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Patient Registration

Patient Information

Patient Name (Last, First Middle):

City:

Sex

Male

Female

Patient Address:

PO Box:

City:

State:

Zip

Patient Date of Birth:

Patient SSN:

Patient Email Address:

Patient Home Phone:

Patient Cell Phone:

Patient Work Phone:

Preferred contact method?

Phone

Postal Service

Place Of Employment:

Are you disabled?

Yes

Disabled since:

Marital Status

Single

Married

Widow

Divorced

Seperated

Parent/Guardian information must be provided

Parent/Guardian (If Under 18, Last, First Middle):

Guardian SSN:

Guardian Email Address:

Guardian Address (If Different):

PO Box:

City:

State:

Zip

Guardian Phone:

Guardian Phone 2:

No Second Parent/Guardian

Second Parent/Guardian (If Under 18, Last, First Middle):

Second Guardian SSN:

Second Guardian Email Address:

Second Guardian Address (If Different):

PO Box:

City:

State:

Zip

Second Guardian Phone:

Second Guardian Phone 2:

Demographics

Race

American Indian

Asian

Black/African American

Hawaiian Native

White

Refuse to Report

Other

If Other

Ethnicity

Hispanic/Latino

Non-Hispanic/Latino

Language Preference

English

Other

If Other

Employment Status

Employed

Not Employed

Retired

Occupation

Directive

No directive exists

If anything is checked other than 'No directive exists', please answer 'Power of Attorney' and 'Where can we find more information or documentation about your Directive'

Discussed, no decision made

Not discussed

Do not resuscitate

Full code

Immunizations up to date

Living Will

No artifical life support

No blood transfusions

No dialysis

No elective Cardioversion

No heroic measures

No hospitalization

No surgery

No transfer from home

Organ donor

Power of Attorney:

Where can we find more information or documentation about your Directive?

Spouse's Information

Spouse's Name:

DOB:

Work Phone:

Cell Phone:

Employer/Occupation:

SSN:

Emergency Contact (Other than Spouse)

Name:

Phone:

Relationship:

Address:

PO Box:

City:

State:

Zip

Pharmacy

Name:

Phone:

Fax:

Address:

PO Box:

City:

State:

Zip

Family Physician

Name:

Phone:

Fax:

Address:

PO Box:

City:

State:

Zip

Consent form for ePrescribe Program

ePrescribe Program

ePrescribe is a way for doctors to send electronically an accurate, error free, and understandable prescription from the doctor's office to the pharmacy. The ePrescribe Program also includes:

Formulary and benefits transactions - Gives the health care provider information about which drugs are covered by your drug benefit plan.
Fill status notification - Allows the health care provider to recieve an electronic notice from the pharmacy telling them if your prescription has been picked up, not picked up, or partially filled.
Medication history transactions - Provides the health care provider with information about your current and past prescriptions. This allows health care providers to be better informed about potential medication issues and to use that information to improve safety and quality. Medication history data can indicate: compliance with prescribed regimins; theraputic interventions; drug-drug and drug-allergy interactions; adverse drug reactions; and duplicative therapy.

The medication history information would include medications provided by other health care providers involved in your care and may include sensitive information including, but not limited to, medications related to mental health conditions, veneral deseases/sexually transmitted diseases, abortion(s), rape/sexual assault, substance (drug and alcohol) abuse, genetic diseases, and HIV/AIDS. As part of this Consent Form, you specifically consent to the release of this and other sensitive health information.

Consent

By signing this form you are agreeing that your provider at the practice may request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payors for treatment purposes.

You may decide not to sign this form. Your choice will not affect your ability to get medical care, payment for your medical care, or you medical benefits. Your choice to give or deny consent may not be the basis for denial of health services. You also have the right to receive a copy of this form after you have signed it.

This consent form will remain in effect until the day you revoke your consent. You may revoke this consent at any time in writing but if you do, it will not have an effect on any actions taken prior to receiving the revocation.

Understanding all of the above, I hereby provide informed consent to the practice to enroll me in this ePrescribe Program. I have had the chance to ask questions and all of my questions have been answered to my satisfaction.

Do you give consent?

Reject

Enter full name

ASSIGNMENT OF INSURANCE BENEFITS

I hereby authorize direct payment of surgical/medical benefits to the Setliff Sinus Institute, for services rendered by him/her in person or under his/her supervision. I understand that I am financialy responsible for any balance not covered by my insurance.

AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize the Setliff Sinus Institute, to release my medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit.

MEDICARE | MEDICAID

I certify that the information given by me in applying for payment is correct. I authorize release of all records on request. I request that payment of authorized benefits be made on my behalf.

Signature

Patient (Please Print):

Parent/Guardian (please print):

Date:

04/20/2024

Sign your name:

Clear

Referred by/or how did you hear about SSI

KELO

KSFY

Radio

Internet

Prior Patient

Who

Other

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Choose the scissors

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Home
About SSI
Sinus Breakthroughs
Sinus Education
Paperwork
Contact Us

Setliff Sinus Institute 2709 E 26th St, Sioux Falls, SD 57103| (605) 339-1872 | Dr. Reuben Setliff is a highly specialized sinus doctor who has been leading the way in sinus relief for over 20 years Directions To Setliff Sinus Institute Website by The Gage Team