Adult Registration Form, MANA Family Medicine Prairie Grove - Medical Associates of Northwest Arkansas

Patient Registration Form MANA Family Medicine Prairie Grove

Name*
First Middle Last
Preferred Name*
Date of Birth*

Social Security Number
Sex
Male
Female
Prefer Not to Answer
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone*
Cell Phone
Work Phone
Preferred Communication Method
Text
Phone
Please check one:*
Married
Single
Partner
Divorced
Widowed
Please check one:
White
African American
Asian
Native Hawaiian/ Other Pacific Islander
Native American/ Alaskan
Are you of Spanish/ Hispanic heritage?
Yes
No
Preferred Primary Language
Primary Physician
Preferred Pharmacy
Please include street and city so we know which branch you prefer.
Would you like to have access to your health record and communicate online with your physician office through a secure myMANA Health Portal?
Yes
No
Email*

Emergency Contact Information
Emergency Contact*
Relationship*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient Notice of Privacy Practices Acknowlegement
If you would like to authorize MANA clinic to release information to a family member, spouse, or personal representative, please complete the Individual Authorization Form at the bottom of this document.
I have received a copy of the Patient Notice of Privacy Practices from Medical Associates of Northwest Arkansas.
Signature*
Choosing "Yes" below is my electronic signature.
Yes
No
Today's Date*

Representative
In the event this Acknowledgement form is being executed by a personal representative, guardian or parent, please give your name, date of birth, social security number and relationship to the patient here:
How did you hear about us?
Thank you for choosing a MANA clinic. How did you hear about us? Check all that apply.
Person responsible for payment
Responsible Party*
Date of Birth*

Relationship to Patient*
Social Security Number
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Health Insurance Information
Please provide a copy of your insurance card to the receptionist. Fill out Medicare information if you use Medicare.
Medicare Number
Effective Date

Primary Insurance
Company Name
Insurance ID Number
Group Number
Phone
Policy Holder's Name
Date of Birth

Social Security Number
Relationship of Patient to Policy Holder
Seconday Insurance Company
Company Name
ID Number
Group Number
Phone
Policy Holder's Name
Date of Birth

Social Security Number
Relationship of Policy Holder to Patient
Patient Authorization*
PATIENT AUTHORIZATION I hereby authorize Medical Associates of Northwest Arkansas {MANA), in its sole discretion, to seek payment of charges for all services rendered during or in connection with my medical treatment from my insurer and/or from third parties {or their insurers} who may have caused, or otherwise be liable for, the incident, injury or condition giving rise to my need for medical treatment. I understand that in the event MANA attempts to collect from those third parties, such attempts are in lieu of, or in addition to, MANA seeking payment from my current medical insurance provider. I understand and agree that any discounts which MANA has agreed to accept from my medical insurance provider will not be applied to reduce amounts payable by, or recoverable from, third parties or their insurers. I hereby assign and authorize payment directly to MANA of all insurance benefits, sick benefits and injury benefits due because of liability of a third party and proceeds of all claims resulting from the liability of a third party to me or for my benefit unless all charges are paid in full immediately upon completion of my medical treatment. I further agree that this assignment will not be withdrawn at any time until the account is paid in full and consent to MANA's assertion of subrogation or lien rights, if necessary, to protect MANA's interest in recovering from third parties the full amount of charges for services rendered during or in connection with my medical treatment. I agree to pay at the time of service any co-pay or amount otherwise required by my current medical insurance provider and understand that I am responsible for any amount not covered by Insurance or collected by MANA from a third party. MANA Is authorized to give information regarding me, my case and my medical treatment to my current medical Insurance provider and/or to potentially financially responsible third parties and their insurers. By choosing YES below I sign this statement.
Yes
No
Adult Health History
Please complete the information below to the best of your knowledge to help the doctor evaluate your health. Ask for assistance at the front desk if you need help filling out this form.
Name
First Last
Today's Date

Date of Birth

Why are you visiting the doctor?
General check up or wellness visit
A particular problem
Do you feel that you are basically healthy?
Yes
No
What is bothering you?
Your Father
Date of Birth

