PATIENT REGISTRATION FORMPATIENT INFORMATION

Name_____________________________________________________ Drivers license #___________________________________

Address___________________________________________________City, ST, Zip_______________________________________

Telephone (__)______________________ Cell (__)_______________________ Birth date_______________________________

Email address______________________________________________Pharmacy:________________________________________

SEX OF PATIENT: ( ) Male ( ) Female MARITAL STATUS: ( )Single ( )Married ( )Divorced ( )WidowedRACE: ( ) White ( ) Black ( ) Hispanic ( ) Other ETHNICITY: ( ) Hispanic ( )Not of Hispanic originPREFERRED LANGUAGE: ( ) English ( )Spanish ( )French ( )German ( )OtherEDUCATION: ( )High school ( )2yr College ( )4yr College ( )Other_________________________________

Social security #________-________-_______RESPONSIBLE PARTY INFORMATION (Fill this section out ONLY IF different from above information)

Name_____________________________________________________________________________________

Address___________________________________________ City, ST, Zip_____________________________

Telephone (_____) _________________________________ Relationship to patient_____________________

EMPLOYMENT INFORMATION

Employer__________________________________________________________________________________

Address__________________________________________ City, ST, Zip______________________________

Telephone (_____) _________________________________ Occupation_______________________________

PRIMARY INSURANCE CARRIER

Company__________________________________________________________________________________

Address__________________________________________ City, ST, Zip______________________________

Policy/Contract #___________________________________ Group # ________________________________

SECONDARY INSURANCE CARRIER

Company_________________________________________________________________________________

Address__________________________________________ City, ST, Zip_____________________________

Policy/Contract #___________________________________ Group #________________________________

EMERGENCY NOTIFICATION/ NEXT OF KIN (NOT living with you)

Name______________________ Telephone (_____) ____________Relationship to patient______________

MISCELLANEOUS INFORMATION

What other doctors have you seen in this area? __________________________________________________________Are you allergic to any medications that you are aware of? ( ) Yes ( ) No If so, please list them below:

__________________________________________________________________________________________________________

RELEASE OF AUTHORIZATION / ASSIGNMENT OF BENEFITSI authorize the release of any medical information necessary to process my insurance claim(s). I authorize and request payment of medical benefits directly to Dr. P. Mora. I agree that this authorization will cover all medical services rendered by Dr. P. Mora until such authorization is revoked by me. I agree that a photocopy of this form may be used in place of the original. I hereby authorize direct payment for surgical benefits to Mora Surgical Clinic, P.C., for services rendered by Dr. P. Mora or under his supervision. I understand that I am financially responsible for any balance not covered by my insurance and collection fees that may occur.____________________________________ _______________________________________________________Print Patient Name Signed (Patient or Patient’s representative/ legal guardian)

Date: ____/____/_______

HOW DID YOU FIND OUT ABOUT US? ٱ Advertisement (what kind?______________________)ٱ phone book ______________________________________Otherٱ Word-of-mouthٱ

MORA SURGICAL CLINIC, P.C.

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.

If you have any questions about this Notice, please see the office manager or call us at (334) 361-6126

This is a summary of our Notice of Privacy Practices which describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. We are required by law to maintain the privacy of your protected health information and to provide you with a notice of our legal duties and privacy practices with respect to protected health information.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time, and reserve the right to do so. The new notice will be effective for all protected health information that we maintain at that time.

We will use your protected health information as part of rendering patient care, including treatment, payment and healthcare operations.

Other uses and disclosures of your protected healthcare information will be made only with your written authorization, unless permitted or required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

We may use or disclose your protected healthcare information in certain situations without your authorization or opportunity to agree or object.

You have the right to request a restriction of your protected healthcare information.You have the right to request to receive confidential communications of your protected health information.You have the right to inspect and copy your protected healthcare information.You have the right to amend your protected health information.You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.You have the right to obtain a paper copy of this notice from us.

You may complain to us or the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

For your convenience, the entire notice of our privacy practices is posted in our lobby beside the check-in window.

I, ________________________________________, acknowledge that I reviewed a copy of the privacy practices and I am aware that there is a copy on the lobby wall.

__________________________________________ _________________________________________Name of Patient or Personal Representative (please print!) Signature of Patient or Personal Representative

______________________________________________ _____________________________________________Date Relationship to patient (if Personal Representative)

Implemented 4/1/03

PATIENT FINANCIAL RESPONSIBILITY

MORA SURGICAL CLINIC, P.C.

I, the undersigned, acknowledge that I am responsible for ALL charges billed for services rendered which are not covered by insurance or other third party payors. My responsibility includes, but is not limited to, deductibles, co-payments, co-insurance and/or another charges incurred but not covered by insurance or other third party payors.

I hereby assign all benefits from any insurance coverage that will pay for this medical service, to Mora Surgical Clinic, P.C. I understand that Mora Surgical Clinic, P.C. will make reasonable efforts to collect on my assigned insurance, but that if my insurer has not paid within ninety (90) days of being billed, that payment of the billed charges will be my responsibility.

I acknowledge and understand that if my account remains unpaid for a period of ninety (90) days and/or financial arrangements I make with Mora Surgical Clinic, P.C. are not met, my account will be referred to an outside collection agency and I will be responsible for an automatic collection fee of 30% of the total debt owed that will be added to the principal balance. Upon default, I agree to pay any and all fees, charges, or expenses incurred by Mora Surgical Clinic, P.C. in the process of collecting the amount owed or incurred while turning over the debt for collection.

