Adult Patient Information

Adult Registration Form - Medical

Patient Information

Spouse / Partner Information

Marital Status

Person(s) OK to release appointment or medically related information to concerning you:

Insurance Information


I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims and to any Physician or Health Care Provider to whom I might be referred for medical reasons. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics.


I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected heatlh information. I have read your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that Surgical Associates, P.C. has the right to change its Notice of Privacy Practices from time to time and that I may contact them at any time to obtain a current copy of the notice.

Authorization use and Disclosure of information for FMLA and Disability Forms

I authorize, Surgical Associates, P.C. to disclose my personal health information to my employer, FMLA and/or disability for short term benefits for the purpose of returning to work and/or disability information.

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