Patient Registration Information Today's Date MM slash DD slash YYYY Social Security Number Date of Birth* MM slash DD slash YYYY Name* First MI Last Email Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing address if different from street address Primary Phone home cell work Primary Phone # Alternate Phone cell home work Alternate Phone # Preferred Method of Contact primary phone alternate phone email Primary Language* Race* Ethnicity* Hispanic Non-hispanic Gender Male Female Marital Status Single Married Significant Other Divorced Separated Widow(er) Employment Full Part Retired Disabled Student None Occupation Employer EMERGENCY CONTACT INFORMATIONDo you have an advanced directive?* Yes No Name First MI Last Relationship to patient Primary Phone Cell or Alternate Phone Work Phone Address PRIVACY INFORMATIONOther than yourself, who do you authorize to receive info? Relationship to patient Address Phone number INSURANCE INFORMATIONType of coverage* Insurance Self-pay Primary Insurance* Member ID* Group Number* Secondary Insurance Member ID Group Number PHYSICIAN INFORMATIONPrimary Care Physician (PCP)* First & Last NamePhone number Address Referring Physician (if not PCP)* First & Last NamePhone number Address POLICIES TO BE AWARE OFCancellation Policy: 48 hour notice is required to cancel an appointment. Less than 48 hour notice will incur a $50 fee ($150 new patient appointment) in order to reschedule the appointment; $150 fee to reschedule a sleep study ($75 for home sleep study). Changes: It is your responsibility to notify us of any changes in your contact information, insurance, or other pertinent data. Referrals: It is your responsibility to insure referrals from Primary Care Providers have been issued and received. Lack of required referrals will require your appointment to be rescheduled. Mid-level providers: We utilize a nurse practitioner. Office Hours: 8:30am – 5:00pm Monday – Friday Medications: All current original medication containers or a current complete list of medications should be brought to all appointments. Equipment: CPAP or BiPAP machines should be brought to all appointments unless instructed otherwise. Financial Agreement: Payment of co-pays must be made at time of visit. Privacy Practices: A copy of Pulmonary & Sleep Specialists, PC “Notice of Privacy Practices” may be found on our website (www.pssatl.com) or a printed copy will be provided upon request. Our office is HIPAA compliant. Data Share with Emory Healthcare Network and electronic communication: I consent to have my personal health information shared through the Emory Healthcare Network interface in compliance with all HIPPA regulations. I consent to electronic communications including patient portal, text messages, email and voice mail. I can withdraw this consent by requesting a decline form and submitting it to Pulmonary & Sleep Specialists, PC.Signature of patient or authorized agent:* Relationship to patient if other than patient:
