Patient Registration

Patient Data

The Hansa Medical Groupe consent packet is for your review; however, all we need the form below (pages 2 and 3 of the packet) completely filled. If something does not apply, please mark it N/A.

Patient's Full Name *

Practice Start Date *

Community Name (if applicable)

Community Type *Independent LivingAssisted LivingMemory Care

Street Address *

Apartment, suite, etc

City

State/Province

Cell Phone *

Home Phone

Referral Source

Referral Name *

Social Security Number *

Spouse’s Name (if applicable)

Spouse's Phone *

Power of Attorney (if applicable)

Power of Attorney Phone *

Insurance Information

Primary Insurance *

Group/Policy Number *

Secondary Insurance

Group/Policy Number

Power of Attorney Contact Information

Name *

Relationship *

Cell Phone *

Home Phone

Pharmacy Name

Pharmacy Phone Number

Medication List *

Medical Conditions *

HANSA MEDICAL GROUPE FULL CONSENT

My signature below will be applied to all consent pages in this packet except for the Advanced Beneficiary Notice or ABN. You may be asked to sign the ABN in the future based on specific non-payment related circumstances. By signing below, I am consenting to have read through and understand all aspects of the Hansa Medical Groupe consent packet and the separate practice packet. I understand and agree to all parts of the Hansa Medical Groupe consent packet and responsibilities as a patient, for any primary care medical service, back-up physician medical services, any specialty care, Chronic Care Mgt, Remote Patient Monitoring, Principal Care Management Service, and/or any telehealth services provided by Hansa Medical Groupe. This includes the Credit Card Authorization, unless specified otherwise.

Please check Service type *PCPBackup PCP

Patient's Full Name *

Birthdate *

Building Name *

Apartment/Suite Number *

Resident Cell Phone Number *

Building Phone Number *

Power of Attorney Name *

Power of Attorney Phone Number *

Email Address *

Signature *