{"id":594,"date":"2022-05-07T12:00:15","date_gmt":"2022-05-07T12:00:15","guid":{"rendered":"http:\/\/www.bayareaprimarycare.org\/?page_id=594"},"modified":"2022-05-07T12:05:36","modified_gmt":"2022-05-07T12:05:36","slug":"new-patient-registration-information","status":"publish","type":"page","link":"http:\/\/www.bayareaprimarycare.org\/?page_id=594","title":{"rendered":"New patient Registration Information"},"content":{"rendered":"<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f593-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F594#wpcf7-f593-o1\" method=\"post\" class=\"wpcf7-form init cf7skins cf7t-event cf7s-caspar\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"593\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.6.4\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f593-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<link rel=\"stylesheet\" href=\"http:\/\/www.bayareaprimarycare.org\/wp-content\/plugins\/pdf-forms-for-contact-form-7\/css\/frontend.css\" \/><script type=\"text\/javascript\" src=\"http:\/\/www.bayareaprimarycare.org\/wp-content\/plugins\/pdf-forms-for-contact-form-7\/js\/frontend.js?ver=2.0.9\"><\/script><fieldset>\n<legend>NEW PATIENT REGISTRATION INFORMATION<\/legend>\n<ol>\n<li class=\"one_third\"><label for='cf7s-last'> Name Last <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-last\"><input type=\"text\" name=\"cf7s-last\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-last\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_third\"><label for='cf7s-first'> Name First <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-first\"><input type=\"text\" name=\"cf7s-first\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-first\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_third\"><label for='cf7s-middle'> Name Middle <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-middle\"><input type=\"text\" name=\"cf7s-middle\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-middle\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li><label for='cf7s-birth'> Date of Birth <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-birth\"><input type=\"text\" name=\"cf7s-birth\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-birth\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li><label for='cf7s-checkbox2'> Sex <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-checkbox2\"><span class=\"wpcf7-form-control wpcf7-checkbox\" id=\"cf7s-checkbox2\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"cf7s-checkbox2[]\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"cf7s-checkbox2[]\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"cf7s-checkbox2[]\" value=\"Others\" \/><span class=\"wpcf7-list-item-label\">Others<\/span><\/span><\/span><\/span> <\/li>\n<li><label for='cf7s-checkbox2'> Marital Status <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-checkbox2\"><span class=\"wpcf7-form-control wpcf7-checkbox\" id=\"cf7s-checkbox2\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"cf7s-checkbox2[]\" value=\"Married\" \/><span class=\"wpcf7-list-item-label\">Married<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"cf7s-checkbox2[]\" value=\"Single\" \/><span class=\"wpcf7-list-item-label\">Single<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"cf7s-checkbox2[]\" value=\"Divorced\" \/><span class=\"wpcf7-list-item-label\">Divorced<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"cf7s-checkbox2[]\" value=\"Widowed\" \/><span class=\"wpcf7-list-item-label\">Widowed<\/span><\/span><\/span><\/span> <\/li>\n<li class=\"one_third\"><label for='cf7s-home'> Home Phone Number <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-home\"><input type=\"tel\" name=\"cf7s-home\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" id=\"cf7s-home\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_third\"><label for='cf7s-mobile'> Mobile Phone Number <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-mobile\"><input type=\"tel\" name=\"cf7s-mobile\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" id=\"cf7s-mobile\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_third\"><label for='cf7s-work'> Work Phone Number <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-work\"><input type=\"tel\" name=\"cf7s-work\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" id=\"cf7s-work\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li><label for='cf7s-checkbox1'> Preferred Method of Contact <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-checkbox1\"><span class=\"wpcf7-form-control wpcf7-checkbox\" id=\"cf7s-checkbox1\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"cf7s-checkbox1[]\" value=\"Mobile Phone #\" \/><span class=\"wpcf7-list-item-label\">Mobile Phone #<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"cf7s-checkbox1[]\" value=\"Home Phone #\" \/><span class=\"wpcf7-list-item-label\">Home Phone #<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"cf7s-checkbox1[]\" value=\"Work Phone #\" \/><span class=\"wpcf7-list-item-label\">Work Phone #<\/span><\/span><\/span><\/span> <\/li>\n<li><label for='cf7s-email'> Email Address <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-email\"><input type=\"email\" name=\"cf7s-email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" id=\"cf7s-email\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li><label for='cf7s-checkbox1'> We may send appointment reminders via TXT\/email\/voice-mail <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-checkbox1\"><span class=\"wpcf7-form-control wpcf7-checkbox\" id=\"cf7s-checkbox1\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"cf7s-checkbox1[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"cf7s-checkbox1[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span> <\/li>\n<li><label