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Available Forms

Child Registration

Patient Information

MM/DD/YYYY
NNN-NN-NNNN Required by hospitals and laboratories.
Select One.

Parent / Legal Guardian:

We hate spam too. Our purpose of requesting your email is to give you access to our patient portal and appointment reminders.
Include area code.
Include area code.
Include area code.
Select One.

Emergency Contact Information:

MM/DD/YYYY
Check box to authorize.
Please type your name to electronically sign.

Insurance Information:

If selected, skip the rest of this section.
Please include full name of insurance company and product.
If applicable.
Select One.
If patient is not subscriber.
If patient is not subscriber.
 

Please Read Carefully and Sign

Payment is due at time of service. We collect payment for services before the patient's visit. Any remaining balance due will be collected upon checkout. After submitting the claim to insurance, if any remaining patient responsibility exists, you will receive a bill.

If you wish for us to file the patient's medical insurance, you must provide us with a current copy of their insurance card.

If we are unable to obtain verification of the patient's benefits from your insurance company, you will be required to pay the full amount due, at the time of service.

If the patient's insurance denies their claim, you will be responsible for any remaining balance.

While we will do our best to obtain the patient's benefits from your insurance company, you are ultimately responsible for knowing their insurance coverage information. For example, what their plan does and does not cover; any deductibles, co-insurance, or co-pays you are responsible for.

If we cannot fully verify the patient's health plan coverage or benefits from your insurance company, we reserve the right to bill you for any additional amount your insurance company informs us is assigned to patient responsibility after processing their claim.

If the patient does not possess health insurance and are "self pay", you are responsible for the full amount due at the time of service.

By electronically signing below, I authorize the release of any medical and personal information necessary to process claims for medical services rendered. I also request payment of government benefits either to myself or the party who accepts assignment. I authorize payment of medical benefits to Clay Primary & Family Care, LLC for any services rendered, medical equipment, and products used in my care and treatment.

By electronically signing below, I am agreeing to all the terms above and that I understand that I am responsible for payment at the time when services will be rendered. I also understand that the patient's total when checking out is an estimate of my financial responsibility, and give Clay Primary & Family Care, LLC the right to bill me for any remaining balance that may result after the insurance company has processed the claim. Finally, I understand that any unpaid balance may result in my personal information being sent to a collections company, for the purpose of collecting my past due debt.

Please type your name to electronically sign.
 

Past Medical History

Select all that apply. Provide additional details below in the "Other Medical Conditions" box.
Type, stage, surgery, current status, etc
Please list all medications including strength dose and how many times you take each per day.
Please include location.
Include area code.
Please list all and include reaction. If you have no known allergies, please write "None".
Please list all and provide dates

Family Medical History

Select all that apply.
Which family member had what condition.
 

HIPAA Patient Consent for Use and Disclosure of Protected Health Information

I hereby give my consent for Clay Primary & Family Care, LLC to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by Clay Primary & Family Care, LLC describes such uses and disclosures more completely.)

I have the right to review the Notice of Privacy Practices prior to signing this consent. Clay Primary & Family Care, LLC reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to, "Attn: Compliance Officer at 865 Blanding Blvd., Orange Park, Fl 32065".

With this consent, Clay Primary & Family Care, LLC may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.

With this consent, Clay Primary & Family Care, LLC may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards, patient statements, and medical records.

With this consent, Clay Primary & Family Care, LLC may electronically (text, patient portal, etc) send any items that assist the practice in carrying out TPO, such as appointment reminders, and patient statements, and medical records. I have the right to request that Clay Primary & Family Care, LLC restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

With this consent, Clay Primary & Family Care, LLC and all its agents may report or otherwise cooperate with any law enforcement officials or regulatory agencies in any investigation which may arise as a result of, or related to, my receiving controlled substances as a patient of Clay Primary & Family Care, LLC, or if Clay Primary & Family Care, LLC or its agents suspect illegal activity.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Clay Primary & Family Care, LLC may decline to provide treatment to me.

By signing this form, I am consenting to allow Clay Primary & Family Care, LLC to use and disclose my PHI to carry out TPO.

Type your name to electronically sign.
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