Registration

Complete the form below and it will be securely sent to your specialist‘s office.

Step 1 of 12 - Personal Information

Contact Information
Primary Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Second Address
Do you have another address?
- Yes
Secondary Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home phone
Cell phone
Day phone
Email
Emergency contact
Emergency Contact Name*
Relationship*
Emergency contact phone

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Insurance
Insured or Self Pay*
- Insured
- Self-Pay
Primary insurance*
Insured person's name*
Insured person's birth date*
Month
Day
Year
Policy ID number
Hidden
Policy ID number (archive)
Group Number
Hidden
Group number (archive)
Primary insurance - claims billing address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Second Insurance
- Yes
Do you have a secondary insurance plan?
Secondary insurance company
Secondary insurance ID number
Hidden
Secondary insurance ID number (archive)
Secondary insurance group number
Hidden
Secondary insurance group number (archive)
Secondary insurance - claims billing address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer
Employer
Occupation
Employer phone number

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Pharmacy
Pharmacy Name*
Pharmacy Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Pharmacy phone number*
Secondary Pharmacy
- Yes
Do you have a second pharmacy we should keep on file?
Pharmacy #2 name
Pharmacy #2 address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Pharmacy #2 phone number

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Medical History
Conditions
Add all medical conditions that apply.
Medical Conditions Actions
Edit

Delete
There are no Conditions.
Maximum number of conditions reached.

Medical Conditions	Actions
	Edit Delete
There are no Conditions.

Surgery

Add all procedures you have had.

Procedure	Archived Procedure Date	Actions
		Edit Delete
There are no Procedures.

Maximum number of procedures reached.

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Medical

Family Conditions

Family conditions	Relation	Onset Age	Actions
			Edit Delete
There are no Conditions.

Maximum number of conditions reached.

Current Medications

Medication	Strength	Daily dose	Reason Prescribed	Actions
				Edit Delete
There are no Meds.

Maximum number of meds reached.

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Allergies

Allergies

Allergies	Note	Actions
		Edit Delete
There are no Allergies.

Maximum number of allergies reached.

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Request for Confidential Communication

HIPAA privacy rules give certain individuals the right to request confidential medical information. In that regard, you may select the method in which this confidential medical information is communicated. Also, ACS may need to communicate with you regarding your confidential medical information. Please select your preferred method of contact. If you would like to change your contact information in the future, please provide your request in writing to the address contained within the Privacy Practice Notice.
Approved Contacts
I give permission to disclose my confidential medical information to the following individuals:
Name Relationship

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Signature

We may be prescribing medications electronically and need your permission to access your prescribed medications to avoid drug interactions and duplication. Your signature below will act as permission.

Completing this documentation prior to your appointment does not establish a Patient-Physician Relationship. Information will be reviewed by your provider when you are seen.
Information Accuracy*
I attest the information provided is true and accurate.
I acknowledge I have read, signed and will abide by the Arizona Community Specialists Patient Payment and Financial Policies.
Notice of Privacy and HIPAA*
I acknowledge and consent to the Notice of Privacy and HIPAA.
I understand that under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the Omnibus Rules of 2013, I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan, and direct my treatment and follow up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such as quality assessments and physician certifications.

I acknowledge that I have received or had the opportunity to review the Notice of Privacy Practices from Arizona Community Specialists (“ACS”), which contains a more complete description of the uses and disclosures of my health information. I understand that ACS has the right to change its Notice of Privacy Practices from time to time and that I may contact ACS at any time to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that ACS restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand ACS is not required to agree to my requested restrictions, but if ACS does agree then ACS is bound to abide by such restrictions.

ACS does not discriminate based on race, age, sex, sexual orientation, or ethnicity.
Finance Policy Acknowledgement
I have read and agree to the Payment Policy.
I agree to the Payment Policy and Assignment and Release of Information stated in the policy. I acknowledge my financial responsibility related to the services provided by Arizona Community Specialists.
Prescriptions and Narcotics Agreement
I have read and agree to the Prescriptions and Narcotics Agreement.
Medication History
I give Arizona Community Surgeons permission to obtain my medication history
Exam and Treatment
I hereby consent to the clinical exam and treatment to be provided.
Insurance
I give ACS permission to bill my insurance company (if applicable).
Arizona Community Services may bill my insurance for services and/or product(s) received on my behalf.
Electronic Signature*
I acknowledge use of E-Signature
My signature is acknowledgement of receipt of the policies and notices above. I understand I am responsible for reviewing and understanding the information provided by ACS and agree to comply. My signature confirms the information provided to ACS is true and accurate.

I ACKNOWLEDGE TYPING MY NAME BELOW CONSTITUTES AN ELECTRONIC SIGNATURE.
Patient Signature*

(or Parent/Guardian if patient is a minor)
Signature Date*
MM slash DD slash YYYY
Guarantor
Guarantor/Persons liable for bill, if other than the patient:
Guarantor Phone
Hidden
Guarantor Signature Date (ARCHIVED)
MM slash DD slash YYYY

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Tobacco used	Daily use?	How many/much per day:	Age started	Age stopped

Vape used	Daily use?	How many/much per day:	Age started	Age stopped

Step 1 of 12 - Personal Information

Contact Information

Emergency contact

Insurance

Employer

Pharmacy

Demographics

Medical History

Tobacco and Nicotine use

Medical

Allergies

Review of Systems

Request for Confidential Communication

Signature

Name	Relationship