for='cf7s-address'> Home Address <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-address\"><input type=\"text\" name=\"cf7s-address\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-address\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_third\"><label for='cf7s-last'> City <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-last\"><input type=\"text\" name=\"cf7s-last\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-last\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_third\"><label for='cf7s-last'> State <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-last\"><input type=\"text\" name=\"cf7s-last\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-last\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_third\"><label for='cf7s-last'> Zip Code <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-last\"><input type=\"text\" name=\"cf7s-last\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-last\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-license'> Driver License # <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-license\"><input type=\"text\" name=\"cf7s-license\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-license\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-Social1'> Social Security # <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-Social1\"><input type=\"text\" name=\"cf7s-Social1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-Social1\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li><label for='cf7s-student'> Student <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-student\"><span class=\"wpcf7-form-control wpcf7-checkbox\" id=\"cf7s-student\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"cf7s-student[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"cf7s-student[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-occupation'> Occupation <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-occupation\"><input type=\"text\" name=\"cf7s-occupation\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-occupation\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-employer'> Employer <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-employer\"><input type=\"text\" name=\"cf7s-employer\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-employer\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li><label for='cf7s-empaddress'> Employer Address <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-empaddress\"><input type=\"text\" name=\"cf7s-empaddress\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-empaddress\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-empaddress'> Language Preferred <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-empaddress\"><input type=\"text\" name=\"cf7s-empaddress\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-empaddress\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-race'> Race <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-race\"><input type=\"text\" name=\"cf7s-race\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-race\" aria-invalid=\"false\" placeholder=\"(can decline to answer)\" \/><\/span> <\/li>\n<li><label for='cf7s-referral'> Referral Source <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-referral\"><input type=\"text\" name=\"cf7s-referral\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-referral\" aria-invalid=\"false\" \/><\/span> <\/li>\n<h2>Complete this section, if Patient is a minor or responsible party is other than Patient:<\/h2>\n<li><label for='cf7s-checkbox1'> Responsible Party: Relationship to Patient <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-checkbox1\"><span class=\"wpcf7-form-control wpcf7-checkbox\" id=\"cf7s-checkbox1\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"cf7s-checkbox1[]\" value=\"Spouse\" \/><span class=\"wpcf7-list-item-label\">Spouse<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"cf7s-checkbox1[]\" value=\"Parent\" \/><span class=\"wpcf7-list-item-label\">Parent<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"cf7s-checkbox1[]\" value=\"Guardian\" \/><span class=\"wpcf7-list-item-label\">Guardian<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"cf7s-checkbox1[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/span><\/span><\/span> <\/li>\n<li class=\"one_third\"><label for='cf7s-rellast'> Name Last <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-rellast\"><input type=\"text\" name=\"cf7s-rellast\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-rellast\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_third\"><label for='cf7s-relfirst'> Name First <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-relfirst\"><input type=\"text\" name=\"cf7s-relfirst\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-relfirst\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_third\"><label for='cf7s-relmiddle'> Name Middle <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-relmiddle\"><input type=\"text\" name=\"cf7s-relmiddle\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-relmiddle\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li><label for='cf7s-birth'> Date of Birth <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-birth\"><input type=\"text\" name=\"cf7s-birth\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-birth\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li><label for='cf7s-checkbox2'> Sex <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-checkbox2\"><span class=\"wpcf7-form-control wpcf7-checkbox\" id=\"cf7s-checkbox2\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"cf7s-checkbox2[]\" value=\"Male\" \/><span