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Registration FormRegistration Form

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Phone#
(972)-295-9090
Fax# (972) - 534-0010
Registration
1200 East Davis St. Suite 113
Mesquite, TX 75149
GENERAL INFORMATION/ INFORMACION GENERAL
DATE/ Fecha (mm/dd/yyyy)
Registration Form
AgePatient's Name:
Nombre de paciente Last/Apellido First/ Primero SI D.O.B/ Fecha de Nacimiento Edad
Address:
Dirreccion: (Street, apt. #)
Phone #/ Numero de telefono
City: State: Zip Code:
Ciudad Estado
Codigo postal
SSN:
M F
Sex:
Phone#
(972)-295-9090
Fax# (972) - 534-0010
Registration
1200 East Davis St. Suite 113
Mesquite, TX 75149
GENERAL INFORMATION/ INFORMACION GENERAL
DATE/ Fecha (mm/dd/yyyy)
Registration Form
AgePatient's Name:
Nombre de paciente Last/Apellido First/ Primero SI D.O.B/ Fecha de Nacimiento Edad
Address:
Dirreccion: (Street, apt. #)
Phone #/ Numero de telefono
City: State: Zip Code:
Ciudad Estado
Codigo postal
SSN:
M F
Sex:
Emergency Contact:
Relationship to patient/Relacion del pacienteContacto de emergencia
Phone #/ Numero de telefono
Name of Insurance: Member ID/ Group ID:
Nombre de seguranza Identificacion
de
miembro/ Identificacion de
grupo
Preferred Pharmacy: E-mail:
Pharmacia preferida:
Correo electronico
Parent or Legal Guardian: I hereby authorize
Pioneer Healthcare
Clinic
and/ or agents to
use my
general
information
(address,
phone
(text messages), and email) to contact me to facilitate anything related to my medical care.
Paciente o Tutor: Autorizo el use de
mi informacion general
(direccion, telefono
(mensajes
de
texto),
y
correo
electronico)
para
ser
contactado por Pioneer Healthcare Clinic y/o agentes para facilitar el siguimiento de mi cuidado medico.
PERSONAL RESPONSIBLE FOR PAYMENT/ PERSONA RESPONSIBLE DE PAGO
Emergency Contact:
Relationship to patient/Relacion del pacienteContacto de emergencia
Phone #/ Numero de telefono
Name of Insurance: Member ID/ Group ID:
Nombre de seguranza Identificacion
de
miembro/ Identificacion de
grupo
Preferred Pharmacy: E-mail:
Pharmacia preferida:
Correo electronico
Parent or Legal Guardian: I hereby authorize
Pioneer Healthcare
Clinic
and/ or agents to
use my
general
information
(address,
phone
(text messages), and email) to contact me to facilitate anything related to my medical care.
Paciente o Tutor: Autorizo el use de
mi informacion general
(direccion, telefono
(mensajes
de
texto),
y
correo
electronico)
para
ser
contactado por Pioneer Healthcare Clinic y/o agentes para facilitar el siguimiento de mi cuidado medico.
PERSONAL RESPONSIBLE FOR PAYMENT/ PERSONA RESPONSIBLE DE PAGO
Relationship
to
patient/
Relacion a Paciente
Last Name
First and Middle Name
Apellido
Primer y Segundo Nombre
Relationship to patient/ Relacion a Paciente
Father/ PadreMother/ Madre Father/ Padre
SSN:
M F
Last Name
First and Middle Name
Apellido
Primer y Segundo Nombre
Father/ PadreMother/ Madre Father/ Padre
SSN:
M F
AgeAge
EdadD.O.B/ Fecha de Nacimiento EdadD.O.B/ Fecha de Nacimiento
Address:
Dirreccion: (Street, apt. #)
Employment/Trabajo:
State:
Codigo postal
EstadoCiudad
Zip Code:City:
Work phone/ Numero de telefono de trabajo
AUTHORIZATION TO RELEASE INFORMATION
AND ASSIGNMENT OF
BENEFITS
I request that
payment
of authorized
insurance
benefits
from any
applicable
insurance
carrier
be made
on
my behalf to Maya
Healthcare
Clinic
for
any services
furnished
me
by
that provider. I authorized
medical
information
needed
to
determine
these
benefits
or
the
benefits
payable
for the
related
services
to be
released
to the
insurance
company
and its agents. I
understand
that
even
though
I have some type
of insurance
coverage, I am responsible for the
payment of
services.
