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Patient Registration Form

Please read, sign and fill in ALL information

Who may we contact in reference to your medical information?

Who may we contact in case of an emergency?

Advanced Directive

PRIVACY POLICY (HIPPA) and {HIE):

Our Notice of Health Information Practices and Privacy (HIPPA) provide information about the privacy rights of our patients and how we may use and disclose protected information (PHI) about our patients. Federal regulation requires that we give our patients or their authorized representative the opportunity to review our Notice of HIPPA before signing this acknowledgment, a copy will be made available to you at your request.

GB Family Care participates in a non-profit, non-governmental health information exchange (HIE) called Health Current. It will not cost you anything and can help your doctor, healthcare providers, and health plans coordinate you care by securely sharing your health information.

By signing this form, you acknowledge only that we have provided you with immediate access to our HIPPA Notice. I acknowledge receipt and have read and understand the Notice of Health Information Practices regarding my provider's participation in the state Health Information Exchange (HIE), or I previously received this information and decline another copy. I understand that my health information may be securely shared through the HIE, unless I complete and return an Opt Out form to my healthcare provider.

Financial Policies

Guarantor/Policy Holder:

Primary Insurance

Secondary Insurance

No Insurance / Self Pay

Assignment Of Benefits

Patient Medical History

List Medication and reaction

List name of medication and dosage that you take on a regular basis.

Please use the plus icon to add another line. One medication per line.

Please circle if you have or have been treated for any of the following

Circle all that apply

Circle All That Apply

Tobacco Use: CIGS

Alcohol:

Recreational Drugs

Quit date

Preventive Medicine/Screening Questions

We would like to inform you of our office policies

NO SHOW POLICY

If you are unable to keep your scheduled appointment, please notify us 24 hours in advance. You may also reschedule your appointment at that time.

Our no-show policy is as follows: a 24-hour notice is required. If you do not show for your scheduled appointment you (not your insurance company) will be charged $85.00 for the no-show. After the 3rd no show, you will be discharged from the practice. A letter will be sent out discharging you from the practice and giving you 30 days to enroll with a new physician. Persistently not attending for scheduled appointments without notifying the practice may also result in a suspension from AHCCCS (Medicaid) medical insurance.

NON-PAYMENT

If you should fail to make payment on your account, and we find it necessary to turn your account over to a collection agency; the cost of collection (30%) will be applied to your balance.

Medical record policy

Each patient has a complete record of all medical care received at our office. Your personal medical record provides a history of treatment, medication, and diagnostic information that enables your health care team to make comprehensive medical evaluations. We consider your record to be confidential. Therefore, information will not be released without your written consent, unless required by law. Copies of your medical record will be released to you or transferred to another physician upon written consent. There will be a $25 - $50 copying fee for this service.

Completion of Forms (Worker compensation, FMLA etc.)

A $25-50 charge will be assessed for the completion of forms outside of an office visit. The charge varies on the length of the form and the time taken to complete.

Preventative Policy

GB Family Care is very proud to implement standardized preventative services to our patients. We strongly believe in preventative guidelines that have been shown to keep our patients healthy and live longer. Curtain test are required depending on the age, sex, risk factor and are strongly recommended by your insurance. Failure to comply with these tests will be considered as non-compliant and at risk of Discharge from GB Family Care.

Should you have any questions, our medical director would gladly address all your concerns.

Authorization for release of medical records for GB Family Care

Please release the health records for the following patient:

The information is to be disclosed to:
Maria Gonzalez Berlari, MD
5251 W Campbell Ave Ste 105
Phoenix, AZ. 85031
Office: 623-547-5235
Fax: 623-533-6271

The supplied information will be used for continuation of my medical care at this office. I understand that this consent may be revoked in writing at any time, except to the extent that action has been taken in reliance on this authorization, Unless otherwise, this authorization will expire one year from the date of signing.