ealthsmart
WEIGHT LOSS &
GYNECOLOGY

(636) 333-1614

Monday - Thursday
8 am - 5:30 pm

Friday
8 am - 12 pm

Saturday
8 am - 12:30 pm

New Patient Preregistration

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New Patient Pre Registration

Please complete the form below to speed up your registration. If you are uncomfortable answering any of these questions, please skip them and they can be completed on your next visit.

Step 1 of 3

Health Smart Weight Loss & Gynecology L.L.C.
NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT RECEIPT
I have received the Notice of Privacy Practices on this visit or a previous one. I understand I can request another copy at any time.
Your Name
First Last
Date of Birth
Digital Signature

Please type your full name to confirm.
Today's Date
MM slash DD slash YYYY
PATIENT RECORD OF DISCLOSURES
IN GENERAL, THE HIPPA PRIVACY RULE GIVES INDVIDUALS THE RIGHT TO REQUEST RESTRICTION ON DISCLOSURE OF THEIR PROTECTED HEALTH RECORD INFORMATION (PHI). THE INDIVIDUAL IS ALSO PROVIDED THE RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS OR THAT A COMMUNICATION OF PHI MAY BE MADE BY ALTERNATIVE MEANS SUCH AS : SENDING CORRESPONENCE TO THE INDIVIDUAL'S OFFICE OR CELL PHONE, INSTEAD OF THE INDIVIDUAL'S HOME PHONE.
PLEASE CHECK ALL THAT APPLY
Home Telephone
- Leave Information With Detailed Information
- Leave Message With Call Back Only
Written Communication
- OK to Mail
- OK to Fax
Work Telephone
- Leave Information With Detailed Information
- Leave Message With Call Back Only
Cell Phone
- Leave Information With Detailed Information
- Leave Message With Call Back Only
I GIVE MY CONSENT TO THIS OFFICE TO RELEASE ANY AND ALL RESULTS TO THE PERSONS LISTED BELOW
Contact Information:
Name Relationship Phone #

I acknowledge that I have read and understand Health Smart Weight Loss & Gynecology L.L.C. Notice of Privacy Practices and consent to use or disclose of my protected health information by Health Smart Weight Loss & Gynecology L.L.C., for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills,to conduct health care operations of Health Smart Weight Loss & Gynecology and as required by law.
I also acknowledge that I understand my rights as a patient of this practice concerning my protected health information, as it is outlined in this notice. I am aware Heath Smart Weight Loss & Gynecology L.L.C., reserves the right to charge the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.
Your Name
First Last

Name of Patient or Personal Representative
Digital Signature

Please type your full name - Signature of Patient or Personal Representative
Today's Date
MM slash DD slash YYYY
This form does not constitute legal advice and is for educational purposes only. This form is based on current federal law and subject to change based on changes in federal law or subsequent interpretative guidance. This form is based on federal law and must be modified to reflect state laws where that state law is more stringent than the federal law or other state law exceptions apply.

REGISTRATION
Patient's Name
First Last
Marital Status
Is This Your Legal Name?
If not, what is your Legal Name?
Former Name:
Birth Date
Age
Sex
- Male
- Female
Address
Street Address Address Line 2 City State ZIP Code
SSN
Home Phone
Cell Phone
Email
Employer
Employer Phone
Referred By
Other Family Members Seen Here
Insurance Information
Please be sure to give your insurance card to the receptionist upon.
Person Responsible for bill:
Is this person a patient here?
Responsible Party Birth Date
Address (If Different)
Street Address Address Line 2 City State ZIP Code
Occupation
Employer
Employer Phone
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Please indicate primary insurance.
Subscriber Name
First Last
Subscriber's SSN
Subscriber Birth Date
Group Numnber
Policy Number
Co-Payment
Patient's Relationship to subscriber
Name of Secondary Insurance (If applicable)
Subscriber Name
Group Number
Policy Number
Patient Relationship to subscriber
In Case Of Emergency
Name of local friend or relative (not living at same address)
First Last
Relationship to patient
Home Phone
Work Phone
Authorization (Patient / Guardian Signature)*
First Last
Today's Date
MM slash DD slash YYYY
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Health Smart Weight Loss & Gynecology, LLC or insurance company to release any information required to process my claims.

ealthsmart
WEIGHT LOSS &
GYNECOLOGY

New Patient Pre Registration

Step 1 of 3

Health Smart Weight Loss & Gynecology L.L.C.

PATIENT RECORD OF DISCLOSURES

REGISTRATION

Insurance Information

In Case Of Emergency

Credentials/Associations

Locations

Name	Relationship	Phone #

ealthsmartWEIGHT LOSS &GYNECOLOGY

New Patient Preregistration

New Patient Pre Registration

Step 1 of 3

Health Smart Weight Loss & Gynecology L.L.C.

PATIENT RECORD OF DISCLOSURES

REGISTRATION

Insurance Information

In Case Of Emergency

Credentials/Associations

Locations

ealthsmart
WEIGHT LOSS &
GYNECOLOGY