class=\"wpcf7-list-item-label\">Male<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"cf7s-checkbox2[]\" value=\"Female\" \/><span class=\"wpcf7-list-item-label\">Female<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"cf7s-checkbox2[]\" value=\"Others\" \/><span class=\"wpcf7-list-item-label\">Others<\/span><\/span><\/span><\/span> <\/li>\n<li><label for='cf7s-checkbox2'> Marital Status <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-checkbox2\"><span class=\"wpcf7-form-control wpcf7-checkbox\" id=\"cf7s-checkbox2\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"cf7s-checkbox2[]\" value=\"Married\" \/><span class=\"wpcf7-list-item-label\">Married<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"cf7s-checkbox2[]\" value=\"Single\" \/><span class=\"wpcf7-list-item-label\">Single<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"cf7s-checkbox2[]\" value=\"Divorced\" \/><span class=\"wpcf7-list-item-label\">Divorced<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"cf7s-checkbox2[]\" value=\"Widowed\" \/><span class=\"wpcf7-list-item-label\">Widowed<\/span><\/span><\/span><\/span> <\/li>\n<li class=\"one_third\"><label for='cf7s-home'> Home Phone Number <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-home\"><input type=\"tel\" name=\"cf7s-home\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" id=\"cf7s-home\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_third\"><label for='cf7s-mobile'> Mobile Phone Number <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-mobile\"><input type=\"tel\" name=\"cf7s-mobile\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" id=\"cf7s-mobile\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_third\"><label for='cf7s-work'> Work Phone Number <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-work\"><input type=\"tel\" name=\"cf7s-work\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" id=\"cf7s-work\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li><label for='cf7s-checkbox1'> Preferred Method of Contact <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-checkbox1\"><span class=\"wpcf7-form-control wpcf7-checkbox\" id=\"cf7s-checkbox1\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"cf7s-checkbox1[]\" value=\"Mobile Phone #\" \/><span class=\"wpcf7-list-item-label\">Mobile Phone #<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"cf7s-checkbox1[]\" value=\"Home Phone #\" \/><span class=\"wpcf7-list-item-label\">Home Phone #<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"cf7s-checkbox1[]\" value=\"Work Phone #\" \/><span class=\"wpcf7-list-item-label\">Work Phone #<\/span><\/span><\/span><\/span> <\/li>\n<li><label for='cf7s-email'> Email Address <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-email\"><input type=\"email\" name=\"cf7s-email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" id=\"cf7s-email\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li><label for='cf7s-checkbox1'> We may send appointment reminders via TXT\/email\/voice-mail <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-checkbox1\"><span class=\"wpcf7-form-control wpcf7-checkbox\" id=\"cf7s-checkbox1\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"cf7s-checkbox1[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"cf7s-checkbox1[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span> <\/li>\n<li><label for='cf7s-address'> Home Address <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-address\"><input type=\"text\" name=\"cf7s-address\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-address\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_third\"><label for='cf7s-last'> City <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-last\"><input type=\"text\" name=\"cf7s-last\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-last\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_third\"><label for='cf7s-last'> State <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-last\"><input type=\"text\" name=\"cf7s-last\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-last\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_third\"><label for='cf7s-last'> Zip Code <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-last\"><input type=\"text\" name=\"cf7s-last\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-last\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-license'> Driver License # <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-license\"><input type=\"text\" name=\"cf7s-license\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-license\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-Social1'> Social Security # <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-Social1\"><input type=\"text\" name=\"cf7s-Social1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-Social1\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li><label for='cf7s-student'> Student <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-student\"><span class=\"wpcf7-form-control wpcf7-checkbox\" id=\"cf7s-student\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"cf7s-student[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"cf7s-student[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-occupation'> Occupation <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-occupation\"><input type=\"text\" name=\"cf7s-occupation\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-occupation\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-employer'> Employer <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-employer\"><input type=\"text\" name=\"cf7s-employer\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-employer\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li><label