Patient Registration

Register online: Fill out the form below and submit it! Prefer to print it out and bring it with you? That works too, download the form!

    Patient Registration Form

    First Name:
    Middle Name:
    Last Name:
    Preferred Name:
    Social Security #:
    Date of Birth:
    Sex:
    Race:
    Ethnicity:
    Martial Status:
    Street Address:
    City:
    State:
    Zipcode:
    Home Phone:
    Cell Phone:
    Authorization to Contact by Cell Phone or Text Message:
    YesNo
    Cell Phone Carrier:
    Employer:
    Work Phone:

    Emergency Contact & Authorized Person(s)

    List person(s) to contact in case of an emergency and person(s) authorized to have access to “ALL” patient medical

    Name:
    Relationship:
    Phone Number
    Name:
    Relationship:
    Phone Number:

    Insurance Information

    Primary Insurance

    Insurance Company:
    Primary Insurance Holder Name:
    Date of Birth
    Member ID#:
    Group ID#:
    Employer:

    Secondary Insurance

    Insurance Company:
    Primary Insurance Holder Name:
    Date of Birth
    Member ID#:
    Group ID#:
    Employer:
    I hereby authorize Dr. Ingram to release any information necessary to process any insurance claim acquired in the course of my examination or treatment to allow a photocopy of my signature to be used to process my insurance claim. I claim, direct, and authorize my carrier to issue payment check(s) directly to Dr. Ingram for any insurance benefits to which I am entitled. I understand that failure to disclose precertification/second opinion requirements for any and all plans to which I subscribe may cause me to incur full liability for professional charged as a result of non-payment by my carrier. Regardless of insurance benefits, if any, I understand that I am fully responsible for any and all fees incurred and I agree the above is legal and lawful debt. If it becomes necessary to forward this account to collections, I agree to be responsible for any/all collections costs, attorney fees and/or court costs. I waive now and forever my right of exemption under the laws of the constitution of the State of Alabama and any other state. I realize that my insurance is filed as a courtesy and I am responsible for the bill. I understand that I have certain rights regarding the privacy of my medical records and have been given the opportunity to review the notice of privacy practices.
    Digital Signiture:
    Date:

    Patient / Responsible Party

    Standard authorization of use and disclosure of protected health information

    Information to be Used or Disclosed:
    The information covered by this authorization includes but is not limited to any and all medication information, records, charts, grafts, histories, data, X-rays, and other information concerning my examination, treatment and/or hospitalizations.
    Persons Authorized to Use or Disclose Personal Health Information

    Information listed above will be used or disclosed by:
    Prattville Primary Care, LLC 461 E. Main Street Prattville, AL 36067

    Persons & Relationship to Whom Information May be Disclosed:
    Information described above may be disclosed to whom the patient wishes to have such information disclosed. It is important that if you wish for a family member, ect. to call and ask for appointment times, dates or medical information you must clearly identify them by name and relationship. Without such information below, Prattville Primary Care, LLC will not be able to disclose any information to any individual. Any chances made to this Authorization Disclosure must be done in person with proper identification.

    Person #1:

    Name:
    RelationShip:

    Person #2:

    Name:
    RelationShip:

    Person #3:

    Name:
    RelationShip:

    Person #4:

    Name:
    RelationShip:

    Person #5:

    Name:
    RelationShip:
    Can Prattville Primary Care, LLC leave messages about appointments, test results, ect.?
    Yes, I give Prattville Primary Care, LLC permission to leave messages on my answering machine.No, I do not wish for Prattville Primary Care, LLC to leave messages or other information on my answering machine.

    Digital Signiture:

    Date:

    Potential for RE-disclosure
    The information that is disclosed under this authorization may be disclosed again by the person or organization to which it is sent. The privacy of this information may not be protected under the federal privacy regulations.

    Controlled Substance Agreement

    The purpose of this agreement is to prevent misunderstandings about certain medicines you may be prescribed for pain, ADD/ADHD, and/or anxiety (nerve) management. This is to help both you and your doctor to comply with the law regarding controlled pharmaceuticals.

    I understand that this agreement is essential to the trust and confidence necessary in a doctor/patient relationship and that my doctor undertakes to treat me based on the agreement.

