May 18, 2011

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 #
THIRD PARTY CLAIMS: THIS OFFICE DOES NOT BILL THIRD PARTY CLAIMS (MOTOR VEHICLE ACCIDENTS, INJURIES SUBSTAINED SHOPPING, HOMEOWNERS LIABILITY CLAIM, ETC.) PAYMENT IS EXPECTED AT THE TIME OF SERVICE AND A BILLING/RECEIPT WILL BE ISSUED TO YOU FOR BILLING PURPOSES. WORKERS COMPENSATION CLAIMS: WE REQUIRE PRIOR AUTHORIZATION FROM YOUR EMPLOYER BEFORE YOU CAN BE SEEN FOR YOUR INITIAL OFFICE VISIT. IF YOUR CLAIM IS DENIED, EVEN THOUGH YOUR EMPLOYER AUTHORIZED THE VISIT, YOU WILL BE HELD FINANCIALLY RESPONSIBLE FOR PAYMENT IN FULL ON YOUR ACCOUNT. NARCOTIC/PAIN MEDICATION: IF THESE MEDICATIONS ARE PRESCRIBED FOR YOU WE REQUIRE A COPY OF YOUR DRIVERS LICENSE AND YOUR THUMB PRINT. PATIENT/PARENT/AUTHORIZED OR LEGAL GUARDIAN SIGNATURE ( SIGNATURE VERIFIES YOU HAVE BEEN NOTIFIED OF THE ABOVE FOR THIS OR ANY FUTURE VISITS THAT MAY APPLY) OUR POLICY IS PAYMENT AT THE TIME OF SERVICE –WE ACCEPT CASH, VISA, MASTERCARD, DISCOVER, OR CHECK Primary Insured Primary Insured Social Security # What is your co-pay or deductible? 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.
Social Security Number
Reason For Visit
By submiting this form you are siging in at the Hilltop Drive Office. Please Note: that our usual wait time runs approx. 30 mins. However, it can be more or less than that on any given day. So you are welcome to call to confirm how long we are estimating the wait to be as of right now. (Ph 530-221-1565). If you do not wish to sign in at this time, you can print this form and bring it with you whenever you decide to come.