regulatory requirement.
Page 3 of 7
California Immunization Registry. MemorialCare may share your immunization or tuberculosis (TB) screening test records
with the California Immunization Registry (CAIR), a statewide, secure and condential database of patient immunization
information. The CAIR is used by health care professionals, agencies, and schools to keep track of all shots and TB tests
you take, and can provide proof about immunizations needed to start child care, school, or a new job. If you do not want
your immunization or TB records to be shared with other registry users, please fax or email the “Decline or Start Sharing/
Immunization Information Request Form,” available on the CAIR website at http://cairweb.org/cair-forms/, to the CAIR Help
Desk at 1-888-436-8320 or CAIRHelpDesk@cdph.ca.gov.
Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an
appointment for treatment or medical care at a MemorialCare Facility.
Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment
options or alternatives that may be of interest to you.
Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related
benets or services that may be of interest to you.
Facility Directory. We may include certain limited information about you in the facility directory of a MemorialCare hospital
while you are a patient at that hospital. This information may include your name, location in the hospital and your general
condition (e.g., fair, good, etc). Unless there is a specic written request from you to the contrary, this directory information
may also be released to people who ask for you by name. This information is released so your family and friends can visit
you in the hospital and generally know how you are doing. If you wish to “opt out” of the facility directory, please contact
the admitting department at the MemorialCare hospital where you are being treated and request that your information not
be included in the facility directory.
Individuals Involved in Your Care or Payment for Your Care; Disaster Relief Efforts. We may release medical information
about you to a friend or family member who is involved in your medical care. We may also give information to someone who
helps pay for your care. Unless there is a specic written request from you to the contrary, we may also tell your family or
friends about your condition. In addition, we may disclose medical information about you to an entity assisting in a disaster
relief effort so that your family can be notied about your condition, status and location.
Research. Under certain circumstances, we may use and disclose medical information about you for research purposes.
For example, a research project may involve comparing the health and recovery of all patients who received one medication
to those who received another for the same condition. All research projects, however, are subject to a special approval
process. This process evaluates a proposed research project and its use of medical information, trying to balance the
research needs with patients’ need for privacy of their medical information. Before we use or disclose medical information
for research, the project will have been approved through this research approval process, but we may disclose medical
information about you to people preparing to conduct a research project, for example, to help them look for patients with
specic medical needs, so long as the medical information they review does not leave our site. We will almost always ask
for your specic permission if the researcher will have access to your name, address or other information that reveals who
you are, or will be involved in your care at the MemorialCare Facility.
Business Associates. There are some services provided for our organization through contracts with an outside organization,
also known as a business associate. Examples include billing services to submit your claim to the insurance company for
payment, transcription services to transcribe dictated reports from the health professionals caring for you in the hospital
and copy services for making copies of your health record. When these services are performed by a business associate, we
may disclose your information to our business associates so they can perform the job we have asked them to do.
Page 4 of 7
As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law.
Averting a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary
to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure,
however, would only be to someone able to help prevent the threat.
Marketing and Sales. Most uses and disclosures of medical information for marketing purposes, and disclosures that
constitute a sale of medical information, require your authorization.
Fundraising Activities. We may use certain information about you (including demographic information and dates you
received service) to contact you in the future in an effort to raise money for a MemorialCare Facility. We may also disclose
this same information to our MemorialCare afliated philanthropic foundations for the same purpose. The money raised will
be used to expand and improve the services and programs we provide to the community. If you do not wish to be contacted
for our fundraising efforts, you must notify the foundation director or a manager at the MemorialCare Facility where you
were treated. Notication may be made in writing, including email, by phone or in person.
Special Situations
Organ and Tissue Donation. We may release medical information to organizations that handle organ procurement or
organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and
transplantation.
Military and Veterans. If you are a member of the armed forces, we may release medical information about you
as required by military command authorities. We may also release medical information about foreign military personnel to
the appropriate foreign military.
Workers’ Compensation. We may release medical information about you for Workers’ Compensation or similar programs.
These programs provide benets for work-related injuries or illness.
Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by
law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are
necessary for the government to monitor the health care system, government programs, and compliance with civil rights
laws.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in
response to a court or administrative order. We may also disclose medical information about you in response to a subpoena,
discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell
you about the request (which may include written notice to you) or to obtain an order protecting the information requested.