    I understand that if I break this agreement, my doctor will STOP prescribing these pain and/or anxiety-control medicines.
    I will communicate fully with my doctor about the character and intensity of my pain and/or nerve problems, the effect of the pain and/or nerve problems on my daily life and how well the medicine is helping to relieve the pain, ADD/ADHD, and/or nerve problems.

    I will NOT use any illegal controlled substances, including MARIJUANA, COCAINE, ect., because doing so may cause FATAL outcomes when combined with prescription controlled substances.

    I will NOT SHARE, SELL or TRADE my medications with anyone.
    I will not attempt to obtain any controlled medicines, including opiate pain medicines, controlled stimulants, or anxiety medicines from any other doctor.

    I will safeguard my pain, ADD/ADHD and/or anxiety medicine and prescriptions from LOSS OR THEFT. LOST or STOLEN medicines or prescriptions WILL NOT BE REPLACED.

    Each visit the physician and I will predetermine the amount of controlled substance to be prescribed until the next visit.

    I agree that refills of my prescriptions for pain and/or anxiety medicines will be made ONLY at the time of an office visit or during regular office hours. No refills will be available after regular office hours.

    No early refills will be authorized.

    I agree to use: pharmacy, located at:

    I authorize Dr. Ingram, Hayley Guthrie CRNP and my pharmacy to cooperate fully with any city, state or federal law enforcement agency, including the state’s Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my pain, ADD/ADHD, and/or anxiety medicine. I authorize my doctor to provide a copy of this agreement to my pharmacy. I agree to waive any applicable or right of privacy or confidentiality with respect to these authorizations.

    I agree with I will submit to a blood or urine test if requested by my doctor to determine my compliance with my program of pain, ADD/ADHD, and/or anxiety control medicine.
    I agree that I will use my medicine at a rate no greater than the prescribed rate and that use of my medicine at a greater rate will result in my being without medicine for a period of time.

    I will bring all unused pain medicine to every office visit.

    I agree to follow these guidelines that have been fully explained to me. All of my questions and concerns regarding treatment have been fully explained to me and adequately answered for me. A copy of this document has been given to me. I understand that not following this agreement can result in my doctor/ patient relationship being permanently terminated verbally or by the doctor’s written request without my consent and without prior notification. I understand this is a legally binding contract.

    This agreement is entered into on

    Patient Digital Siginiture:

    Patient Responsibilites & Finacial Procedures

    Please read each line thoroughly and initial. A copy of this form will be provided to you if you request.

    SCHEDULED OFFICE VISITS: Due to the high volume of patients we seen on a daily basis, it is important that we remain on a timely schedule. If you are 15 minutes late for your scheduled office visit, you may be asked to reschedule. If you are unable to make it to a scheduled appointment, please let us know as soon as possible. Failure to notify the office shall result in a $25 no show fee.

    REFILL REQUESTS: Due to the high volume of medication refill requests, please allow the physician office 24 hours to process all routine medication renewals. Most insurance companies are now requiring Prior Authorizations for certain medications. If the prescription needs a Prior Authorization, it can take up to a week, depending on the insurance company requirements. Please, call your pharmacy to check if the prescription is ready before calling the office. NOTE: No routine medications will be refilled after regular business hours- this includes weekends.

    COPAYMENTS DUE AT TIME OF SERVICE: Our physicians are contractually obligated per your insurance company to collect payment at the time of service. An additional billing fee may be applied if all the out of pocket responsibility is not paid at the time of service.

    SELF-PAY: If there no medical coverage at the time of service or our physician is out of network, then the responsible party is liable for all the charges incurred at the time of service.

    REQUEST FOR COMPLETION OF MEDICAL FORMS: Patients may be required to an office visit with a physician to have certain medical forms completed, such as disability determination, family medical leave, or any lengthy documents that require a substantial amount of the physician’s time to complete. The patient may be required to pay up to $25 for completion of forms if not willing to schedule a visit.

    MEDICAL QUESTIONS: Patients must allow 48 business hours for responses to any non-urgent medical questions or messages left for the nurse/or physician. Any life threatening emergency shall warrant the patient calling 911 for an emergency.

    Patient Digital Siginiture:
    Date: