[[[["field108","equal_to","Other Cancers?"]],[["show_fields","field109"]],"and"],[[["field110","equal_to","Other Cancers?"]],[["show_fields","field111"]],"and"],[[["field112","equal_to","Other Cancers?"]],[["show_fields","field113"]],"and"],[[["field114","equal_to","Other Cancers?"]],[["show_fields","field115"]],"and"],[[["field97","equal_to","Yes"]],[["show_fields","field98,field99,field100"]],"and"],[[["field104","equal_to","Yes"]],[["show_fields","field102,field179"]],"and"],[[["field106","equal_to","Yes"]],[["show_fields","field107,field108,field110,field112,field114,field116"]],"and"],[[["field132","equal_to","Yes"]],[["show_fields","field133,field140,field139,field138,field137,field136,field135,field141,field134,field142"]],"and"]]
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CAROLINA COLORECTAL SURGERY
New Patient Registration
Patient Information
Today's Date
date_range
Last Name
First Name
Middle
Date of Birth
date_range
Sex
Social Security #
Parent or Guardian Last Name
Parent or Guardian First Name
Address
City
State
Zip
Home PhoneBest Daytime
Mobile PhoneMobile
Preferred Contactplease choose one
Ethinicity
Race
Emergency Contact Person:
Name
Relationship
PhoneEnsure its not your phone number
Referring Physician:
Full Name
Phone
AddressPractice name & address/city
Fax
Cardiologist Physician:
Full Name
Phone
AddressPractice name & address/city
Fax
Insurance Information
Primary Insurance
Insurance Name
ID Number
Group#
Policy Holder Informationcheck if same as above
Last Name (Policy Holder)
First Name
Middle Initial
Date of Birth
date_range
Sex
SSN
Relationship to the patient
explain(if selected 'Other' above)
Mailing Address(if different from patient's address above)
Secondary Insurance
Insurance Name
ID Number
Group#
Policy Holder
explain(if selected 'Other' above)
Medications
Current MedicationsList all medications, both prescription and non-prescription that you are taking:
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(2)
Allergies to MedicationsList all medications, both prescription and non-prescription that you are allergic to:
Medication NameType of allergic reaction (such as rash or breathing difficulty)
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(2)
Are you allergic to LATEX?
Pharmacy Details (Preferred)
Pharmacy Name
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Intersecting Streets
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PAST OR PRESENT MEDICAL CONDITIONS
Have any past medical history?(if you selected 'Yes', please check conditions below)
Check all medical conditions
Cancer, any other type
Other(list any other health conditions)
SURGICAL HISTORY
Do you have any surgical history?(if 'Yes', check all procedures below)
Check all past procedures
Other Surgeries
FAMILY MEDICAL HISTORY
Any known family history?(if 'Yes', check all procedures below)
Has any member of your family ever had the following
MOTHERcheck all applicable
If 'Other Cancers'explain
FATHERcheck all applicable
If 'Other Cancers'explain
SISTERcheck all applicable
If 'Other Cancers'explain
BROTHERcheck all applicable
If 'Other Cancers'explain
Other Family Medical History
SOCIAL HISTORY
Marital Status
I currently live
Employment
Occupation
Alcohol History
Tobacco History
Recreational Drug History
If used recreational drugs or substancesprovide which ones did you use
0 /
Review of Current Symptoms
Do you have any current symptoms?
General Symptoms
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Women ONLY Symptoms
Please list any other symptoms you have
0 /
AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

It is our policy at Carolina Colorectal Surgery to never release your medical records to anyone. However, we understand the need to allow certain access to protected information at your request. In order to be able to release any information regarding your care to anyone (spouse, family, significant other, etc...) you will need to complete the form below. If not just select the box below.

The below named person(s) is/are given authorization to my medical records. I understand that I can revoke my authorization at anytime. I understand that the request for revocation will have to be given to Carolina Colorectal Surgery in writing. I further understand that any information released prior to receiving the request for revocation cannot be contested.

Name
Relationship
Phone#
Name
Relationship
Phone#
Name
Relationship
Phone#
Name
Relationship
Phone#
By signing, I authorize Carolina Colorectal Surgery to use and/or disclose certain protected health care information.
Patient Name
Patient Signature (Parent if minor)
Clear
Date
date_range
MEDICAL SERVICE COVERAGE AND PAYMENT AGREEMENT

I hereby authorize Carolina Colorectal Surgery to perform Medical Services.


I hereby agree that any insurance benefits associated with any services rendered by Carolina Colorectal Surgery or their representatives are hereby assigned to Carolina Colorectal Surgery.

I FURTHER AGREE THAT ANY PORTION OF THE BILL UNPAID IS MY RESPONSIBILITY.

I understand the following:

  • It is my responsibility and not that of "Carolina Colorectal Surgery" to check my insurance policy for coverage and benefit information.
  • Any services not covered by my insurance company are my responsibility.
  • Co-pays are to be paid at check-in.Any bill unpaid after 30 days will be subject to a late fee of $20 per month until bill is paid.
  • Any bill unpaid after 90 days will be subject to be turned into Collections.
  • Patients who miss an appointment without 24 hour notice will be charged a fee of $25.00
  • If you are scheduled for surgery and miss your pre-testing, your surgery will be cancelled and rescheduled for the next available time.
  • All surgeries must be cancelled 1 week prior to the date of surgery or you will be charged a fee of $150.00
  • All returned or cancelled checks will be charged a fee of $25.00
  • Prescriptions and refills may take up to 48-72 business hours to process.
  • All calls will be returned within 24 business hours.
I have carefully read the above statements and am in complete understanding of them.
Patient Name
Patient Signature
Clear
Date
date_range
HIPAA Agreement

I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 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 care among the multiple healthcare providers who may be involved in that treatment directly or indirectly.
  • Obtain payment from designated third-party payers.
  • Conduct normal health care operations such as quality assessments or evaluations and physician certifications.
I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. Available upon request in the office in print form and is also available online (https://ccrsurgeons.com/notice-of-privacy-practices/). I have reviewed or have chosen not to review such Notice of Privacy Practices prior to signing this consent, and acknowledge that I have studied or have chosen not to study the Privacy Practices prior to signing this consent. I understand that this organization has right to change its Notice of Privacy Practices from time to time, and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that this organization restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand the organization is not required to agree to my requested restrictions, but if the organization does agree, then it is bound to abide by such restrictions.

I understand that I am able to revoke this consent in writing at any time, except to the extent that the organization has taken action relying on this consent.
Patient Name
Patient Signature
Clear
Date
date_range
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