7053 Johnston St, Lafayette, La 70503
Patient Registration Forms & Privacy Notices
If you are a new patient, please fill out the registration forms listed below in advance of your appointment to assist the staff in making sure that we have all the information necessary to provide you with quality care and treatment. Please bring the completed forms with you to your appointment.
Medical/Personal History: necessary for your Beacon Internal Medicine Physician
Review of Systems for Physical Exam: necessary for your Beacon Internal Medicine Physician
Patient Registration: provides us with your basic demographic and insurance information so that we can contact you as needed and bill your insurance appropriately. Please sign the bottom of this form and make sure to include proper subscriber information.
Patient Consent: This form is needed for both Beacon Internal Medicine and Beacon Rheumatology New Patients and it allows us to treat you.
Authorization for Release of Protected Health Information: offers you the opportunity to allow for your medical records to be released from Beacon Internal Medicine to parties that you have designated on the form or for your medical records to be released from parties that you have designated on the form to Beacon Internal Medicine.
Patient Rights & Responsibilities
We respect our patients’ dignity and pride. This document will explain your patient rights and responsibilities. It is part of your patient registration and is an important part of your health care plan.
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