Please
note: It
is
the
policy of this
office
that any parent who requests
treatment
for the
child
is responsible
for the
payment
of all subsequent
fees.
Solicito
que el pago de las
presentaciones
de seguros
autorizadas
de cualquier
compania
de
seguro aplicables
se
hagan
en
mi nombre a
Maya
Healthcare
Clinic para
todos
los
servicios prestados por mi
a ese
proveedor. Yo
autorize
la
informacion
medica
necesaria para determinar
estos beneficios
o,
los
beneficios
pagaderos
por
los
servicios
relacionados
sean entregados a la
compania
de seguros
y sus agentes.
Entiendo
de
incluso
pense que
tener
algun tipo
de
cobertura de
seguro,
yo
soy
responsible del pago
de
los servicios.
Tenga en
cuenta, es la
politica
de
esta
oficina
que qualquier
padre
se
solicita
tratamiento
para
el
nino
es
responsible del pago
de los
servicios del pago de
todas
las
cuotas subsiguentes.
Name/Nombre: Signature/Firma:
Relationship/Relacion: Date/ Fecha:
6330 Broadway Blvd. Ste. C
Garland TX 75043
Phone Number: (972)-544-0400
Fax Number: (972)-544-0401
6330 Broadway Blvd., Ste. C
Garland, TX 75043
Phone #: (972)-544-0400
Fax #: (972)-544-0401
click to sign
signature
click to edit
Authorization Form
1200 East Davis St. Suite 113
Mesquite, TX 75149
Phone#
(972)-295-9090
Fax# (972) - 534-0010 Registration
Patient Name: DOB:
Medicare Assignment of benefits to Statement to Permit of Heath and/or Medical insurance benefits To Maya Healthcare
Clinic and Providers
I certify that the information given by me in applying for payment under title XVLlll of the Social Security Act is correct. I authorize any holder
of medical or other
information about me to
the centers
for
Medicare
and
Medicaid
Services
or
its
intermediaries
or
carriers any information
needed or for this
or a related Medical claim. I request
that
payment
of authorized
benefits
be
made
on
my
behalf.I
assign
the benefits
payable for physician and / or mid level (Nurse Practitioner or Physician Assistant) provider services to the provider or organization furnishing
the services or authorized such provider or organization to submit a claim to Medicare for payment to me. I understand that I am responsible
for any health insurance
deductibles and
co insurance.
I understand that regardless of my assigned insurance benefits, I am responsible for the total charges for all services rendered and I agree to
honor the
current
Clinic
payment policy. I
understand
that, in
the unable
to
pay
in
full
at
the
time
service
is
rendered;
Maya
Healthcare
Clinic may inquiry
of my
credit history to evaluate my credit
worthiness.
I further
understand
that
unpaid
patient
accounts
may accrue
interest (1.5%)per month/ 18% per year) and I agree to pay any such interest charges in addition to any amount unpaid by any insurance
coverage. I further understand that should this account become delinquent and it becomes necessary for the account to
be referred to as
attorney or collection agency for collection
suit, I agree
to pay
all reasonable
attorney
fees
and/
or
collection
expense.
FINANCIAL
RESPONSIBLITY
INSURANCE ASSIGNMENT
In consideration of services rendered or to be rendered, I hereby irrevocably assign and transfer to Maya Healthcare Clinic, Mesquite, Texas
any benefits under hospitalization, sickness liability, auto or accident insurance, and any other coverage for the payment of such services
rendered. I agree to cooperate, aid and assist the clinic in procuring all possible insurance benefits, including initiation and fulfillment of all
policy provisions such insurance companies may require for payment. I understand it is my responsibility to the provider for charges not paid
pursuant to
this
assignment.
AUTHORIZATION FOR CARE
I hereby authorize the staff of Maya Healthcare Clinic to administer such care/ treatment as it is necessary based on the clinical providers
assessment and diagnosis. I understand that such care may include medical and surgical treatment, and laboratory, and radiologic test. I
certify that no guarantee of assurance has been made to the results that may be obtained.
AUTHORIZATION FOR
RELEASE
OF INFORMATION
I hereby authorize staff of Maya Healthcare Clinic to disclose necessary information from my medical record to the following parties when
requested for the purpose as stated herein: to any health care provider for the purpose of providing
continuing professional care and to any
insurance company or third party payer (or their agent/s) for the purpose of obtaining payment to employees, offices and attending clinical
providers
are released from legal responsibility
or
liability
for the above
information to
the
extent
indicated
and
authorized herein.
I
understand this released specifically includes any and all blood and related tests including test results reflecting presence of HIV, HBV and
other diseases,
all of which
I specifically
authorize to be
so released.
Signature of Patient or Representative
Relationship
to
patient
Date
DateRelationship to patient
Responsible Party (if different)
6330 Broadway Blvd. Ste. C
Garland TX 75043
Phone Number: (972)-544-0400
Fax Number: (972)-544-0401
6330 Broadway Blvd., Ste. C
Garland, TX 75043
Phone #: (972)-544-0400
Fax #: (972)-544-0401
click to sign
signature
click to edit
Phone#
(972)-295-9090
Fax# (972) - 534-0010
Registration
Authorization Form
1200 East Davis St. Suite 113
Mesquite,
TX 75149
Advanced practice
nurses Consent for Medical
Treatment
Maya Healthcare Clinic has an advanced
practice
nurse
to assist in
the
delivery
of
primary
health care.
Maya
Healthcare Clinic is a family medical clinic that is owned and operated by Vishnu Maya Upadhyay,
a
certified family and women’s
health
nurse
practitioner.
　　　
A nurse practitioner is a registered nurse (RN), also known as
nurse practitioners (ANP) has a
Masters Degree in Nursing and a board certification in their specialty. They have education and training
in specialty areas such
as family practice, women’s
health
or
pediatrics. Family
Nurse
Practitioners
have
acquired the
necessary
knowledge and expertise,
skills and
training
in
the
care of
people
of
all
ages.
I
have read this document and hereby confine
the
services
of
a nurse
practitioner
for
my
health care
needs.
Patient’s Name
Date
Date of Birth
Patient’s Signature
Parent/ Guardian Signature and Date
How did you hear about us?
6330 Broadway Blvd. Ste. C
Garland TX 75043
Phone Number: (972)-544-0400
Fax Number: (972)-544-0401
6330 Broadway Blvd., Ste. C
Garland, TX 75043
Phone #: (972)-544-0400
Fax #: (972)-544-0401
click to sign
signature
click to edit
1200 East Davis St. Suite 113
Mesquite,
TX 75149
Patient Consent Form
Phone#
(972)-295-9090
Fax# (972) - 534-0010
Registration
In April of 2003, new federal requirements regarding privacy of information for health care patients took effect. HIPAA,
the Health Insurance Portability and Accountability Act requires that all medical providers, insurance companies, and others,
put in place controls to ensure the
your personal
medical
information
is safe.
　　　　Pioneer Healthcare Clinic requires that each patient sign this consent form which allows us to share protected health
information with other physician offices, your hospital, and insurance company.
　　　　By signing this form, consent to our use and disclosure of protected health information about your treatment,
payment, and health care operation. You
have the right to revoke
this
consent
in
writing,
except
where
we
have already
made
disclosures in reliance on
your prior
consent.
　　　　Our Notice of Privacy Practices provides information about how we may use and disclose protected health
information about you. You
have
the right to review
our notice
before signing
this
consent.
Signature of Patient: Date:
Name of Patient: Date of birth:
Authorization to Release Information to Family Members
Many of our patients allow family members such as their spouse, parents, or other to call and request the results of
tests and procedures. Under the requirements of HIPAA we are not allowed to give this information to anyone without the
patient’s consent. If you wish to have your test results released to a family member you must sign this form. Signing this form
will only give consent to release laboratory and radiology results to family members indicated below. This consent will not
allow Pioneer Healthcare Clinic Associates
to release
any other information to
these
family
members.
　　　　You have
the right to revoke this
consent in writing,
except where
we have
already
made
disclosures in
reliance
to
your prior consent.
1.) Relation to patient: Date:
Date: Relation to patient: 2.)
Patient name: Patient Signature: Date:
Authorization to Leave Messages with Household Members/ Answering Machine
From time to time it is necessary for representatives of Maya Healthcare Clinic to leave messages for patients. The purposes of
these messages is to remind patients that they have
an
appointment, to notify
the
patient
that
medical
staff
would
like to
discuss lab
or procedure results, or to ask
a patient to call CMC
regarding an
issue
or
concern.
The
purpose
of this
consent is
to
leave massages with members of your household or on your answering machine. You have the right to revoke this consent, in
writing, except
where we have already
made disclosures
in
reliance
on
your
prior
consent.
Patient name: Date:
Phone Number: (972)-544-0400
Fax Number: (972)-544-0401
6330 Broadway Blvd., Ste. C
Garland, TX 75043
Phone #: (972)-544-0400
Fax #: (972)-544-0401
click to sign
signature
click to edit
click to sign
signature
click to edit
Phone#
(972)-295-9090
Fax# (972) - 534-0010
Registration
1200 East Davis St. Suite 113
Mesquite,
TX 75149
Consent and
acknowledgement
of Receipt
of Privacy
Notice
I understand
that as part of provision of
healthcare service,
Maya
Healthcare
Clinic,
create
and
maintain
health record and other information
describing
among other
things,
my health
history
symptoms,
diagnosis, treatment, examination, and test results, prescription drug history, and any plans for future
care
or treatment.
I have been
provided with a notice
of privacy
practice
that
provides
a more description
of
the
use
and
disclosures of certain health information.
I understand
that
I
have
the
right
to
review
the
notice
prior to
signing
this consent.
I understand that the
organization
reserves
the right
to
change
their
notice
and
practices and
prior to implementation
will mail a copy
of
revised
notice
to
the
address
I have provided. I
understand
that I have the right to request
restriction
as to
how
my
information
may
be
used
or
disclosed to carry out treatment,
payment
or
healthcare
operation
(Quality
assessment
and
improvement
activities,
underwriting,
premium
rating,
conducting
or
arranging
for
medical
review,
legal services, and auditing functions, etc.) and
that
the
organization
is
not
required
to
agree
to
the
restriction requested.
By signing
this form, I consent to the use
and disclosure
of
protected
health information
about
me
for
the purpose
of
treatment,
payment
and healthcare
operations.
I
have
the
right
to
revoke
this
consent,
in
writing, except where disclosures
have already
been
made
in
reliance
on
my
prior
consent.
This consent
is given
freely
with the understanding
that:
1.Any
and
all records, where
written or oral
in
electronic
format,
are
confidential
and
cannot
be
discussed for reasons outside of
treatment,
payment
or
healthcare
operation
without
my
prior
written
authorization, except as otherwise
provided
by
law.
2.A photocopy or fax of
this consent is as valid
as
the
original.
3.I have
the
right to request
that the
use
of
my
protected
health
information,
which
is
or
disclosed
for
the purposes of treatment,
payment
or
healthcare
operations,
be
restricted.
I also
understand
that
Pioneer Healthcare Clinic and I must agree
to
any
restriction
in
writing
that
I
requested
on
the
use
and
disclosure of
my protected
information
which
have
been
previously
agreed upon.
Full Name Date
Date of BirthSignature
Guardians Signature (if
child)
6330 Broadway Blvd. Ste. C
Garland TX 75043
Phone Number: (972)-544-0400
Fax Number: (972)-544-0401
6330 Broadway Blvd., Ste. C
Garland, TX 75043
Phone #: (972)-544-0400
Fax #: (972)-544-0401
Email
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Completed 17 February 2022

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