July 6, 2010

ATTENTION PLEASE: YOU CANNOT SIGN IN ONLINE BEFORE 8AM OR AFTER 4PM WEEKDAYS, OR BEFORE 9AM OR AFTER 4 PM ON WEEKENDS!

Last Name	First Name	MI SEX
Mailing Address
Street	APT#
City	State	ZIP
Birthdate: Year:		Employer
Home Phone	Cell Phone	Employer’s Phone
Spouse’s Name

IF PATIENT IS A MINOR, PLEASE FILL OUT THIS SECTION:
Responsible Party	Relationship to Patient
Parent’s Name	Parent’s Social Security#
Responsible Party’s Phone	Cell Phone #
Responsible Party’s Employer	Employer Phone #

Please list the person(s) that we, as healthcare professionals –using our best judgment –may contact and/or disclose your health or payment information.
Emergency Contact: Name	Phone #
Please list the person(s) that we, as healthcare professionals –using our best judgment –may contact and/or disclose your health or payment information.
MEDICAL RECORDS RELEASE AUTHORIZATION TO DISCLOSE HEALTH INFORMATION Hilltop Medical / Hilltop Medical West must have authorization from the patient (by law) to speak to anyone else regarding health and/or medical billing. This includes spouses and/or parents of children that are 18 years or older. I understand that authorizing the disclosure of health/billing information in voluntary. I can choose not to designate anyone to release my records to. I understand I have the right to revoke this authorization in writing at any time. I understand that the revocation will not apply to information that has already been released in response to this authorization. Please mark ONE of the following boxes. I DO NOT WISH to designate an authorized person at this time. I authorize Hilltop Medical / Hilltop Medical West to release any health and/or billing information to the following individual (other than parent of a minor) Name: Relationship:
OUR POLICY IS PAYMENT AT THE TIME OF SERVICE –WE ACCEPT CASH, VISA, MASTERCARD, DISCOVER, OR CHECK Primary Insured Primary Insured Social Security # Co-pays and deductibles are due at the time of service. TREATMENT AUTHORIZATION – I grant permission to the physician and staff as directed by the physician of Hilltop Medical Clinic/Hilltop Medical Clinic West to perform any medical or surgical treatment and to administer such local anesthetics and/or drugs as may be deemed necessary in the diagnosis and treatment of said patient for today and future office visits. FOR A CHILD PATIENT – I understand by authorizing treatment I am also accepting responsibility to be the financial party on this and all future office visits for this minor patient until (s)he is legally considered and adult at age 18. PATIENT/PARENT/AUTHORIZED OR LEGAL GUARDIAN SIGNATURE
Social Security Number
Reason for Visit:
By submiting this form you are siging in at the Eureka Way Office. You are expected to show up within 30 minutes.