Register for Personalized On-Site Medical Care

Patient Data

The Hansa Medical Groupe consent packet is for your review; however, all we need on 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(Required)

Practice Start Date(Required)

Social Security Number(Required)

Marital Status(Required)

Single

Married

Widowed

Divorced

Birthdate(Required)

Age(Required)

Sex(Required)

Male

Female

Community Name (If Applicable)

Community Type(Required)

Independent Living

Assisted Living

Memory Care

Address

Street Address City State

Power of Attorney Name (If Applicable)

Relationship to Patient

Power of Attorney Cell Phone

Power of Attorney Email

Insurance Information

Primary Insurance(Required)

Group/Policy Number(Required)

Secondary Insurance

Group/Policy Number

Independent Living Information

Patient's Email

Patient's Cell Phone

Pharmacy Name

Pharmacy Phone Number

Medication List(Required)

Medical Conditions(Required)

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.

Service Type (Select All That Apply)(Required)

PCP

Secondary PCP

Name of Person Signing(Required)

Digital Signature(Required)

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Signature

Patient Registration

The HMG Consent Packet

Patient Registration

Patient Data

Insurance Information

Independent Living Information

HANSA MEDICAL GROUPE FULL CONSENT

Hansa Medical Groupe

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