Patient Information

First Name:

Middle Name:

Last Name:

SSN:

DOB:

Gender:

AKA:

Mailing Address:

City/State/Zip:

Phone(H):

Phone(W):

Cell:

Preferred Phone for Messages:

Email:

Race:

Ethnicity:

Language:

Marital Status:

Employment:

Driver's License:

Primary Doctor:

Phone #:

Referring Doctor:

Phone #:

Pharmacy:

City:

Phone #:

Responsible Party (Bill To)

First Name:

Last Name:

DOB:

SSN:

Gender:

Mailing Address:

City/State/Zip:

Phone(H):

Phone(W):

Cell:

Employment:

Relationship to Patient:

Emergency Contact

First Name:

Last Name:

Phone(H):

Phone(W):

Cell:

Relationship to Patient:

Page 1/5

Primary Insurance

Patient Name:

If you don't have Primary Insurance check "none."

None:

Insurance Name:

ID:

Group No.:

Group Name/Employer:

Insured Name:

Insured Address:

City/State/Zip:

Insured Relationship to Patient:

DOB:

SSN:

Secondary Insurance

Insurance Name:

ID:

Group No.:

Group Name/Employer:

Insured Name:

Insured Address:

City/State/Zip:

Insured Relationship to Patient:

DOB:

SSN:

Photo of Front and Back of Insurance Card

Front of Card:

Back of Card:

Photo of Front and Back of Secondary Insurance Card

Front of Card:

Back of Card:

Statesboro Psychiatric Associates (SPA) does not participate with Medicare (or its commercial products), Tricare or Medicaid. I understand that if covered by any of these entities that I must sign a waiver in order to receive treatment at SPA. I understand that the waiver states that I may not file claims with Medicare, Tricare or Medicaid for services rendered by SPA, and that I am fully responsible for payment of these services. I also understand that neither I nor SPA will file with insurance that is secondary to Medicare, and that by signing the waiver I am fully responsible for office visits.

I understand that it is my responsibility to alert Statesboro Psychiatric Associates to any and all changes in my insurance coverage, and that failure to provide these updates in a timely fashion may result in denial of claims by my new insurance company, and that I will be fully responsible for payment of these services.

I understand that unpaid balances are cause for dismissal from the practice, and that in the event that my account is forwarded to an outside agency for collection, a charge of 33% will be added to the outstanding balance to cover this cost.

Signature of Patient/Responsible Party:

Date:

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Credit Card Permission Form

Patient Name:

Date:

Full name as seen on credit card:

American Express: Discover: Master Card: Visa:

Card #:

Expiration date on card:

CVV Code:

Payee Phone Number:

Billing address on card:

City:

State:

Zipcode:

I give Statesboro Psychiatric Associates permission to charge the above credit card for payments due after each visit, and for any balances to include charges incurred due to appointments missed or canceled without appropriate notice.

Signature of Cardholder:

Date:

If I have questions about these charges, I agree to contact Statesboro Psychiatric Associates. I agree that I will not pursue a refund directly through my credit/debit card company, bank, or financial institution. If any of my actions yield a chargeback for any reason, I agree to pay any and all penalty fee(s) incurred by Statesboro Psychiatric Associates. I also understand that my card information will be kept secure.

Signature of Cardholder:

Date:

Page 3/5

Legal Custody Information

Required only for Patients Ages 17 and under:

Age:

Click Validate Age below to continue.

✖ Please enter age (numbers only)

✔ Under 17 - Custody Information required

✖ Over 17 - Custody Information not required

Does the patient live with both married parents?

Yes
No

If No:

With whom does the patient live?

Who has legal custody of the patient?

If parents have joint custody, who has the medical tiebreaker?

If parents are divorced, we require a copy of the court custody order, including power of medical decision making.

If patient is in foster care and/or has a temporary guardian, we require a copy of the court custody order, including power of medical decision making.

Page 4/5

Patient Privacy Form

In addition to my emergency contact, I authorize Statesboro Psychiatric Associates to talk with the following parties regarding my treatment and appointments:

Replace my Privacy Policy contacts

Add to my Privacy Policy contacts

Name:

Relationship:

Phone(H):

(W):

(C):

Address:

Name:

Relationship:

Phone(H):

(W):

(C):

Address:

Name:

Relationship:

Phone(H):

(W):

(C):

Address:

Name:

Relationship:

Phone(H):

(W):

(C):

Address:

I understand that in addition to other providers involved in my care, Statesboro Psychiatric Associates can provide treatment information to other providers for the purpose of coordination of care. This includes my primary care physician, referring physician, and other health care providers involved in my care.
In the case of a child, I understand that in many circumstances, a custodial parent or legal guardian other than the person bringing the child to appointments may have legal right to obtain the medical records of the minor.

Patient's Name:

Patient's Date of Birth:

Signature of Patient:

Date:

Signature of Parent/Guardian/Personal Representative:

Date:

Submit Form

(page may load slowly - click only once to submit)

Established Patient Registration Update

Patient Information

Responsible Party (Bill To)

Emergency Contact

Primary Insurance

If you don't have Primary Insurance check "none."

Secondary Insurance

Photo of Front and Back of Insurance Card

Photo of Front and Back of Secondary Insurance Card

Credit Card Permission Form

Legal Custody Information

Patient Privacy Form

Submit Form