Patient Registration Form

By signing below I understand that I am responsible for payment of all co-payments, deductibles and any non-covered services as determined by my insurance plan. I understand that I will be required to provide proof of current insurance and pay all required copayments at each office visit. I also understand that I am responsible for payment of any and all charges should I fail to follow my insurance plans' guidelines; and, for full payment each time services are rendered if my doctor is not contracted with my insurance carrier or if I do not have health insurance.

I hereby authorize and request that my insurance company or any government agencies pay medical benefits directly to Rio Abajo Family Practice, PC for assigned insurance claims. I also authorize the release of any and all medical information, including, but not limited to, HIV status, substance abuse and mental health diagnoses necessary to process any claim for medical services rendered. I also authorize electronic transfer of my medication history, lab and x-ray reports, and vaccination records. If I have provided a message phone number below, I understand that messages may contain basic legally protected health information (PHI) such as lab results or the need for an appointment. The authorization for PHI messaging may be cancelled at any time by written notice to this office. You may decline PHI messaging by writing "decline" in the space below. A photocopy of this authorization will be honored as an original. You will be asked to update this registration at least annually or when there are any changes.

In the space provided, please write in the phone number that we should use to leave detailed messages that might contain confidential protected health information (PHI)