Registration

Provider*

Which surgeon will you be seeing?

First name*

Middle Name

Last name*

Preferred Name

Social Security

Birth Date*

Birth state

Age*

Height

Weight

Hidden

partnerid

filled automatically based on other fields. Used for to validate permissions on form entries

Hidden

partneremail

filled automatically based on other fields. Used for to validate permissions on form entries

Birth Sex*

Female

Male

Preferred pronoun

Current Gender

Female

Male

Choose not to disclose

Other

Gender Identity

Female

Male

Choose not to disclose

Other

Hidden

Sexual Orientation (ARCHIVED)

Straight or heterosexual

Choose not to disclose

Bisexual

Lesbian, gay, or homosexual

Don't know

Other

Contact Information

Primary Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Hidden

Second Address (ARCHIVED)

Do you have another address?

Yes

Hidden

Secondary Address (ARCHIVED)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home phone

Cell phone

Hidden

Day phone (ARCHIVED)

Email

Emergency contact

Emergency Contact Name*

Relationship*

Emergency contact phone

Insurance

Insured or Self Pay*

Insured

Self-Pay

Primary insurance*

Policy ID number

Group Number

Policy Holder

If other than the patient

Policy holder birth date*

Relationship to patient?

Hidden

Policy ID number (archive)

Hidden

Group number (archive)

Primary insurance 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 policy holder

If other than the patient

Secondary insurance policy holder birth date

Relationship to patient?

Hidden

Secondary insurance - claims billing address (ARCHIVED)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you have AHCCCS?

Yes

No

Employer

Occupation

Employment status

Hidden

Employer phone number (ARCHIVED)

Pharmacy

Pharmacy Name*

Pharmacy Cross Streets*

for example: Ft. Lowell & Campbell

Pharmacy phone number (ARCHIVED)

Hidden

Pharmacy Address (ARCHIVED)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Hidden

Secondary Pharmacy (ARCHIVED)

Yes

Do you have a second pharmacy we should keep on file?

Hidden

Pharmacy #2 name (ARCHIVED)

Hidden

Pharmacy #2 Cross Streets (ARCHIVED)

for example: Ft. Lowell & Campbell

Hidden

Pharmacy #2 address (ARCHIVED)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Hidden

Pharmacy #2 phone number (ARCHIVED)

Medical History

Conditions

Add all medical conditions that apply.

Medical Conditions	Actions

There are no Conditions.

Surgery

Add all procedures you have had.

Procedure	Archived Procedure Date	Actions

There are no Procedures.

Medical

Family Conditions

Family conditions	Relation	Onset Age	Actions

There are no Conditions.

Current Medications

Medication	Strength	Daily dose	Reason Prescribed	Actions

There are no Meds.

Allergies

Allergies	Note	Actions

There are no Allergies.

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

Signature

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.

Electronic Prescriptions*

I give ACS permission to access my prescribed medications

ACS providers may prescribe medications electronically. By initialing, you give ACS permission to access your prescribed medications.

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*

Guarantor

Guarantor/Persons liable for bill, if other than the patient:

Guarantor Phone

Hidden

Guarantor Signature Date (ARCHIVED)

Contact Information

Emergency contact

Insurance

Employer

Pharmacy

Demographics

Medical History

Tobacco and Nicotine use

Medical

Allergies

Review of Systems

Request for Confidential Communication

Signature