Dear New Patient,
Thank you for choosing Azalea Gynecology. Our all-female staff has been providing exceptional
healthcare for women since 1994. We hope that you will find our providers and staff exceeding your
expectations.
Please complete the enclosed forms and bring them with you the day of your scheduled appointment.
Also, remember to bring your insurance card, a photo ID and your co-pay, if applicable, with you each
time you come to our office.
OUR OFFICE COLLECTS ALL OUT OF POCKET PATIENT EXPENSE AT TIME OF SERVICE, SUCH
AS COPAY, COINSURANCE AND DEDUCTIBLE.
We ask that you give us at least 24 hours' notice if you need to reschedule. ALL PATIENTS WHO
CANCEL, NO SHOW OR RESCHEDULE WITHIN 24 HRS. OF THEIR SCHEDULED APPOINTMENT
WILL BE CHARGED A $35-$100 NO SHOW FEE DEPENDING UPON APPOINTMENT TYPE. BE
ADVISED THAT CANCELLATIONS OR RESCHEDULES CAN ONLY BE ACCEPTED MONDAYTHURSDAY
8:30AM - 5:00PM & FRIDAY 8:30AM – 12:00PM.
Please make us aware of any special concerns you may have so that we may better serve you. If you
have any questions regarding these forms or your visit, please do not hesitate to call our office.
We look forward to seeing you!
Sincerely,
The Staff of Azalea GYN
736 Medical Center Drive, Suite 102
Wilmington, NC 28401
Telephone: 910-452-3666
Fax: 910-397-0930
PATIENT ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE
1. I acknowledge that I have received or have been offered a copy of Azalea Gynecology Notice of Privacy
Practices, effective September 23, 2013. ______________(Initial)
2. I acknowledge my right and have been offered the option to request to receive communications of my
personal health information by alternative means or at alternative locations. I understand that Azalea
Gynecology may refuse to accommodate my request if it is not reasonable. ____________ (Initial)
3. Please indicate the address and telephone number you would like our office to use for appointment
reminders or other office communications (including but not limited to billing matters, pap smear
and mammogram results). All other test results require direct communication with our staff.
Address:________________________________________ Phone: _______________________
City:________________________________ State:________ Zip:___________________
4. Please list ALL persons who patient will allow Azalea Gynecology staff to discuss or to leave messages with
regarding billing or medical information (including Patient Representative).
N/A, None: ___________________
Name: ___________________________________ Phone: __________________________
Name: ___________________________________ Phone: __________________________
A current Notice of Privacy Practices for Azalea Gynecology is attached and also available at
the check-in counter.
____________________________________________ _________________
Print Name Date
____________________________________________
Signature of Patient or Patient Representative
______________________________________________________________
Relationship of Representative/Authority to act on behalf of the Patient
Notice of Privacy Practices
Your Information. Your Rights. Our Responsibilities.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Please review it carefully.
Your Rights
You have the right to:
• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we've shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated
Your Choices
You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds
Our Uses and Disclosures
We may use and share your information as we:
• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers' compensation, law enforcement, and other government
requests
• Respond to lawsuits and legal actions
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our
responsibilities to help you.
Get an electronic or paper copy of your medical record
• You can ask to see or get an electronic or paper copy of your medical record and other health information we have
about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may
charge a reasonable, cost-based fee.
Ask us to correct your medical record
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do
this.
• We may say "no" to your request, but we'll tell you why in writing within 60 days.
Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different
address.
• We will say "yes" to all reasonable requests.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not
required to agree to your request, and we may say "no" if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the
purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to share
that information.
Get a list of those with whom we've shared information
• You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date
you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and
certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will
charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will
provide you with a paper copy promptly.
Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise
your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting us using the information on page 6.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a
letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting
www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we
share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your
instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your
information if we believe it is in your best interest. We may also share your information when needed to lessen a serious
and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes
In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
Treat you
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public
health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more
information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone's health or safety
Do research
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and
Human Services if it wants to see that we're complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers' compensation, law enforcement, and other government requests
We can use or share health information about you:
• For workers' compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can,
you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will
be available upon request, in our office, and on our web site.
