Patient Online Forms

REGISTRATION FORM



PATIENT INFORMATION











     I authorize Premier Medical Associates to release to any insurance company/Medicare or its carriers any information needed to process and pay my claims. I permit a copy of this to be used for that purpose and to request payment of medical insurance and medical benefits to be made directly to Premier Medical Associates. I understand that it is mandatory to inform the healthcare provider of any other party who may be responsible for paying any deductible amount, co pay, or any percentage fees not paid by the insurance company of third party within a reasonable time which is not to exceed 60 days. I also authorize payment of my insurance/ Medicare benefits to be paid directly to Premier Medical Associates for my treatment. I also understand that it is my responsibility to pay any unpaid amounts not paid by the insurance company/Medicare.

     Insurance regulations suggest that we inform you in advance of we believe a service may not be covered or fully reimbursed by your insurance. In the doctors professional judgment certain services are needed in order to give high quality healthcare and to help provide a diagnosis, but some services may not be reimbursed by them. These services may include but are not limited to an EKG, lipid profile, protime, biopsy, etc. We will only perform these services when required and the results will help us to provide you with optimum care. Patient Agreement: I certify that I have read and fully understand the above information. I understand that I will be responsible for payment of any medically necessary services should they be denied by my insurance.

     I understand that I have the right to accept and refuse medical treatment and to exercise my right and implement an Advance Directive. An Advance Directive refers to any legal document that informs family members and medical personnel how you wish to be treated if you are hospitalized and cannot communicate your wishes. Please check the following statements that apply: Our office requires a copy of such documents.

 I have not executed an Advance Directive
 I have executed an Advance Directive
 Living Will
 Durable Medical Power of Attorney
 Do Not Resuscitate (DNR)