MMCWH 360 PATIENT REGISTRATION INFORMATION – Please Complete All Sections

Last Name First Name Middle Initial

Date of Birth Mailing Address

SSN Mailing City Mailing State Mailing Zip Code

Employer Employer Address

Home Telephone ❑ Preferred Work Telephone ❑ Preferred Cellular Phone ❑ Preferred q Single ❑ Married ❑ Divorced ❑ Widowed Marital Status Spouse Name/SSN Pharmacy Phone Number

Emergency Contact Emergency Contact Telephone

Patient E-mail Address

Primary Insurance Company Group Number Policy Number

Policy Holder Policy Holder Date of Birth

Self ❑ Spouse ❑ Child ❑ Other (specify) Relation to Policy Holder

Primary Insurance Mailing Address

Insurance Telephone

Secondary Insurance Company Group Number Policy Number

Policy Holder Policy Holder Date of Birth

Self ❑ Spouse ❑ Child ❑ Other (specify) Relation to Policy Holder

Secondary Insurance Mailing Address Insurance Telephone

Primary Care Physician – Name and Address PCP Telephone

How did you hear about McDonald Murrmann Center for Wellness & Health?

Release of Information The patient (or parent or other authorized representative) consents to the use and disclosure of information relating to the services provided by the MMCWH 360 for the purpose of treatment, payment or health care operation, including submission of a claim for medical benefits to a provider or administrator of medical benefit plans. This consent will be valid for as long as the patient is entitled to coverage under a medical plan. You are entitled to a copy of this consent. This consent may be revoked in writing delivered to your MMCWH 360, but such revocation will not affect any action taken in reliance on this consent prior to revocation. Upon receipt of revocation or refusal to sign this consent, MMCWH 360 may decline to provide or continue treatment. If this consent is signed by the authorized representative of the patient, the relationship of the authorized representative must be provided below.

Assignment of Benefits I authorize payment of any insurance benefits for services rendered by MMCWH 360 to be paid directly to MMCWH 360 and its physicians.

Financial Agreement I understand that verification of insurance benefits and authorization for services is not a guarantee of payment in full fo r services rendered by MMCWH 360. I understand that I am fully responsible for payment for services rendered by MMCWH 360. I agree to pay any applicable copayments, deductibles, and coinsurance amounts at the time services are rendered, unless prior arrangements are made with MMCWH 360. I understand that MMCWH 360 may refer any unpaid balance to a collection agency for resolution. I understand that I will be responsible for the costs of collection, legal fees and other costs incurred in collection of my balance in addition to my account balance with MMCWH 360.

q I would like to receive e-mail notices and newsletters from McDonald Murrmann Center for Wellness & Health

Authorized Signature Date

Name of Authorized Signatory, if not Patient Relationship to Patient

q Parent ❑ Legal Guardian ❑Other

Mary N. McDonald, MD * Susan G. Murrmann, MD * Heather O. Donato, MD

Blanche Petty, APRN * Mariana Rizzo, APRN * Meredith Ryan, PA * Natalie Narrow, APRN * Wendy Mink, APRN

HEALTH HISTORY UPDATE

Please update any changes, List all medication below.

Name : DOB:

Marital status: Single Partnered Married Separated Divorced Widowed

Physician: Date of last physical exam:

List any medical problems that other doctors have diagnosed

Surgeries

Year Reason Hospital

Other hospitalizations

Year Reason Hospital

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

Name the Drug Strength Frequency Taken

Allergies to medications

Name the Drug Reaction You Had

MEDICAL HISTORY

Date of last menstruation:

Period every _____ days

Heavy periods, irregularity, spotting, pain, or discharge? Yes No

Are you pregnant or breastfeeding? Yes No

Have you had a D&C, hysterectomy, or Cesarean? Yes No

Any urinary tract, bladder, or kidney infections within the last year? Yes No

Any blood in your urine? Yes No

Any problems with control of urination? Yes No

Any hot flashes or sweating at night? Yes No

Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period? Yes No

Experienced any recent breast tenderness, lumps, or nipple discharge? Yes No

Signature: Date:

Permission for Verbal Communication

I, ____________________________ permit McDonald Murrmann Center for Wellness & Health, PLLC, their

physicians, nurses, and other personnel (“Health Care Providers”) to discuss health information, in person or by

telephone, with the following family members or friends involved in my medical care: (List family members/friends

and state the person’s relationship to the patient).

CHECK ONE BOX ONLY

Option 1.

This authorization in limited to discussions regarding the following medical condition(s):

Option 2.

Discussions will be permitted regarding any medical condition, including mental illness and/or HIV status,

for which the patient has received care.

PERSON(S) AUTHORIZED TO RECEIVE VERBAL COMMUNICATION

Release of information under this document is limited to verbal discussions with my Health Care Providers. This

document does not permit release of any written health information to the individuals named above.

This authorization is limited to the following timeframe:

From________________________________ (date) to___________________________________ (date)

If no dates are indicated, this form will remain in effect for an unlimited amount of time.

If, at any time, I do not want verbal discussions to be permitted between my Health Care Providers and any of the

individuals named above, I must notify McDonald Murrmann Center for Wellness & Health, PPLC, in writing of the

change.

