Patient Information and Registration Record
Billing Information
Emergency Contact Information
Payment and Treatment Consent
Consent for Treatment: I hereby consent to any treatments, diagnostic tests or studies necessary by any physician or staff member of Northridge Family
Healthcare Center. Release of informatyion to third party. I hereby authorize Northridge Family Healthcare Center to furnish information concerning
my treatment, diagnosis, tests, and illness to third party payers for payment of fees incurred during treatment and diagnosis. I also understand that any
portion that is not covered by insurance is my responsibility to pay. I understand Northridge Family Healthcare Center may use any means deemed
necessary to collect a debt. Payment is expected at time of service for all co-pays and deductibles.
Patient Medical History
Family History
Other Health Issues
Immunizations
Please include other pertinent medical history and/or medication information that may
not have been covered in this form.
Controlled Substance Agreement
I agree I will not receive any controlled substances from any other facility while being
treated by Burton Medical Group. I will keep all my follow up appointments and I
understand that two missed appointments may result in dismissal from the practice. I
further understand that if I breach this agreement I will be dismissed as a patient from
Burton Medical Group.
NO-Show Fee
I understand there will be a $25.00 no-show fee applied to account for every missed
appointment that isn’t cancelled or rescheduled within 24 hours of made appointment,
without a valid excuse.
Patient History
Allergies
Current Medications
Procedures/Surgeries
Preventitive Screening
Women’s Health
Patient Health Questionare (PHQ-9)
Over the last two weeks, how often
have you been bothered by any of the
following problems?
CONSENT TO THE USE OF DISCLOSURE OF PROTECTED HEALTH
INFORMATIONFOR TREATMENT, PAYMENT OR HEALTHCARE
OPERATIONS
I consent to the use of disclosure of my protected health information (PHI) by Burton
Medical Group, LLC for the purpose of diagnosing or providing treatment ot me,
obtaining payment for my health care bills or to conduct health care operations of Burton
Medical Group, LLC. I understand that diagnosis or treatment of me by Burton Medical
Group, LLC may be conditioned upon my consent as evidence by my signature on this
document.
I understand that I have the right to request a ristriction as to how my (PHI) is used or
disclosed to carry out treatment, payment or healthcare operations of the practice. Burton
Medical Group, LLC is not required to agree to the restrictions that I may request.
However, if Burton Medical Group, LLC agrees to a restriction that I request, the
restriction is binding on Burton Medical Group, LLC.
Mid-Level Providers
Our office utilizes Nurse Practitioners/Physician Assistants for those levels of practice
that have been approved by Georgia State Board of Medical Examiner. I understand and
agree with being treated by a Nurse Practitioner/Physician Assistant, who is ating under
the supervision of Dr. Frederick A. Burton, Jr. for minor illnesses and injuries.
External Prescription History and Consent
I authorize Burton Medical Group and it’s affilliated providers to view my external
prescription history via the RxHub or similar service. I understand that prescription
history from multiple other unaffiliated medical providers, Insurance companies, and
pharmacy benefit managers may be viewable by my providers and staff at Burton
Medical Group, LLC, and it may include prescriptions for the past several years. My
signature below certifieds that I have read and understand the scope of my consent and
that I authorize access as described.
Controlled Substance Privacy
I understand I must comply with the following rules retgarding prescription medications
while being treated by Burton Medical Group, LLC.
● I will note share, exchange, or sell my prescription medications.
● I will not use narcotic medications unless prescribed to me by my provider at
Burton Medical Group, LLC.
● It is my responsibility to keep my medication safe. Medications that are lost,
damaged, or stolen may or may not be refilled early at the sole discretion of
Burton Medical Group, LLC after case-by-case, individual consideration.
● I agree to provide samples for random drug testing. If I fail to provide the
requested samples when requested or if the results of a drug test are
unsatisfactory, I may forfeit the right to continue receiving medications and/or
healthcare from Burton Medical Group, LLC.
I have the right to revoke this consent, in writing, at any time, except to the extent that
Burton Medical Group, LLC has taken action in reliance on this consent.
My “protected health information” (PHI) means my individually identifiable health
information, including my demographic information, collected from me and created or
received by my physician, another health care provider, my health plan, my employer or a
healthcare clearing house. This protected health information relates to my past, present
or future physical or mental health or condition and identifies me, or there is reasonable
basis to believe the inforation may identify me.
I understand that I have a right and have been given an opportunity to review Burton
Medical Group, LLC’s Notice of Privacy Practices prior to signing this document.
Burton Medical Group, LLC’s Notice of Privacy Practices has been provided to me. The
Notice of Privacy Practices describes the types of uses and disclosures of my protected
health information that will occur in my treatment, payment of my bills or in the
performance of healthcare operations of Burton Medical Group, LLC. The Notice of
Privacy Practices is also posted in our waiting room and on our website at
www.burtonmedicalgroup.com. This Notice of Privacy Practices also describes my
rights and Burton Meidcal Group, LLC’S duties with respect to my protected health
information.
Burton Medical Group, LLC reserves the right to change the terms and conditions that
are described in the Notice of Privacy Practices. I may obtain ba revised notice of
Privacy Practices by accessing the Burton Medical Group, LLC’s website, calling the
office and requesting a revised copy be sent in the mail or asking for one at the time of
my next appointment.
HIPAA/RELEASE OF INFORMATION PER PATIENT’S ASSIGNMENT
I have acknowledged/received
a written copy of the Burton Medical Group Notice of Privacy Practices and I authorize
any physician/staff employee of Burton Medical Group to engage in any verbal or written
communication to any/all persons listed below regarding my medical
history/care/records/appointment and/or information pertaining to my personal
account/billing history with Burton Medical Group.
VOICEMAIL/ANSWERING MACHINE
I authorize any physician/staff employee of Burton Medical Group to leave health
information on a voicemail/answering machine at the following numbers:
I understand that this authorization may be revoked or modified at any time on
submission of my written request or that of my representative.