Effective Date of this Notice: September 23, 2013
Privacy Official: Craig Allard, Practice Manager admin@azaleagyn.com
910-452-3666
AZALEA GYNECOLOGY www.azaleagyn.com
736 Medical Center Drive, Suite 102
Wilmington, NC 28401
910-452-3666
PATIENT ACCT NO:
PATIENT DEMOGRAPHIC WORKSHEET
P A T I E N T
PATIENT NAME MARITAL STATUS DATE OF BIRTH SEX AGE RACE
STREET ADDRESS APT/SUITE#/PO Box #
City STATE ZIP SSN
PATIENT HOME PHONE EMERGENCY CONTACT EMERGENCY CONTACT PHONE
PATIENT EMPLOYER/SCHOOL NAME PATIENT OCCUPATION (IF STUDENT, INDICATE FULL TIME OR PART TIME) PATIENT WORK PHONE
PATIENT EMAIL ADDRESS REFERRED TO THIS PRACTICE BY: PATIENT MOBILE PHONE
RESP
PARTY
RESP PARTY NAME RELATIONSHIP TO PATIENT RESP PARTY HOME PHONE
STREET ADDRESS APT/SUITE #
City STATE ZIP CODE RESP PARTY MOBILE PHONE
INSURANCE INFORMATION
INSURANCE
PRIMARY INSURANCE EFFECTIVE DATE ID /GROUP NUMBER
POLICY HOLDER NAME RELATIONSHIP TO INSURED POLICY HOLDER DATE OF BIRTH POLICY HOLDER SOCIAL SECURITY
NUMBER
POLICY HOLDER EMPLOYER NAME
SECONDARY INSURANCE EFFECTIVE DATE ID / GROUP NUMBER
POLICY HOLDER NAME RELATIONSHIP TO INSURED POLICY HOLDER DATE OF
BIRTH
POLICY HOLDER SOCIAL SECURITY NUMBER
POLICY HOLDER EMPLOYER NAME
PHARMACY NAME AND LOCATION PHARMACY PHONE NUMBER
AUTHORIZATION & CONSENT
CONSENT
I HEREBY AUTHORIZE THIS PRACTICE TO RELEASE INFORMATION TO MY INSURANCE COMPANY. I ALSO AUTHORIZE
THIS PRACTICE TO RELEASE MY MEDICAL INFORMATION, INCLUDING PRIVILEGED, SENSITIVE INFORMATION, TO ANY
HOSPITAL, PHYSICIAN OR PROVIDER THIS OFFICE AND MY PRIMARY CARE PHYSICIAN MAY REFER ME TO. I
AUTHORIZE PAYMENT OF MEDICAL BENEFITS DIRECTLY TO THE PHYSICIAN AND I AUTHORIZE THE USE OF THIS
SIGNATURE ON ALL INSURANCE CLAIMS FORMS. I AUTHORIZE A COPY OF THIS AUTHORIZATION TO BE USED IN
PLACE OF THE ORIGINAL.
SIGNED: _____________________________________ DATE: ________________________________
Rev. 2/17
AZALEA GYNECOLOGY OFFICE POLICY
Patient Name:________________________________________ Date of Birth:___________________
HOURS: 8:30 am – 5:00 pm, Monday – Thursday & Friday 8:30 am -12 pm.
CONTACT / INSURANCE INFORMATION: Patients are responsible to contact our office and provide us with any and all new contact
information when it changes. This includes any changes to: name, address, phone numbers, email addresses, employer, insurance, and
responsible parties. Failure to do so may result in our inability to contact you regarding your healthcare and financial concerns which may
lead to your dismissal from Azalea Gynecology.
SOCIAL SECURITY NUMBERS: Unless paying in full at time of service, Azalea Gynecology requires patient and policyholder social
security numbers on all accounts. It is also office policy to obtain drivers licenses or other photo identification of patients or the responsible
party. Proper identification is required for all patients.
APPOINTMENTS: All patients are seen by appointment only. Our office will make a courtesy call to confirm all appointments 3-4 days prior
to your appointment. Due to the nature of our practice, we occasionally need to reschedule an appointment you have made and appreciate
your understanding should this be the case. We ask that you give us at least 24 hours' notice if you need to reschedule.
? A PATIENT WHO MISSES, CANCELS OR RESCHEDULES WITHIN 24 HOURS OF HER SCHEDULED APPOINTMENT WILL
BE CONSIDERED A "NO-SHOW".
? THESE PATIENTS WILL BE CHARGED A $35 - $100 NO-SHOW FEE BASED UPON THE APPOINTMENT TYPE THEY MISS.
