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SOUTHERN ILLINOIS FAMILY MEDICINE PATIENT REGISTRATION FORM

First Name

Last Name

CELL PHONE ONLY

Address

SSN

Emergency contact phone number and relationship

Guarantor Name/address/phone # (Person responsible for insurance)

Parent guardian name and phone number and address (pediatric patient only)

The undersigned consents to Southern Illinois Family Medicine releasing his/her medical information to the following individuals: Name and Relationship to the patient

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I acknowledge that I have received a copy of private notice from Southern Illinois Family Medicine, and I understand it is my responsibility to read the notice and as question as necessary.

Your Signature

I hereby cnset to the medical treatment as ordered by Dr. Jim Hong or his designees. I authorize the release of meical information toprocess paymenet on my account. I authorize payment of mdical benefits directly to the prvide of service. I understand I will be rsonsible for the unpaid balance of my account. I certify that the information is correct to the best of my knowledge.

Your Signature

NO SHOW POLICY: Please call 24 hours/ or 2 hours (emergency), in advance to cancel appointment. If you do not show up for your appointment without prior notice, there will be a $25.00 fee assessed to your account. The no show fee must be satisfied before your next appointment. If you have multiple no shows, we may discharge you as a patient.

Your Signature

LAB AND MEDICAL TEST POLICY: Please contact office regarding your lab and medical test results. Do not assume your test is normal unless you confirmed your result verbally or in writing from our office.

Your Signature

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SOUTHERN ILLINOIS FAMILY MEDICINE

JIM HONG, MD

618-288-9466

SOUTHERN ILLINOIS FAMILY MEDICINE PATIENT REGISTRATION FORM

For Life-Threatening Emergencies Call 911