Please Note: Before starting this form, please be sure you have approximately 10 minutes to complete. You cannot save your work and return later.

Patient Registration Form

  • If your Primary Care Provider (PCP) is not CHC, please list the PCP/Practice name and Phone Number:

  • Drop files here or
    Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.
      Please upload a photo of your insurance card.

    • *PLEASE NOTE: YOU MUST BRING YOUR INSURANCE CARD TO YOUR APPOINTMENT

    • Emergency Contact
    • Caregiver's Information (if applicable)
    • Certification
    • I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge.

    • NOTICE OF AUTHORIZATIONS & ASSIGNMENT OF BENEFITS

       Assignment of Insurance Benefits: I HEREBY AUTHORIZE DIRECT PAYMENT OF INSURANCE BENEFITS TO COMPASSION HEALTH CARE, INC. or the physician individually for services rendered to my dependents, or me, by the physician or those under his/her supervision. I understand that it is my responsibility to know my insurance benefits and whether or not the services I am to receive are a covered benefit. I understand and agree that I will be responsible for any co-pay or balance due that Compassion Health Care, Inc. is unable to collect from my insurance carrier, for whatever reason.
    •  Authorization to release non-public information: I certify that I have read and been offered a copy of the Compassion Health Care, Inc. “HIPAA Notice of Privacy Practices”, as well as receipt of Compassion Health Care, Inc.’s Office Practices and Patient Rights & Responsibilities. I hereby authorize Compassion Health Care, Inc. and/or the physician individually to release any of my or my dependent’s medical or incidental nonpublic personal information that may be necessary for medical evaluation, treatment, consultation, or the processing of insurance benefits. Compassion Health Care, Inc. reserves the right to revise its Notice of Policy Practices, Office Practices, and Patient Rights and Responsibilities at any time. A copy of such revisions will be available upon request.
    •  Medicare/Medicaid Information: I certify that the information given by me in applying for payment under these programs is correct. I authorize the release of any of my or my dependent’s records that these programs may request. I hereby direct that payment of my or my dependent’s authorized benefits may be made directly to Compassion Health Care, Inc., or the physician on my behalf.
    •  Lab Testing: I understand that I may receive a separate bill if my medical care includes lab services. I further understand that I am financially responsible for any co-pay or balances due for these services if they are not reimbursed by my insurance for whatever reason.
    •  Prescriptions: I acknowledge that my treating physician/medical provider may obtain a prescription history if it is deemed necessary.
    •  Consent to Treatment: I hereby consent to the evaluation, testing, and treatment as directed by my Compassion Health Care, Inc. physician or those under his/her supervision.
    •  
    •  My signature below certifies that I have read and agree to all of the information stated above.
    • *Note: When you enroll, you will receive an email message at the address you gave us at the beginning of this form. You are strongly encouraged to use an email address that only you have access to.
    •  

    • PATIENT MEDICAL HISTORY INFORMATION

    •  
    • Do you have, or have you had, any of the following health conditions?
    •  
    • Have any family members had the following health problems?
    •  
    • Have you had any of the following surgeries?
    •  
    • Social History (Please check all that apply)
    •  
    • Female Patients Only
    •  
    • Do you have any of the following symptoms or conditions? (Please check all that apply)
    •  

    • DISCLOSURE OF PROTECTED HEALTH INFORMATION

    • HIPAA (The Health Insurance Portability and Accountability Act) gives you the right to request that we communicate financial and/or medical information to you in confidence by a particular method. In order to protect the privacy and confidentiality of your information, please complete the following. This form will tell us how you wish to be contacted and with whom we may discuss your healthcare, insurance, and billing questions.
    • CHC may contact me at the following phone numbers:
    • This authorization permits the disclosure of protected health information that includes, but is not limited to, test results, diagnosis, treatment, and billing information. This information includes mental illness or developmental disability, psychotherapy notes, HIV/AIDS testing or treatment (including information regarding test order, performance, or results, regardless if the results were positive or negative), sexually transmitted disease, substance abuse, abused of an adult with a disability, sexual assault, child abuse or neglect, genetic testing.
    • I hereby authorize that the protected health information regarding the above-named person may be discussed with me or the following person(s):
    • CHC will continue to communicate with you according to your above response(s) until you change your preferences. We will continue to leave appointment confirmations on your primary phone number. You can make a change by completing a new form. By signing below, you grant permission to the communication outlined above.

    Having trouble with this form?

    CONTACT US