CANCELLATIONS OR RESCHEDULES MAY ONLY BE MADE M – TH, 8:30AM – 5 PM & F 8:30AM – 12 PM.
? PATIENTS WHO NO-SHOW THREE TIMES WITHIN A 12 MONTH PERIOD WILL BE DISMISSED FROM OUR PRACTICE.
TELEPHONE: During office hours the Azalea staff attempts to answer each call. However, from noon – 1pm and when phone lines are
busy, please follow the telephone prompts for voicemail. If you have a medical question or concern, our staff will take your information, and
our clinical staff will return your call. After office hours, a Physician is on call at all times for emergency situations only. Patients may be
charged for non-emergent calls made to the on-call Physician. If you feel you have an emergency that cannot wait for regular office hours,
please go to the nearest emergency room and they will contact the on-call Physician. For urgent issues that must be addressed outside our
normal office hours, call the office and listen to the answering machine for instructions.
PRESCRIPTION REFILLS: Contact your pharmacy for all prescription refills. The Pharmacy will contact our office with any concerns. Our
office processes refills within 48-72 hours.
ANNUAL WELLNESS VISIT: Wellness visits and problem visits may sometimes be combined and will be billed accordingly. Complex
problems may require additional visits.
TEST RESULTS: Azalea Gyn patients will be notified of all test results unless otherwise specified. Please be advised that if you have not
heard from us within the time frames furnished, contact our office for your results.
Pap Smears - 3 weeks, Ultrasounds - 2 weeks, Biopsies & Blood Testing - 2 weeks, Mammograms - within 2 weeks of testing.
SELF-PAY: You will be required to pay in full at completion of your visit.
LABORATORY CHARGES: All laboratory tests performed at Azalea are processed and billed to you by outside laboratories. The charge for
this testing is in addition to your office visit. Your insurance information will be forwarded as a courtesy for billing purposes. We will not file
claims with Medicare, Medicaid and Tricare.
FINANCIAL / INSURANCE: Azalea Gynecology participates with several major insurance carriers and we will file your insurance claims as
a courtesy. HOWEVER, IT IS YOUR RESPONSIBILITY AS THE INSURED, TO DETERMINE IF WE ARE A NETWORK PROVIDER AND
HOW YOUR BENEFITS APPLY. Understand that if you do not have a valid authorization from your insurance company to cover services
performed, or Azalea Gynecology does not participate with your insurance company, you will be personally responsible for the charges in
full, and agree to pay, in full, any co-pays, deductibles, or co-insurance amounts that your insurance company deems your responsibility,
including those resulting from your failure to obtain the necessary referrals and/or other authorizations from your primary care and/or
referring physician when required. Patient credit balances of $50.00 or less will remain on account at Azalea unless specifically requested by
the patient. Verification of eligibility will be determined by our office as a courtesy but does not insure payment for the services provided.
ELIGIBILITY INFORMATION IS OBTAINED FROM YOUR INSURANCE COMPANY BUT IS NOT GUARANTEED BY AZALEA
GYNECOLOGY. Our practice is committed to providing the best treatment possible for our patients and we charge what is usual &
customary for our area. You are responsible for payments in full regardless of any arbitrary determination of usual & customary rates. ALL
OUTSTANDING BALANCES, CO-PAYMENT, DEDUCTIBLE, AND COINSURANCE AMOUNTS ARE DUE PRIOR TO SERVICES BEING
PROVIDED AND YOU WILL BE BILLED AFTER YOUR VISIT FOR ANY ADDITIONAL AMOUNTS YOUR INSURANCE CARRIER
DETERMINES TO BE YOUR RESPONSIBILITY. Outstanding balances 120 days and older will accrue interest charges of 1.5% per month.
Failure to comply with this financial policy may include collection activity and legal action. Any fees incurred in the collection of an
outstanding debt will be the patient's additional responsibility.
AZALEA GYNECOLOGY DOES NOT PARTICIPATE WITH MEDICARE, MEDICAID,
TRICARE, AND MANY OTHER INSURANCE PLANS.
Do you have Medicare coverage? Please check YES or NO. YES _________ NO __________
I HAVE READ AND AGREE TO COMPLY WITH AZALEA GYNECOLOGY OFFICE POLICY.