___________________________ __________________________________Witness Patient Signature

________________________ _____________________________Date Responsible party/ Legal Guardian

(if applicable)

Mora Surgical Clinic, P.C.

Parham Mora, M.D.645 McQueen Smith Road

Suite 205Prattville, AL 36066

HIPAA – Medical Information Release for Mora Surgical Clinic, P.C.

Due to federal privacy guidelines under HIPAA, we are required to have a medical release of information on file for each patient. This authorizes our office to release medical information to your designated family members, caregivers, and friends, as well as, pharmacists, hospitals, emergency medical personnel, and referral specialists about you or your minor (under 14 years of age) children’s PROTECTED HEALTH INFORMATION (PHI). Included would be all health and indentifiable information. This authorizes us to share your health information, after proper identification, by verbal or written communication, telephone, answering machine, fax, mail or e-mail as needed for your care to only those that you have identified below.

PLEASE PRINT CLEARLY!

I ________________________________________ (print patient’s name or child’s name), __________________________(print patient’s or child’s date of birth), give my authorization to the following individual(s) listed below to discuss my medical care with you and/or your staff on my behalf.

NAME AND RELATIONSHIP DATE OF BIRTH PHONE #

______________________________________ ________________ ________________

______________________________________ ________________ ________________

______________________________________ ________________ ________________

If there is any health information you DO NOT WISH to be given out, please list below.________________________________________________________________________________________________________________________________________________________

The above information is private and confidential and will be placed in your medical record. This authorization will expire 12 months from the date signed.

Signature________________________Relationship if minor___________ Date_______

Witness__________________________ Date_____________

DISCLAIMER (Check below ONLY if you want NO ONE else to have access to your information.)

________ I DO NOT want you to discuss my medical care with anyone other than myself.

Patient Name:__________________________________ Date:___________________________

Do you have a Primary Care doctor?: Yes No Name of Doctor:______________________

Doctor’s phone #:____________________ Date and Year last seen:_______________________

Medical History

Complaint:_______________________________________________________________________

History of present illness: (please circle each item that applies to YOU) Asthma Depression Lung disease

Seizure Esophageal reflux Thyroid diseaseStroke Blood transfusion Heart disease

Hepatitis HIV/Aids Kidney/bladder disease Osteoarthritis Urinary incontinence High blood pressure Diabetes Sleep apnea Cancer of:____________________ Other:_____________________________

Have you EVER had surgery? : (include year of the procedure)_____________________________________ ______________________________________________________________________ ______________________________________________________________________ _________________________________

Family history: (please circle each item that has occurred in YOUR PARENTS, CHILDREN, BROTHERS, SISTERS, GRANDPARENTS, UNCLES, AND AUNTS) High blood pressure Liver disease Heart disease Ulcers Diabetes Thyroid disease Kidney disease Cancer of:_____________________ Other:__________________________Autoimmune connective tissue disease HIV Systemic Lupus ErythematosusScleroderma

Social history: (please fill in the information of all that are applicable) Currently smoke ( _____packs per day for _______ years) Former smoker Never smoked Alcohol________ use for ________ years Street drugs_________________use for _________years

Allergies: Current medication:_____________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ _________________________________ _____________________________ ______________________________________________________________ ______________________________________________________________ _________________________________

Patient Name_________________________________________ Date___________________

PLEASE CIRCLE ALL THAT APPLY TO YOU

GENERAL: Fatigue/Weakness Weight loss Fever Chills

SKIN: Change in size/color of moles Rash

EYES: Poor vision Double vision Blurred vision

Ears, Nose: Sore throat Deafness Ringing in ears HoarsenessMouth, Sinus Drainage Nose bleedThroat

CARDIAC: Difficulty breathing going up stairs (circle YES or NO). How many floors? 1 or 2High blood pressure Palpitations (heart racing/beating irregularly)Shortness of breath at rest Swelling in feet/legs Chest pain

LUNGS: Wheezing Snoring Waking up at night(not to urinate) Falling asleep in the day Coughing up blood Use oxygen at homeCough (Does anything come up? Circle YES or NO) Describe:_____________________

DIGESTION: Heartburn Painful swallowing Nausea Vomiting Vomiting bloodIndigestion Diarrhea Constipation Tarry stools Yellow jaundiceBloody stools Change in bowel movements

URINARY: Kidney/bladder disease Unable to urinate Painful urination Kidney failure/dialysisBlood in urine Inability to control urine if straining/laughing/coughing Frequency/

UrgencyMUSCLE/: Weakness Trauma Limited motionSKELETAL Bone/joint deformity Swelling of joints Joint pain

BRAIN: Paralysis Weakness Seizure Fainting Headache Stroke/Mini-strokeMigraine Incoordination Head trauma Numbness/tingling in extremities

PSYCH: Anxiety Depression Hallucinations ENDOCRINE: Change of appetite Excessive thirst/urination Goiter Diabetes/Diabetes problems

HEMATO: Swollen lymph nodes Bleeding disorders

IMMUNO: Immune disorders HIV Immunosuppressive medication Autoimmune connective tissue disease Systemic lupus erythematosus Scleroderma

Symptoms of one of the above named diseasesFEMALES ONLY:

BREAST: Lumps Pain Nipple discharge Infection TraumaLast mammogram (date)_____________________

GYN: Irregular periods Hormone therapy MenopauseLast pelvic exam (date)_________________ Last period date)________________

Patient signature:_____________________________ Date:______________________Physician signature:___________________________