Read the scenario below and complete the tasks that follow.

Scenario

You just accepted a role as medical administrator at a podiatrist medical office. There are many responsibilities associated with this position including managing the office, patient registration, insurance verification/referrals, and scheduling following up appointments. As you navigate through your first day at work, the waiting room is full and a patient with a severe foot infection is seeking treatment without an appointment. As part of your new position and responsibilities, you will be required to review, assess, and participate in all medical administrative duties that will support this patient.

As the new medical administrator, you have will complete an encounter form of the new patient with a severe foot infection.

Identify and summarize the steps for registering this patient by completing the encounter form as the patient and the registration form as the medical administrator, which includes verification of the patient insurance. HIPAA privacy rule should be adhered when registering the patient.

In order to successfully complete the Outpatient Encounter Form and the Patient Registration Form below, please use the information contained in the following document:

Patient and Outpatient Information

• Patient Welcome/Managing Wait Time

  In one page summarize how to greet the patient and manage the waiting room
  Include a brief outline describing how to verify the patient’s insurance

• Outpatient Encounter Form

  Complete this form as the medical administrator: Outpatient Encounter Form

• Patient Registration Form

  Complete this form as the patient: Patient Registration Form

• Apply HIPAA rules when documenting patient information

  Outline the five steps under the HIPAA privacy rule to ensure patient information is protected while registering the patient. The summary should follow the “Guidelines for Ensuring” patient privacy isn’t breached in the reception area

Outpatient Encounter Form

CATEGORY

CODE

MOD

FEE

Other

Other

Other

Other

Other Visit Information:

Fees:

Lab Work to Order:

Total Charges:
$

Referral to:

Copay Received:
$

Provider Signature:

Other Payment:
$

Next Appointment:

Total Due:
$

� MACROBUTTON DoFieldClick [Company Name]�

Company Name, Street Address, City, State ZIP Code, phone number

[NAME OF PRACTICE]

(Please Print)

Today’s date:

PATIENT INFORMATION
Patient’s last name: First: Middle:  Mr.

 Mrs.
 Miss
 Ms.

Marital status (circle one)

Single / Mar / Div / Sep / Wid

Is this your legal name? If not, what is your legal name? (Former name):

 Yes  No / /  M  F

Social Security no.: Home phone no.:

( )

P.O. box:

Employer phone no.:

( )

Chose clinic because/Referred to clinic by (please check one box):  Dr.  Insurance Plan  Hospital

 Family  Friend  Close to home/work  Yellow Pages  Other

INSURANCE INFORMATION
(Please give your insurance card to the receptionist.)

Birth date: Address (if different): Home phone no.:

/ / ( )

Is this person a patient here?  Yes  No

Occupation: Employer:

Employer phone no.:

( )

Is this patient covered by
insurance?  Yes  No

Please indicate primary
insurance  [Insurance]  [Insurance]  [Insurance]  [Insurance]  [Insurance]

 [Insurance]  [Insurance]  [Insurance]  Welfare (Please provide coupon)  Other

Subscriber’s name: Subscriber’s S.S. no.: Birth date: Group no.: Policy no.: Co-payment:

/ / $

Patient’s relationship to subscriber:  Self  Spouse  Child  Other

Name of secondary insurance (if applicable): Subscriber’s name: Group no.: Policy no.:

Patient’s relationship to subscriber:  Self  Spouse  Child  Other

IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address):

Home phone no.: Work phone no.:

( ) ( )

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand
that I am financially responsible for any balance. I also authorize

or insurance company to release any information required
to process my claims.

Patient/Guardian signature Date

[Name of Practice]
REGISTRATION FORM

1. Todays date:

PCP:

2. Patients last name First Middle:
3. salutation:
4. salutation_2:
5. Yes:
6. No:
7. If not what is your legal name:
8. Former name:

Birth date:
Age:
Sex:
Street address:

9. Social Security no:
10. Home phone no:
11. PO box:

City:
State:
ZIP Code:
Occupation:
Employer:

12. Employer phone no:
13. Chose clinic becauseReferred to clinic by please check one box:
14. Family:
15. Friend:
16. Close to homework:
17. Other:
18. Yellow Pages:
19. Dr:
20. Insurance Plan:
21. Hospital:

Other family members seen here:
Person responsible for bill:

22. Birth date_2:
23. Address if different:
24. Home phone no_2:
25. Is this person a patient here Yes No:
26. :
27. _2:
28. Occupation_2:
29. Employer_2:

Employer address:

30. Employer phone no_2:
31. Is this patient covered by insurance Yes No:
32. _3:
33. _4:
34. Insurance:
35. Insurance_2:
36. Insurance_3:
37. Insurance_4:
38. Insurance_5:
39. Welfare Please provide:
40. Insurance_6:
41. Insurance_7:
42. Insurance_8:
43. Other_2:
44. Subscribers name:
45. Subscribers SS no:
46. Birth date_3:
47. Group no:
48. Policy no:
49. Patients relationship to subscriber Self Spouse Child Other:
50. _5:
51. _6:
52. _7:
53. _8:
54. Name of secondary insurance if applicable:
55. Subscribers name_2:
56. Group no_2:
57. Policy no_2:
58. Patients relationship to subscriber Self Spouse Child Other_2:
59. _9:
60. _10:
61. _11:
62. _12:
63. Name of local friend or relative not living at same address:

Relationship to patient:

64. Date:

Module03

Course Project – Part 1

PATIENT REGISTRATION FORM

 Practice – The People’s Clinic

 Address – 1000 Town Square, Anytown Pennsylvania 54321

 Phone – 555-741-8529

PATIENT INFORMATION

 Patient – Mrs. Jane Doe

 Married

 Former name – Jane Smith

 DOB – 01/01/1960

 SSN

– 123-45-6789

 Address – 123 Main Street, Anytown Pennsylvania 54321

 Phone – 555-987-6543

 Occupation – Nurse

 Employer – The People’s Hospital

 Employer Phone – 555-456-7890

 Doctor referral to clinic

INSURANCE INFORMATION

 Jane Doe is responsible for payment

 Primary insurance is Blue Cross Blue Shield

 Subscriber – Jane Doe

 ID – 123123123

 Grp – 00550055

 No secondary insurance

IN CASE OF EMERGENCY

 Suzie Smith (sister)

 Home – 555-567-8910

 Work – 555-678-9012

OUTPATIENT ENCOUNTER FORM

Jane Doe (chart #0987) saw Dr. Brown on 1-1-2015.

She is 5’5’’ tall and weighs 130 pounds

Her blood pressure was 120/70

Her pulse was 60

Her temperature was 98.6

This was her second visit with Dr. Brown after she was referred by Dr. White. She is seeing Dr. Brown

for adult onset IDDM (insulin dependent diabetes mellitus).

Jane’s visit was only for an office visit and laboratory tests. Dr. Brown spent 25 minutes with Jane at this

visit and ordered lab testing for Hemoglobin A1C. Jane needs to return to see Dr. Brown in 1 month.

When Jane checked out she gave the receptionist her encounter form which had the office visit at a cost

of $100. She paid the amount of her copayment which was $20.