for='cf7s-empaddress'> Employer Address <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-empaddress\"><input type=\"text\" name=\"cf7s-empaddress\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-empaddress\" aria-invalid=\"false\" \/><\/span> <\/li>\n<h2>Insurance Information:<\/h2>\n<li class=\"one_half\"><label for='cf7s-primary'> Primary Insurance <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-primary\"><input type=\"text\" name=\"cf7s-primary\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-primary\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-primary'> Secondary  Insurance <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-primary\"><input type=\"text\" name=\"cf7s-primary\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-primary\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-insured'> Name of Insured <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-insured\"><input type=\"text\" name=\"cf7s-insured\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-insured\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-insured'> Name of Insured <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-insured\"><input type=\"text\" name=\"cf7s-insured\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-insured\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-patientrel'> Relationship to Patient <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-patientrel\"><input type=\"text\" name=\"cf7s-patientrel\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-patientrel\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-patientrel'> Relationship to Patient <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-patientrel\"><input type=\"text\" name=\"cf7s-patientrel\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-patientrel\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-policy'> Policy# <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-policy\"><input type=\"text\" name=\"cf7s-policy\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-policy\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-policy'> Policy# <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-policy\"><input type=\"text\" name=\"cf7s-policy\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-policy\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-group'> Group# <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-group\"><input type=\"text\" name=\"cf7s-group\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-group\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-group'> Group# <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-group\"><input type=\"text\" name=\"cf7s-group\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-group\" aria-invalid=\"false\" \/><\/span> <\/li>\n<p> The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the Physician. I understand that I am financially responsible for any balance\/or patient portion due. I also authorize Bay Area Primary Care Associates or Insurance Company to release any information required to process my claims.<\/p>\n<p><center><br \/>\n<h1>Bay Area Primary Care Associates<\/h1>\n<p><\/center><\/p>\n<h2>Patient Preferences Regarding Communication of PHI (Patient Health Information)<\/h2>\n<h3>Preferred  Method of Communication<\/h3>\n<p>My preferred method of communication regarding my Medical Conditions is indicated below:<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-525\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-525\" value=\"Home Phone\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Home Phone<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-525\" value=\"Mobile Phone\" \/><span class=\"wpcf7-list-item-label\">Mobile Phone<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-525\" value=\"Work Phone\" \/><span class=\"wpcf7-list-item-label\">Work Phone<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-525\" value=\"Mailed Letter\" \/><span class=\"wpcf7-list-item-label\">Mailed Letter<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-525\" value=\"Guardian\" \/><span class=\"wpcf7-list-item-label\">Guardian<\/span><\/label><\/span><\/span><\/span><\/p>\n<p>If the above method of communication is by phone, please check the appropriate box below:<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-734\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-734\" value=\"Leave a message with detailed information\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Leave a message with detailed information<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-734\" value=\"Leave a message with a call-back number only\" \/><span class=\"wpcf7-list-item-label\">Leave a message with a call-back number only<\/span><\/label><\/span><\/span><\/span><\/p>\n<p>Please note that you are responsible for any charges incurred in receiving our communications. For example, if you provide a cell phone number as a method of contact, then you are responsible for any charges imposed by your mobile carrier for receiving calls or text messages from the clinic.<\/p>\n<p><br><\/p>\n<p>Please let our office know if you have any special directions or requests regarding our communication with you. For example, please let us know if you would like for us to call you at a different phone number for a particular test results or you do not want to called at all.\n<\/p>\n<p><br><\/p>\n<h3>HIPPA Approved  Contacts<\/h3>\n<p>Keeping our patient\u2019s information private is important to us and by default we will only disclose  information related to the patient\u2019s Billing Account and Medical Conditions to the patient or legal guardian.