Full Name (Last, First, MI) *

Nickname (Name you would like to be called)

Date of Birth *

Maiden Name (if applicable)

Marital Status *

Child

Single

Married

Widowed

Divorced

Separated

Other

Gender *

Male

Female

Ethnic Group *

Hispanic or Latino

Not Hispanic or Latino

Declined Answer

Race *

Caucasian (White)

African American

Native American

Hispanic

Other

Declined to Answer

Home Address (Street, City, State, Zip Code) *

Home Phone Number

Cell Phone Number

Work Phone Number

Preferred Reminder Method

Cell Phone

Home Phone

Work Phone

Email Address

Preferred Contact Method

Phone

Mail

Email

Employer Name (if applicable)

Employer Address (Street, City, State, Zip Code)

Occupation

Responsible Person (If other than patient, person responsible for billing) Guarantor's Name

Guarantor's Date of Birth

Guarantor's Full Address (Street, City, State, Zip Code)

Guarantor's Employer

Guarantor's Occupation

Guarantor's Relationship to Patient

Guarantor's Home Phone Number

Guarantor's Cell Phone Number

Guarantor's Work Phone Number

AUTHORIZATION TO RELEASE INFORMATION

I give Cedar Hill Medical, P.C./Cedar Hill Bayside/Cedar Hill Walk-In Clinic, permission to speak with the following people regarding my medical information. This authorization is valid until I provide Cedar Hill Medical, P.C./Cedar Hill Bayside/Cedar Hill Walk-In Clinic written revocation of it.

Primary Emergency Contact Name

Phone Number

Relationship to Patient

Other Contact(s) Name

Phone Number

Relationship to Patient

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT The Notice of Privacy Practices for Cedar Hill Medical, P.C. and/or Cedar Hill Bayside and/or Cedar Hill Walk-In Clinic are available for you to review. I understand that I may request a copy of the notice at any time.

ACUPUNCTURE SERVICES WAIVER I understand that my insurance will be billed for acupuncture and that I will be liable for the entire bill if my insurance does not cover these services.

I hereby state that all information listed above, to my knowledge, is accurate and give consent for treatment. I authorize the release of medical information to obtain payment of any benefits available to me to CHM/CHB/CHWI for services rendered. I authorize that direct payment of any benefits available to me be released to Cedar Hill Medical, PC for services rendered. I also understand that if my insurance company(s) denies payment, because services are not covered under my insurance plan, that I will be responsible for payment or contacting them with any questions on billing. This may include office visits, laboratory or other rendered services. I authorize the disclosure of my personal health information to obtain payment from third parties that may be responsible for such costs. I authorize the disclosure of my personal health information electronically to UPHIE.  I also understand that I may opt-out of sharing my personal health information by requesting an opt-out form from the front office staff. I have read the bottom of this registration and am aware that CHM/CHB/CHWI is a Patient Centered Medical Home.

Patient Digital Signature

Date

Parent / Guardian Digital Signature

Date

To All Patients,

Thank you for choosing Cedar Hill Medical P.C., Cedar Hill Bayside, or Cedar Hill Walk-In Clinic to provide for your health care needs! We are striving to improve the services we offer to you.

We are currently a patient centered medical home. A patient centered medical home is a model of healthcare based on a personal relationship between the patient, provider and the patient’s care team. Whatever the medical needs – primary, preventive care, acute care, chronic care, or end-of-life care – the patient has a medical “home”. A single, trusted provider and care team, through which continuous, comprehensive and integrated care is provided.

In order to best serve your needs, we must work as a team. Below is a description of your responsibilities and those of the provider.

Patient Responsibilities

• Make healthy decisions regarding your health
• Prepare for and keep scheduled visits or reschedule visits in advance
• Tell your doctor about any changes in your health status
• Take all medications as prescribed and follow the provider’s orders
• End every visit with a clear understanding of your provider’s orders, medications, treatment goals and follow up
• Ask questions if unclear
• Come to Cedar Hill Medical P.C. / Cedar Hill Bayside / Cedar Hill Walk-In Clinic or call for all medical concerns, unless it is a medical emergency

Provider Responsibilities

• Listen to patient’s health concerns, symptoms and questions
• Explain diseases, treatments and results in an easy to understand manner
• Assist patient in medical decision making based on current medical research
• Give clear directions about medications and treatments
• Send patients to trusted experts, when needed
• End every visit with clear instructions about orders, treatment goals, and follow up
• Keep all patient information private
• Provide 24 hour access to medical care, same-day and walk-in appointments, whenever possible
• Provide instructions on how to meet your health care needs when the office is not open