State of Health
Age of Death
Health Conditions
Your Mother
Date of Birth

State of Health
Age of Death
Health Conditions
Other Family Members
Your Siblings
Please list date of birth, state of health, age of death, and health conditions for any siblings. Use the + button to add more rows.
Sibling 1 Sibling 2 Sibling 3

Your Children
Please list date of birth, state of health, age of death, and health conditions for any sons and daughters. Use the + button to add more rows.
Child 1 Child 2 Child 3 Child 4 Child 5

Mark any diseases known to have occurred in the family with the appropriate initial: M(Mother), F(Father), GM (Grandmother), GF(Grandfather), A(Aunt), U(Uncle), C(Cousin), B(Brother), S(Sister). Use the plus button to add more rows if needed.
Alzheimer Asthma Alcoholism Blood Disease Coronary Artery Disease Cancer Stroke Depression Development Problems Diabetes

Hearing Problems Cholesterol High Blood Pressure Mental Disease Migraines Obesity Blood Clots Kidney Problems Seizures Sickle Cell

About You
Education
Present Occupation
Previous Occupation
Marital status
Single
Married
Widowed
Divorced
I live with...
Family
Alone
Tobacco Use
Please specify amount used.
Alcohol Use
How much alcohol and how often?
Illicit Drug Use
Please list drugs used
Caffeine Use
Yes
No
Type and amount of caffeine use
Allergic to to any medications?
Please specify any allergies.
Medications
Please list medications you take regularly, with the dosage. Include over the counter and prescription drugs.
Your Health History
Medical conditions
Other Medical Conditions
Operations
List type, cause, where, and when.
Injuries
List type, cause, where, and when.
Have you been in the hospital for anything other than surgeries?
Yes
No
When and where
Please mark anything you have experienced recently or frequently.
Items left blank will be considered a "no" answer in your medical record.
Has your weight changed in the past year?
Enter approximate weight one year ago.
For Women
Are you currently pregnant?
Yes
No
Number of Pregnancies
Number of Miscarriages
Number of Living Children
Age when menstrual periods began
Age when periods ended
Are periods regular?
Yes
No
Excess flow?
Yes
No
Spotting between periods?
Yes
No
Authorization to Individuals
I give all physicians and professional staff employed by Medical Associates of NWA, PA, permission to disclose the protected health information set forth below to the following people at the request of one or more of these individuals.
Patient Name
First Last
Date of Birth

Information to be released to the below referenced entity:
Specific Information
Use + button to add more rows
Name Relationship to patient Phone

I give Medical Associates of Northwest Arkansas P.A., permission to leave a message (s) on my answering machine if they should need to remind me of an appointment, change an appointment, etc, and are unable to reach me in any other way.
Yes
No
Electronic Signature
In addition, I understand or acknowledge the following: 1. I understand that Medical Associates of Northwest Arkansas, P.A ., will not release any information to any person(s) not listed above. 2. I have the right to revoke this Authorization at any time by giving Medical Associates of Northwest Arkansas, P.A., a written notice. I understand this does not apply to the release of PHI pursuant to my prior authorization. 3. I have received Medical Associates of Northwest Arkansas’s Notice of Privacy Practices 4. My protected health information may be subject to re-disclosure by one or more of the persons named above and as such may no longer be protected by federal or state law. 5. My treatment is not conditional on signing this statement, except as allowed by Privacy Rule.
Yes
No
In the event the Authorization is being executed by a personal representative, guardian, or parent, please print your name, relationship to the patient, and basis of authorization to act on the patient’s behalf.
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Feel anxious, depressed, or irritable
Nervous breakdown
Fever, chills, night sweats
Skin rashes
Severe or frequent headaches
Hearing trouble
Goiter or thyroid trouble
Vision trouble
Shortness of breath
Asthma
Cough
Heart trouble
Pain in chest
Recent change in bowel habits
Diarrhea
Frequent indigestion or gas
Blood in urine
Burning when passing urine
Sexually transmitted disease
Arthritis
Excessive thirst
Swollen glands
Hay fever or allergies