NEW PATIENT REGISTRATION FORM

Emergency Contact

Complete list of ALL medications taken in past year:

Insurance Policy Subscriber Information

Please provide all applicable insurances.

CONSENT FOR EXAMINATION, MEDICAL TREATMENT AND CONDITIONS OF EXAMINATION

Consent is hereby given to perform any and all examinations, tests, procedures, and treatments necessary and/or advisable; and in an emergency, without the presence of parents or responsible adults. I hereby authorize examination and treatment of the above-named patient by the physicians and physician extenders employed by The Healthy Cocoon Practice. I realize that the practice of medicine is not an exact science, and I acknowledge that no guarantees have been made to me as to the result of treatments or examination in this practice.

INFORMATION CONCERNING FILING A CLAIM WITH YOUR INSURANCE COMPANY

If we participate with your primary insurance. The Healthy Cocoon Practice will gladly file a claim for you. We will allow your insurance company up to 45 days from the date of service to pay the claim. If your insurance company fails to fully compensate The Healthy Cocoon Practice within this time frame, any unpaid balance becomes your sole responsibility.

Consent to Appointment Policy

I understand that The Healthy Cocoon Practice requires 24-hours advance notice for an appointment to be rescheduled. A cancellation with less than 24-hoursʼ notice results in a “No Show.” I acknowledge that The Healthy Cocoon Practice reserves the right to discharge a patient after 3 missed appointments. I also understand that for each “No Show” I may accumulate a $25 No Show Fee, which I must pay to be seen again. Failure to pay this fee may result in discharge.

AUTHORIZATION TO FILE INSURANCE CLAIMS, TO RELEASE MEDICAL INFORMATION AND
ASSIGNMENT OF BENEFITS

• I authorize The Healthy Cocoon Practice to file insurance claims for services and supplies rendered to and for the patient.
• I authorize The Healthy Cocoon Practice to release information, including my medical and billing information, to referring or consulting doctors and to my insurance company. The transmission of all information may be done electronically, including the Internet.
• I authorize that payment of all third-party benefits otherwise payable to me be made directly to The Healthy Cocoon Practice.
• I assign to The Healthy Cocoon Practice all payments for medical services and supplies.

I understand that I am financially responsible to The Healthy Cocoon Practice for the above-named patient(s). If my insurance company fails to fully compensate The Healthy Cocoon Practice, any unpaid balance becomes my sole responsibility. I agree to pay all amounts not covered or paid by a third-party payer within 30 days after notification from The Healthy Cocoon Practice and/or a billing company acting on its behalf. I agree to pay all costs of collection, including attorneyʼs fees and agree to pay the legal rate of interest on the account until paid in full.