Public Health Risks. We may disclose medical information about you for public health activities. These activities generally
include the following:
to report reactions to medications or problems with products;
to notify people of recalls of products they may be using;
to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease
or condition;
to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or
domestic violence. We will only make this disclosure if you agree or when required or authorized by law;
to prevent or control disease, injury or disability;
to report births and deaths;
to report the abuse or neglect of children, elders and dependent adults;
to notify emergency response employees regarding possible exposure to HIV/AIDS, to the extent necessary to comply
with state and federal laws.
Page 5 of 7
Law Enforcement. If permitted by applicable law, we may release medical information if asked to do so by a
law enforcement ofcial:
in response to a court order, subpoena, warrant, summons or similar process;
to identify or locate a suspect, fugitive, material witness, or missing person;
about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement;
about a death we believe may be the result of criminal conduct;
about criminal conduct at the hospital; and
in emergency circumstances to report a crime, the location of the crime or victims; or the identity, description or
location of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner or medical
examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also
release medical information about patients to funeral directors as necessary to carry out their duties.
Protective Services for the President, National Security and Intelligence Activities. We may release medical information
about you to authorized federal ofcials so they may provide protection to the President, other authorized persons or foreign
heads of state or conduct special investigations, or for intelligence, counterintelligence, and other national security activities
authorized by law.
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement ofcial, we may
release medical information about you to the correctional institution or law enforcement ofcial, if the release is necessary
(1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others;
or (3) for the safety and security of the correctional institution.
Multidisciplinary Personnel Teams. We may disclose health information to a multidisciplinary personnel team relevant
to the prevention, identication, management or treatment of an abused child and the child’s parents, or elder abuse and
neglect.
Note on Other Restrictions. Please be aware that certain federal or state laws may have more strict requirements on how
we use and disclose your medical information. If there are stricter requirements, even for the purposes listed above, we will
not disclose your medical information without your written permission, or as otherwise permitted or required by such laws.
For example, we will not disclose your HIV test results without obtaining your written permission, except as permitted by
state law. We may also be restricted by law to obtain your written permission to use and disclose your information related
to treatment for certain conditions such as mental illness, or alcohol or drug abuse.
Your Rights Regarding Medical Information About You
You have the following rights regarding medical information we maintain about you:
Right to Inspect and Copy. You have the right to inspect and copy the information that we have about you that may be
used to make decisions about you and your care, including your medical and billing records. We may deny your request
to inspect and copy in certain very limited circumstances. To inspect and copy your information that may be used to make
decisions about you, you must submit your request in writing to the Medical Records Department at the MemorialCare
Facility where you received health care services. If you request a copy of the information, we may charge a fee for the costs
of copying, mailing or other supplies associated with your request.
Page 6 of 7
Right to Amend. If you feel that information we have about you is incorrect or incomplete, you may ask us to amend the
information. You have the right to request an amendment for as long as the information is kept by or for the MemorialCare
Facility where you were treated. To request an amendment, your request must be made in writing and submitted to the
medical records department of the MemorialCare Facility where you were treated. In addition, you must provide a reason
that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason
to support the request. In addition, we may deny your request if you ask us to amend information that:
was not created by us, unless the person or entity that created the information is no longer available to make the
amendment;
is not part of the medical information kept by or for the MemorialCare Facility where you were treated;
is not part of the information which you would be permitted to inspect and copy; or
is accurate and complete.
You also may have the right to ask us to add an addendum to your records, which can be up to 250 words for each item
you believe to be incorrect or incomplete. Please submit your request for an addendum to the medical records department
of the MemorialCare Facility where you were treated.
Right to an Accounting of Disclosures. You have the right to request an “Accounting of Disclosures.” This is a list
of the disclosures we made of medical information about you other than disclosures for certain purposes, such as for
treatment, payment and health care operations purposes, as those functions are described above, or any disclosures that
have been specically authorized by you. To request this list or accounting of disclosures, you must submit your request
in writing to the Medical Records Department of the MemorialCare Facility where you were treated. Your request must
state a time period, which may not be longer than six (6) years or three (3) years depending on the MemorialCare Facility’s
implementation date of an electronic health record (EHR). The rst list you request within a 12-month period will be free.
