Patient Registration and Financial Agreement Form
This form is used for patient registration and financial agreement with PORT Health Services. It includes personal details, insurance information, emergency contacts, and consent for treatment. Patients must review and fill out this form to receive services.
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How do I fill this out?
Completing the Patient Registration and Financial Agreement Form is simple. Start by providing your personal details, followed by your insurance information. Finally, read through the financial agreement, sign the consent for treatment, and submit the form.
How to fill out the Patient Registration and Financial Agreement Form?
1
Provide your personal details.
2
Fill in your insurance information.
3
Enter your emergency contact details.
4
Review the financial agreement.
5
Sign the consent for treatment.
Who needs the Patient Registration and Financial Agreement Form?
1
Patients registering for PORT Health Services need it to provide their personal and insurance information.
2
Caregivers of minors need it to give consent for treatment and indicate custody details.
3
Veterans or active military personnel need it to disclose their military status and housing arrangements.
4
Students seeking mental health or substance use treatment need it for school-based therapy services.
5
Uninsured patients need it to apply for a reduced fee based on their monthly income and household size.
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1
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2
Click on the text fields to begin editing.
3
Enter your information and make necessary adjustments.
4
Add your signature in the designated fields.
5
Save and download the edited document.
What are the instructions for submitting this form?
Submit the completed form via email to info@porthealthservices.org, fax to (252) 830-7551, or mail to PORT Health Services, 1035 Medical Center Blvd, Greenville, NC 27834. Ensure all required fields are filled out and all necessary documents are attached. For online submission, use PrintFriendly's PDF editor to fill out and submit the form directly. If you have any questions, contact PORT Health Services at (252) 830-7551 for assistance.
What are the important dates for this form in 2024 and 2025?
The form should be submitted annually. For 2024 and 2025, ensure to update and submit your form at the beginning of each year.
What is the purpose of this form?
The purpose of this form is to gather all necessary information for patient registration with PORT Health Services. This includes personal details, insurance information, and any specific medical conditions or allergies the patient may have. Additionally, the form ensures that patients understand and agree to the financial policies and consent to treatment, providing a clear and comprehensive overview of their responsibilities and rights while receiving care.
Tell me about this form and its components and fields line-by-line.
- 1. Personal Details: Includes name, gender, social security number, birth date, address, and contact information.
- 2. Insurance Information: Contains details about the patient's insurance plan, policy number, and a requirement for a copy of the insurance card.
- 3. Emergency Contacts: Lists the patient's emergency contacts and their relationship to the patient.
- 4. Financial Agreement: Outlines the financial policies, including patient payment responsibilities, insurance claims process, and credit and collection terms.
- 5. Consent for Treatment: Includes consent for various treatment options and services provided by PORT Health Services.
What happens if I fail to submit this form?
Failure to submit this form may result in inability to receive services from PORT Health Services. Additionally, patients may miss out on potential benefits and reduced fees.
- Ineligibility for Services: Without submission, the patient may not be registered for necessary health services.
- Insurance Issues: Failure to provide insurance information may lead to denial of coverage.
- Missed Appointments: Incomplete registration may result in missed appointments and delays in treatment.
How do I know when to use this form?
- 1. New Patient Registration: For first-time patients registering with PORT Health Services.
- 2. Updating Information: To update personal or insurance information for existing patients.
- 3. Consent for Treatment: Required for receiving mental health or substance use treatment services.
Frequently Asked Question
Can I edit this PDF form on PrintFriendly?
Yes, you can easily edit the form using PrintFriendly's PDF editor.
How do I fill out the personal details section?
Enter your name, address, contact information, and other personal details in the respective fields.
What should I do if I don't have insurance?
You can apply for a reduced fee based on your monthly income and household size.
How do I add my emergency contact information?
Enter the name, relationship, and contact number of your emergency contact in the designated fields.
Can I sign the PDF on PrintFriendly?
Yes, you can add your signature using PrintFriendly's PDF editor.
Is it possible to share the completed form?
Yes, you can share the PDF via email or generate a shareable link on PrintFriendly.
How do I review the financial agreement section?
Carefully read through the financial agreement terms provided in the form.
What information is required for the insurance section?
Provide your insurance details including plan name, policy number, and a copy of your insurance card.
How long is the consent for treatment valid?
The consent for treatment is valid for one year unless you withdraw it.
Can I change my consent preferences?
Yes, you can change your preferences by editing and resubmitting the form.
