HCMC # 1
Healing Companion Medical Clinic
New Patient Registration
PATIENT INFORMATION: (Please print)
Last Name ______________________ First Name ________________________ Sex
M
F
Address _________________________________________________________________________
City __________________________ State __________ Zip _____________________________
Home Phone ____________________ Cell Phone ___________________ Email ______________
Date of Birth ____________________ Social Security __________________ Marital Status _____
How were you referred to our office? __________________________________________________
EMPLOYMENT INFORMATION:
Name of Employer _________________________________________________________________
Employer Address _________________________________________________________________
City __________________________ State __________ Zip _____________________________
Work Phone Number __________________________________ Extension ___________________
INSURANCE INFORMATION:
Name of Insurance Company ________________________________________________________
Claim Address ____________________________________________________________________
City __________________________ State __________ Zip _____________________________
Insurance Phone # ____________________________
Name of Policy Holder _________________________________ Relationship to Patient ________
Policy Holder SS # __________________________ Policy Holder’s DOB ___________________
Policy ID # ________________________________ Group # ______________________________
Policy Holder Employer ______________________ Phone # ______________________________
SECONDARY INSURANCE INFORMATION:
Dr. Nhu Q. Tran, Board Certified in Internal Medicine
3671 Broadway Boulevard Suite 500 Garland, TX 75043
Phone (972)675-3818
Fax (972)692-0443
HCMC # 2
Name of Insurance Company ________________________________________________________
Claim Address ____________________________________________________________________
City __________________________ State __________ Zip _____________________________
Insurance Phone Number ______________________
Name of Policy Holder _________________________________ Relationship to Patient ________
Policy Holder SS # __________________________ Policy Holder’s DOB ___________________
Policy ID # ________________________________ Group # ______________________________
Policy Holder Employer ______________________ Phone # ______________________________
Please remember that insurance is considered a method of reimbursing the patient for fees paid to the
doctor and is not a substitute for payment. Some insurance companies pay fixed allowances for
certain procedures and others pay a percentage of the charge. It is your responsibility to pay any
deductable amount, coinsurance, or any other balance not paid by your insurance company.
In order to control the cost of billing, we request that your co-payment, co-insurance, deductable or
any other expected balance not covered by your insurance be paid at the conclusion of each visit. If
the balance is unknown, it must be paid upon received when it is firstly mailed out to you. There
will be an additional charge once your balance is mailed out after the first time. Your balance will be
forwarded to a medical collection agency after 90 days.
If this account is assigned to an attorney for collection and/or suit, the prevailing party shall be
entitled to reasonable attorney’s fee and cost of collection to the extent necessary. To determine
liability for payment and to obtain reimbursement I authorize disclosure of portions of the patient
records.
I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am
entitled including Medicare, Private Insurance, and other health plans to Healing Companion
Medical Clinic. This assignment will remain in effect until evoked by me in writing. A photocopy
of this assignment is to be considered as valid as an original. I understand that I am responsible
for all charges whether or not paid by said insurance. I hereby authorize said assignee to
release all information to secure payment.
Signed ___________________________________________________ Date _________________
Printed Name _____________________________________
Dr. Nhu Q. Tran, Board Certified in Internal Medicine
3671 Broadway Boulevard Suite 500 Garland, TX 75043
Phone (972)675-3818
Fax (972)692-0443
HCMC # 3
PATIENT’S EMERGENCY CONTACTS AND INFORMATION:
Nearest Relative Name: ___________________
Emergency Contact and Address:
________________________________________
Address: _______________________________ ________________________________________
______________________________________ ________________________________________
City: __________________State: ___________ City: __________________State: ____________
Zip Code: ____________
Zip Code: ___________
Phone: ( )
Home Phone: ( )
Work Phone: ( )
Work Phone: ( )
Cell Phone: ( )
Cell Phone: ( )
Relationship to Patient: ___________________
Relationship to Patient: _____________________
Do you have a durable power of an attorney for healthcare?
Yes
No
If yes, please provide the name: _______________________________________________________
Home phone: ( )
Cell phone: ( )
Do you have a legal guardian?
Yes
No
Would you like to be an organ donor?
Yes
No
_______________________________________________________________________________________________
RELEASE OF HEALTH INFORMATION AND ACKNOWLEDGEMENT FOR PRIVACY
NOTICE
I , _______________________________, acknowledge that I have received a copy of the Privacy
Notice. This is describes how my doctor may use and disclose my protected information. It also
describes restrictions on the use and disclosure of healthcare information and the patient’s rights. In
addition, I only allow Dr. Tran or The Healing Companion Medical Clinic, to release or discuss my
health information to the following individuals (family relatives or friends):
Name
1 ___________________________
Relationship
______________
Phone number
__________________
2 ___________________________
______________
__________________
3 ___________________________
______________
__________________
Sign: ________________________________________
Dr. Nhu Q. Tran, Board Certified in Internal Medicine
3671 Broadway Boulevard Suite 500 Garland, TX 75043
Phone (972)675-3818
Fax (972)692-0443
Date: _____________
HCMC # 4
HEALING COMPANION MEDICAL CLINIC’S POLICY
Revised 1/6/14
It is our goal to provide you, the patient, with the highest and most efficient level of health services
available. Your assistance is necessary and plays an integral part in helping us obtain that goal as well as
preserving the quality of care that other patients deserve.
1) Please give us a 24-hour notice prior to your appointment IF you are unable to keep your appointment
and want to reschedule your appointment. You will be charged $30.00 fee for the first time, $50.00
for the 2nd time and $75.00 after if you cancel your appointment less than 24 hours or do not show up
for your appointment with Dr. Nhu Tran unless you have an unexpected and reasonable emergency.
2) You are aware that you would lose your privilege of being a patient of Healing Companion Medical
Clinic if you miss three (3) appointments without any reasonable explanation.
3) If you choose to be scheduled your appointment on Saturday and you are unable to come for your
appointment, you will not be allowed to schedule any appointment on Saturday again. Saturday’s
appointment is mainly reserved for the patients who are unable to come during the weekly hours.
4) In term of medication refill, please call your pharmacy to fax the refill form over to us and it will be
taken care within 24 to 48 hours from Monday to Friday. The clinic does not do medication refill on
Saturday. If you want to pick up a prescription, please kindly call us at least 24 to 48 hours before
you pick it up.
5) If you are sick and would like the doctor to see you as soon as possible, please call us ahead of time to
schedule the appointment. We will do our best to fit you in the earliest opening schedule that we
have. Please DO NOT show up without calling and expect to be seen in the clinic right away.
6) For private insurance patients, please pay your co-pay BEFORE seeing the doctor. Your service
will be REJECTED if you do not pay your co-pay or any remaining balances.
7) If you cannot make your payment, please kindly call our office and make arrangement for your
payments. If you do not pay in full within three (3) months or within the arrangement period, you
will lose the privilege of being a patient of this clinic and your due amount will be sent to a
professional medical collection agency.
8) If we receive a bounced check from you, you will be charged $40.00 fee for bounced check plus the
amount on the check. You will be reported to the District Attorney Office if you refuse to pay the
requested amount after thirty (30) days since the bounced check was given.
I, _________________________________, have read the above and agree to be compliant.
Patient Signature: _________________________________________
Date: _________________
Dr. Nhu Q. Tran, Board Certified in Internal Medicine
3671 Broadway Boulevard Suite 500 Garland, TX 75043
Phone (972)675-3818
Fax (972)692-0443