For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may
choose to withdraw or modify your request at that time before any costs are incurred.
In addition, we will notify you as required by law following a breach of your unsecured protected health information.
Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use
or disclose about you for treatment, payment or health care operations purposes. You also have the right to request a limit
on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like
a family member or friend. We are not required to agree to your request, except to the extent that you request us to restrict
disclosure to a health plan or insurer for payment or health care operations purposes if you, or someone else on your behalf
(other than the health plan or insurer), has paid for the item or service out of pocket in full. Even if you request this special
restriction, we can disclose the information to a health plan or insurer for purposes of treating you. If we agree to another
special restriction, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to the medical records department of the MemorialCare
Facility where you were treated. In your request, you must tell us (1) what information you want to limit; (2) whether you
want to limit our use, disclosure or both; and (3) to whom you want the limits to apply.
Right to Request Confidential Communications. You have the right to request that we communicate with you in a certain
way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request condential
communications, you must make your request in writing to the medical records department at the MemorialCare Facility
where you seek treatment. We will not ask you the reason for your request. We will accommodate all reasonable requests.
Your request must specify how or where you wish to be contacted.
Page 7 of 7
Right to Authorize or Refuse to Authorize Other Uses and Disclosures of Medical Information. Other uses and
disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written
authorization. If you provide us your authorization to use or disclose medical information about you, you may revoke that
authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information
about you for the reasons covered by your written authorization. You understand that we are unable to take back any
disclosures we have already made with your authorization, and that we are required to retain our records of the care that
we provided to you.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. Even if you have agreed to receive
this Notice electronically, you are still entitled to a paper copy of this Notice. You may obtain a copy of this Notice at our
website (www.memorialcare.org). A paper copy of this Notice is also available in the admitting departments or registration
desks of all MemorialCare Facilities.
Changes To This Notice
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical
information we already have about you as well as any information we receive in the future. We will post a copy of the current
Notice in each MemorialCare Facility, as well as our website (www.memorialcare.org). The Notice will contain on the rst
page, in the bottom left-hand corner, the effective date.
Complaints
If you believe your privacy rights have been violated, you may le a complaint with us and with the Secretary of the United
States Department of Health and Human Services. For information on ling a complaint with us, contact the MemorialCare
Chief Compliance/Privacy Ofcer at (714) 377-3218 for information on how to le your complaint. All complaints must be
submitted in writing. We will take no action against you and you will not be penalized for ling a complaint.
MemorialCare Facilities Covered By This Notice
The list of MemorialCare (MC) Facilities covered by to this Notice may be found at www.memorialcare.org or may be
obtained by contacting the MC Chief Compliance Ofcer at the address or phone number below.
MC Chief Compliance/Privacy Officer Contact Information:
Chief Compliance Ofcer/Privacy Ofcer
MemorialCare
17360 Brookhurst Avenue
Fountain Valley, CA 92708
(714) 377-3218 Phone
(714) 377-3225 Fax
I
R
S#
27-1504911
Assignment of Insurance Benefits/Eligibility Certification MRN: ___________
Primary Insurance Plan
Patient Name Date of Birth
Insurance Plan Group # Policy #
Insurance Company Address Phone #
Subscriber Name Relationship to Patien
t
Subscriber Certificate/Social Security # Subscriber Date of Birth
Subscriber Employe
r
Employer Phone #
Employer Address
For Medicare Patients Only
Health Insurance Claim # Part A Effective Date Part B Effective Date
Other Insurance Coverage for Patient
Patient Name Date of Birth
Insurance Plan Group # Policy #
Insurance Company Address Phone #
Subscriber Name Relationship to Patien
t
Subscriber Certificate/Social Security # Subscriber Date of Birth
Subscriber Employe
r
Employer Phone #
Employer Address
I hereby authorize and request that payment of
authorized Medicare/other
insurance company benefits
be made on my behalf, be paid directly to MemorialCare
Medical Foundation for any medical or surgical services
rendered by its affiliated medical groups to me or a
member of my family. I authorize any holder of medical
or other information about me to release to the Social
Security Administration, Health Care Financing
Administration, its agents or carriers, or the insurance
company any information needed for this or a related
Medicare/other insurance claim to determine these
benefits or the benefits payable for related services. I
understand that it is mandatory to notify the healthcare
provider of any other party who may be responsible for
paying for my treatment.
I understand that I am eligible for benefits through
my HMO policy. I understand that my assigned
IPA/Medical Group chosen for my benefits is a
MemorialCare Medical Foundation affiliated medical
group listed above. I am aware that if the above is not
true, I (or the person financially responsible for me) am
responsible for all charges related to services provided to
me. I agree that if the above is not true, I (or the person
financially responsible for me), will pay in full all such
charges.
__________________________________________
________________________________________
Signature of Patient /Responsible Party Date
__________________________________________ ________________________________________
Name of Patient/Responsible Party (please print) Relationship to Patient
MCMG-permission-to-relay-info_2018
MRN: ______________________
Communicating with You
In order to effectively communicate with you about your medical information we request that you complete this form
identifying the best ways to provide you with your confidential information. We may need to communicate test results,
prescription information or respond to a message you left for your physician’s office. We may communicate with you
through mail, secure email, and telephone, including leaving messages on your answering machine’s/voice mail.
Please check all boxes that give MemorialCare permission to use for your communications:
You may contact me by telephone Phone Number: ___________________________________
You may leave a message/voice mail Phone Number: ___________________________________
You may contact me by mail
You may contact me through email (myChart)
Please list any persons you would like to have access to your billing, appointment or health information, such as your
spouse, caretaker or other family member. We will ask for additional consent prior to releasing information related
to psychiatric services and/or HIV test results.
Name/Phone Number
Relationship
Options
1.
Billing Information
Appointment Information
Medical/Health Information
2.
Billing Information
Appointment Information
Medical/Health Information
3.
Billing Information
Appointment Information
Medical/Health Information
4.
Billing Information
Appointment Information
Medical/Health Information
This request supersedes any prior request for communication of information I may have made.
___________________________________________ ___________________________________________
Signature of Patient/Responsible Party Date
___________________________________________ ___________________________________________
Name of Patient/Responsible Party (Print) Relationship to Patient
MRN: ____________
HMO-0325 11/11
Agreement of Financial Responsibility
Thank you for choosing us as your health care provider. We are committed to providing quality care and
service to all of our patients. The following is a statement of our financial policy, which we require that
you read and agree to prior to any treatment.
Please understand that payment of your bill is considered part of your treatment. Fees are payable
when services are rendered. We accept cash, check, credit cards, and pre-approved insurance for
which we are a contracted provider and are the designated Primary Care Provider (PCP), if
applicable.
It is your responsibility to know your own insurance benefits, including whether we are a
contracted provider with your insurance company, your covered benefits and any exclusions in
your insurance policy, and any pre-authorization requirements of your insurance company.
We will attempt to confirm your insurance coverage prior to your treatment. It is your
responsibility to provide current and accurate insurance information, including any updates or
changes in coverage. Should you fail to provide this information, you will be financially
responsible.
If we have a contract with your insurance company we will bill your insurance company first, less
any copayment(s) or deductible(s), and then bill you for any amount determined to be your
responsibility. This process generally takes 45-60 days from the time the claim is received by the
insurance company.
If we do not contract with your insurance company, you will be expected to pay for all services
rendered at the end of your visit. We will provide you with a statement that you can submit to
your insurance company for reimbursement.
Proof of payment and photo ID are required for all patients. We will ask to make a copy of your
ID and insurance card for our records. Providing a copy of your insurance card does not confirm
that your coverage is effective or that the services rendered will be covered by your insurance
company.
Please understand some insurance coverages have Out-of-Network benefits that have co-insurance
charges, higher co-payments and limited annual benefits. If you receive services are part of an
Out-of-Network benefit, your portion of financial responsibility may be higher than the In-
Network rate.
I have read the financial policies contained above, and my signature below serves as acknowledgement of
a clear understanding of my financial responsibility. I understand that if my insurance company denies
coverage and/or payment for services provided to me, I assume financial responsibility and will pay all
such charges in full.
_______________________________________ _____________________________
Signature of Patient /Responsible Party Date
_______________________________________ _____________________________
Name of Patient/Responsible Party (please print) Relationship to Patient
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