Playa Vista Medical Center Registration Form

PUT A CHECK IF THERE IS A FAMILY HISTORY OF:
strokes	high blood pressure	heart disease	stomach problems	cancer
asthma	emphysema	diabetes	kidney problem	psychiatric problems
Parents Alive?	Yes	No
Mother Deceased?	Cause and Age:
Father Deceased?	Cause and Age:

PUT A CHECK IF YOU HAVE HAD ANY OF THE FOLLOWING IN THE LAST 24 HOURS:
fever	eye problems	nausea	fast heart beat	leg swelling
sore throat	ear problems	vomiting	urinary problems	headache
cough	irregular heartbeat	diarrhea	abdominal pain	weakness
difficulty breathing	chest pain	shortness of breath	pain with urinating	wheezing

Are there any questions you would like to discuss with the physician in private? Yes No

SAFE ENVIRONMENT FOR PATIENT CARE: Weapons or other dangerous objects, illegal drugs and drugs not prescribed by the patient's physician are not permitted in the patient treatment area. The medical center's obligation to provide a safe environment for patient care must override the patient's right to privacy. The medical center reserves the right to search the patient treatment area and to confiscate such objects upon reasonable probable cause.

FINANCIAL AGREEMENT: The undersigned agrees whether he/she signs as agent or patient, that in consideration of the services to be rendered to the patient, he/she here by individually obligates himself/herself to pay the account of the medical clinic in accordance with the regular rates and terms of the medical clinic and or as set forth by the terms of managed care contracts entered into by medical center, and/or applicable Workers' Compensation regulation. Sh,?uld the account be referred to an attorney for collection, the undersigned shall pay actual attorney's fees and collection expense. All delinquent~ccount shall bear interest at the legal rate.

RELEASE OF INFORMATION: To the extent necessary to determine liability for payment and to obtain reimbursement, the medical clinic or attending physician may disclose portions of the pa.tient's record, including his/her medical records, to any person or corporation which is or may be liable, for all or any portion of the hospital's charge, including but not limited to, insurance companies, health care services plan, or worker's compensation carriers. (Special permission is needed to release this information where the patient is being treated for alcohol or drug abuse.)

ASSIGNMENT OF INSURANCE BENEFITS: The undersigned authorizes, whether he/she as agent or patient, direct payment to the medical clinic or physicians, medical groups, and practitioners of any insurance benefits otherwise payable to the undersigned for his/her services at the rate not to exceed medical clinic regular charges. It is agreed that payment to the clinic, pursuant to this authorization, by an insurance company shall discharge said insurance company of any and all obligations under a policy to the extent of such payment. It is understood by the undersigned that he/she is financially responsible for charges not covered by this assignment.

MEDICARE INSURANCE BENEFITS AND EXCLUSIONS: I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers and information needed for this or a related medical claim. I request that payment of authorized benefits be made on my behalf. Some services may not be covered by Medicare, such as the following: 1) Worker's Compensation 2) dental 3) cosmetic surgery 4) custodial care 5) personal comfort items, and any service determined to be unnecessary or unreasonable by Medicare. The undersigned understand that the Department of Health and Human Services Health Care and Financing Administration requires that the patient's signature be released Medicare/Medi-Cal eligibility information. The undersigned authorizes the Social Security Administration to release the following information to medical health center.

PATIENT ENROLLED IN MANAGED CARE HEALTH PLAN: I understand that I am responsible for guarantee of my eligibility and obtaining approval for services from my HMO/PPO plan. Or I must plan for payment of services rendered at this time. I agree to be financially responsible for any and all charges for the visit if not covered by my health plan.

HEALTH CARE SERVICES PLANS: This clinic maintains a list of health care services plan with which it has contracted. A list of such plans is available upon request from the financial office. The medical clinic has no contract, express or implied, with any plan that does not appear on the list. The undersigned agrees that he/she is individually obligated to pay the full cost of all services rendered to him/her by the clinic if he/she belongs to a plan which does not appear on the above mentioned list.