Patient’s Signature_________________________________________________ Date_____________________

If this Release is signed by a representative on behalf of the patient, complete the following:

Representative’s Name______________________________ Relationship to Patient: ______________________

Name Telephone Number Relationship

The HIPAA Privacy Rule permits health care providers to communicate with patients regarding their health care. This includes communicating with patients at their homes, whether through the mail, by phone, or in some other manner. In addition, the Rule does not prohibit covered entities from leaving messages for patients on their answering machines. However, to reasonably safeguard the individual’s privacy, covered entities should take care to limit the amount of information disclosed on the answering machine. For example, a covered entity might want to consider leaving only its name and number and other information necessary to confirm an appointment or ask the individual to call back. A covered entity also may leave a message with a family member or other person who answers the phone when the patient is not home. The Privacy Rule permits covered entities to disclose limited information to family members, friends, or other persons regarding an individual’s care, even when the individual is not present; however, professional judgment should be exercised. The HIPAA Privacy Rule also prohibits the practice from using or disclosing patient protected health information (PHI) outside the Notice of Privacy Practice without the authorization of the patient. Messages that contain patient PHI require the patient to sign an authorization form to receive messages by phone, fax, e-mail, voice mail, or any other means by which someone other than the patient might reasonably have access to the message, thereby potentially violating the patient’s privacy rights under HIPAA. For example, messages that contain PHI would be test results, medication information, payment information, treatment plans, patient condition information, and anything else that is considered patient condition, treatment, or payment related. You may elect to have your PHI provided to you by a message from the physician’s office by signing this form in the space provided below. Once you have signed the form, future communication with you concerning your PHI may be provided to the designated relative or friend, sent by e-mail, fax or left on your voice mail at the number you provide to this office.

I understand my HIPAA rights and I request that this office leave messages, including those containing PHI, for me with either of the two individuals listed below or by e-mail or voice mail at the numbers noted below. I understand that it is my responsibility to keep the practice informed of any changes to this information.

I do not want the office to leave messages containing PHI.

Patient Name: _____________________________ Date: ____________________________ Signature: __________________________________________________ Phone Number: ______________________________ Email: _____________________________

Financial Policy

Mary N. McDonald, MD, Susan G. Murrmann, MD, Heather O. Donato, MD

Blanche Petty, NP, Meredith Ryan, PA, Natalie Narrow, NP, Wendy Mink, NP

Thank you for choosing our practice! We are committed to the success of your medical

treatment and care. Please understand that payment of your bill is part of this treatment and care.

How May I Pay? We accept payment by cash, check, Visa, Mastercard, American Express and Discover. We also

accept online payment on our website www.mmcwh360.com.

Do I Need a Referral?

If your insurance company requires a referral and/or prior authorization, you are responsible for

obtaining it. Failure to obtain the referral and/or prior authorization may result in a lower or no

payment from the insurance company, and the balance will be your responsibility.

Self-pay Accounts

Self-pay accounts are patients without insurance coverage, patients covered by insurance plans in

which our office does not participate, or patients without an insurance card on file with us. It is

always the patient’s responsibility to know if our office is participating with their plan. If there

is a discrepancy with our information, the patient will be considered self-pay unless otherwise

proven. Upon receipt of your services, you will be advised of an estimate of the amount needed

to pay for your services and you will be asked to make payment arrangements for any remaining

balance. Extended payment arrangements are available if needed. Please ask to speak with a

billing specialist to discuss a payment plan. It is never our intention to cause hardship to our

patients, only to provide them with the best care possible and the least amount of stress.

TennCare/ Medicaid

We are not providers in TennCare or any state Medicaid program and we will not file claims to

any Medicaid plan.

Wellness/Annual Visits with Other Problems

If during your annual/well women preventive care exam, you have or need treatment for a

problem, if the problem is addressed during the visit in lieu of scheduling a separate

appointment, in addition to the preventive exam it may be necessary that a problem/E&M visit

be billed with other labs, testing, and/or procedures, which may be subject to copays and/or

deductible.

Deductible Plans A deposit of $150 will be collected at time of service for all new patients, problem and follow

up visits. We will bill for the remaining of the balance once your claims are processed.

Surgery

If your physician recommends surgery, the billing department will request a pre-surgical deposit,

the amount of which depends on your coverage and deductible amount. A cost estimate which

shows your financial responsibility, based on the benefit level and coverage of your insurance

plan will be provided and explained in detail for you.

Outstanding Balance Policy

* It is our office policy that all past due accounts be sent three statements. If payment is not

made on this account, a single phone call will be made to try to make payment arrangements. If

no resolution can be made, the account will be sent to the collection agency, or attorney, and

discharge from the practice.

* If your account or any account for which you are responsible is sent to collection agency due to

non-payment of any patient balance, you may be dismissed from the practice for any future care

and services, which include all providers at MMCWH. Additionally, a collection fee of 33%

will be added to your account balance.

Returned Checks

The Charge for a returned check is $50 payable by cash or money order. This will be applied to

your account in addition to the insufficient fund amount. You may be placed on a cash only

basis following any returned check.

This financial policy helps the office provide quality care to our valued patients. If you have any

questions or need clarification of any of the above policies, please feel free to contact us at (901)

752.4000 or ask to speak to a billing representative.

I accept and understand the McDonald Murrmann Center for Wellness & Health Financial Policy

_______________________________________ _____________________

Patient Signature (Parent or Guardian, If Minor) Date

Printed Name of Signer