<\/p>\n<p><br><\/p>\n<p>If you would like to add additional contacts (other than the patient or legal guardian) that  Bay Area Primary Care Ass: is allowed to disclose this type of information to, please complete the fields below and select the appropriate checkboxes based on your approval for each person you list. In addition, please choose the person you would like Bay Area Primary Care Ass: to list as your Emergency Contact in the event an emergency situation was to take place at our office.<\/p>\n<li class=\"one_half\"><label for='cf7s-cntname1'> Contact Name# 1 <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-cntname1\"><input type=\"text\" name=\"cf7s-cntname1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-cntname1\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-reltopatient1'> Relationship to Patient <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-reltopatient1\"><input type=\"text\" name=\"cf7s-reltopatient1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-reltopatient1\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-cntphone1'> Contact Phone# <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-cntphone1\"><input type=\"text\" name=\"cf7s-cntphone1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-cntphone1\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-date1'> Date <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-date1\"><input type=\"text\" name=\"cf7s-date1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-date1\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-cntname2'> Contact Name# 2 <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-cntname2\"><input type=\"text\" name=\"cf7s-cntname2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-cntname2\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-reltopatient2'> Relationship to Patient <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-reltopatient2\"><input type=\"text\" name=\"cf7s-reltopatient2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-reltopatient2\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-cntphone2'> Contact Phone# <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-cntphone2\"><input type=\"text\" name=\"cf7s-cntphone2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-cntphone2\" aria-invalid=\"false\" \/><\/span> <\/li>\n<li class=\"one_half\"><label for='cf7s-date1'> Date <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"cf7s-date1\"><input type=\"text\" name=\"cf7s-date1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"cf7s-date1\" aria-invalid=\"false\" \/><\/span> <\/li>\n<p>Expiration or termination of authorization \u2013 This authorization will remain in effect until terminated by patient\u2019s personal representative, or another individual of legal entity authorized to do so by court order or law.<\/p>\n<p><br><\/p>\n<p>Right to revoke or terminate \u2013 As stated in our Notice of Privacy practices, you have the right to revoke or terminate authorization by submitting a written request to Bay Area Primary Care Ass:<\/p>\n<p><center><br \/>\n<h1>Bay Area Primary Care Associates<\/h1>\n<h1>Financial Policy<\/h1>\n<p><\/center><\/p>\n<p>Unless arrangements have been made in advance, co-payments, co-insurance, deductibles, and any outstanding balances <b><u>are expected<\/u><\/b> at the time of service. Patients may be financially responsible for payment of all services if insurance does not pay. <b>Patient accounts not paid promptly are subject to third party collections and\/or legal procedures.<\/b><\/p>\n<p><br><\/p>\n<p>If we are not participating providers with your plan, we will provide you with a receipt for you to file with your insurance carrier.<b> If your insurance carrier has not responded to a claim within 90 days, we reserve the right to formally transfer all associated liability for the claim to the patient\/guarantor.<\/b><\/p>\n<p><br><\/p>\n<p>Please keep a close watch for carrier claim payment and contact the insurance carrier or the office at 281-554-2846 in the event a claim is not resolved within 60 days from the date of service. We do realize that emergencies do arise that may affect timely payment of your account. If such extreme cases do occur, please contact the office. Any questions regarding bills should be directed to the office.<\/p>\n<p><br><\/p>\n<p><b><u>There will be a charge for NO SHOW appointments, a fee of $25 may be charged to the patient if you do not call and cancel your appointment within 24 hours.<\/u><\/b><\/p>\n<p><br><\/p>\n<p>Please always notify our office of any change in name, address, phone or insurance information.<\/p>\n<\/ol>\n<p>\t<input type=\"submit\" value=\"Submit\" class=\"wpcf7-form-control has-spinner wpcf7-submit\" \/>\n<\/p><\/fieldset>\n<p style=\"display: none !important;\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"16\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"http:\/\/www.bayareaprimarycare.org\/index.php?rest_route=\/wp\/v2\/pages\/594"}],"collection":[{"href":"http:\/\/www.bayareaprimarycare.org\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"http:\/\/www.bayareaprimarycare.org\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"http:\/\/www.bayareaprimarycare.org\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/www.bayareaprimarycare.org\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=594"}],"version-history":[{"count":1,"href":"http:\/\/www.bayareaprimarycare.org\/index.php?rest_route=\/wp\/v2\/pages\/594\/revisions"}],"predecessor-version":[{"id":596,"href":"http:\/\/www.bayareaprimarycare.org\/index.php?rest_route=\/wp\/v2\/pages\/594\/revisions\/596"}],"wp:attachment":[{"href":"http:\/\/www.bayareaprimarycare.org\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=594"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}