MEDICAL AND SURGICAL CONSENT: The patient is in the care and supervision of his/her attending physicians and it is the responsibility of the medical clinic and its staff to carry out the instructions of such physician. The undersigned hereby consents to x-ray examinations, laboratory procedures, anesthesia, emergency treatment, medical or surgical treatments or medical clinic services rendered to the patient under general and special instructions of the physician.

NOTICE OF PRIVACY PRACTICE: The privacy practice notice is posted in Playa Vista Medical Center. I have read and understand how my health
information may be used and disclosed. If I have questions or concerns I may request a copy of the Notice of Privacy Practice from Playa Vista
Medical Center.

CLAIMS PROCESSING: We have verified your eligibility on-line. In order for us to see you today, we will need to collect $__________. Once the
insurance processes your claim, you will receive an explanation of benefits notifying you of the final amount you are responsible for. If we have
under collected, we will balance bill you, if we have over collected, we will send you a refund after the first of next month. _________________

The undersigned certifies that he/she has read the foregoing, receiving a copy thereof, and is the patient, or is duty authorized by the patient as
patient’s general agent to execute the above and accept its terms.

	Date:
Signature of Patient or Responsible party

	Date:
Signature of Witness

	Today’s Date
PLAYA VISTA MEDICAL CENTER - PATIENT REGISTRATION FORM

Social Security # Patient Name
Date of Birth	Sex: Female Male
Address Apt # City State Zip
Home Phone	Cell Phone
Email Address:	Would you like informational emails? Yes No
Preferred Method of Communications: Email Home Phone Cell Phone Mail Other
Reason For Today's Visit:
Marital Status Single Married Divorced Widow
Race (please check one): American Indian or Alaska Native Asian Black or African American
Native Hawaiian or Other Pacific Islander Hispanic White Other
Ethnicity: Hispanic or Latino Not Hispanic or Latino Language:
Employer / Occupation Work Phone
Employment Status: Full Time Part Time Retired Self Employed Not Employed
Primary Care Physician (optional):	Phone / fax #
Pharmacy Name / Location	Pharmacy Phone #

Financial Responsible Party: If same as patient, check here If not the patient, complete this section:
Last Name: First Name:
Date of Birth	Social Security #
Address Apt # City State Zip
Employer	Employer Phone
Employer Address	Occupation


Insurance Information:
Name of Insurance Carrier:	Do you have a Secondary?
Subscriber’s name:	Date of Birth
Patient’s relationship to the insured Self Spouse Child Other

How did you hear about us?
MDR ER Referral	Friend	Returning	Live in Playa Vista	Drive By	Relative
Employer Non-WC	Letter	Insurance Co Website	Work	Pharmacy	Yahoo
MDR Hospital Employee	YELP	Internet-Other	Google	MSN	School
Safari (iPhone)	Signage	Insurance Co Referral	Doctor's Office	Other

PLAYA VISTA MEDICAL CENTER PATIENT INFORMATION
To better serve you, please be as complete as possible.

Name:
Main Problem (5 words or less):
PAST MEDICAL PROBLEMS (check if you have had):
migraine headaches	tuberculosis (TB)	elevated cholesterol	kidney / bladder problems
blood transfusion	seizures	lung problems	elevated triglycerides
stomach ulcers	blood clots	diabetes	high blood pressure
heart problems	blood from rectum	leg swelling	other problems
surgery (please list operations and year done)


Been Pregnant?	How many times?		How many children?

Date of last period:
PLEASE LIST YOUR MEDICATIONS (frequency of use and dosage):
PLEASE LIST YOUR ALLERGIES TO MEDICATIONS (and what kind of allergic reaction you have):

PLEASE CHECK IF YOU:
Smoke cigarettes.	Number a day?	How many years?
Drink alcohol	Amount each week?	Number of years?
use any non-prescription drugs

LIVING SITUATION:	Alone With Spouse With Family Other
What is / was your occupation?
Are you Retired?