Patient Signature: ________________________________________ Date: ________________ Rev. 2/17
HSA/HRA & Deductible Plans Office Policy
Patient Written Acknowledgment
We participate with several major insurance carriers and file your claims as a courtesy. Our office policy
concerning the HSA/HRA & Deductible Plans are as follows: Patients are responsible for their
coinsurance, deductibles, and copays in full. Payment is due at the time of service and is based on the
patient's insurance company's contracted rates.
I, ______________________________________, have read and understand the
Azalea Gynecology policy concerning HSA/HRA & Deductible Plans.
____________________________ ___________________________
Patient printed name Patient signature
____________________________ ___________________________
Patient's date of birth Date completed
736 Medical Center Drive, Suite 102, Wilmington, NC 28401
Phone: 910-452-3666 Fax: 910-397-0930
Mississippi Sports Medicine and Orthopaedic Center
& The Therapy Center for Mississippi Sports Medicine
Mississippi Sports Medicine and Orthopaedic Center – New Patient Forms ? v11.11.2014 1
New Patient FormOverview
Patient Account No.______________________
Office Location:______________________
Thank you for choosing Mississippi Sports Medicine & Orthopaedic Center for your care and
treatment.
Please complete the enclosed forms and bring them with you when you arrive for your appointment
on ____________ at _____________.
If you need to cancel or reschedule your appt., please call us at 354-4488 at least 24 hours in
advance. There is a $30 fee if you do no cx/rs within 24 hours.
Please arrive 15 minutes prior to your appointment, if you have finished all paper work. If you DO
NOT have your paperwork completed, please arrive 30 minutes prior to your appointment.
Please bring your picture I.D. & insurance cards along with these completed forms. Any applicable
co-pays or coinsurance will be collected at the time of service.
PLEASE BRING ALL MEDICATIONS THAT YOU ARE CURRENTLY TAKING, X-RAYS, MRI FILMS, OR
ANY OTHER MEDICAL RECORDS THAT MAY BE PERTINENT TO THIS VISIT.
If this visit is due to an accident that is covered by worker's compensation, please have your
employer or adjuster furnish our office with the name, injury date, worker's comp. carrier name,
claim number, billing address & phone number . You will have to reschedule if we do not have your
worker's comp information.
DO NOT MAIL THE PAPERWORK, BRING THIS WITH YOU. THANK YOU!
Scheduled by: ________________________________
Mississippi Sports Medicine and Orthopaedic Center
& The Therapy Center for Mississippi Sports Medicine
Mississippi Sports Medicine and Orthopaedic Center – New Patient Forms ? v11.11.2014 2
Important Insurance Information
We at Mississippi Sports Medicine strive to make your visit a pleasant one. Our staff is here to help
ensure your claims are paid in a timely manner. We need your assistance in getting your claims paid.
Please take a minute to read the information below.
• If your visit is due to an injury, your insurance company may require additional information
from the patient. Your insurance company will mail the patient or the guarantor a form to fill
out. If this form is NOT filled out, the claim is usually denied pending this information and
will be the patient's responsibility. You should receive this request within 30 days of your
visit.
• IF YOU DO NOT RECEIVE AN INJURY FORM OR AN EXPLANATION OF BENEFITS (details on
what has been paid or denied by your insurance company) PLEASE CONTACT YOUR
INSURANCE COMPANY!
• If your injury is due to an auto accident, we will need a letter from your auto insurance
stating you have exhausted your med pay. We will need this letter to file your claim to your
health insurance.
• Please let our front desk personnel know if your insurance has changed since your last visit
with Mississippi Sports Medicine. Keeping us informed of any changes will help us in filing
your claim correctly and in a timely manner. Please always use your complete legal name. If
your name on the insurance card and the name you give us DO NOT match, we will not be
able to file your claim.
NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU MAY GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.
Mississippi Sports Medicine and Orthopaedic Center is dedicated to protecting your medical
information. We are required by law to maintain the privacy of protected health information and to
provide you with this notice of our legal duties and privacy practices with respect to protected
health information. Mississippi Sports Medicine and Orthopaedic Center is required by law to abide
by the terms of this notice, and we reserve the right to change the terms of notice, making any
revision applicable to all the protected health information we maintain. If we revise the terms of
this notice, we will post a revised notice at the hospital and/or clinic and will make paper copies of
this notice or Privacy Practices for Protected Health Information available upon request.
Mississippi Sports Medicine and Orthopaedic Center
& The Therapy Center for Mississippi Sports Medicine
Mississippi Sports Medicine and Orthopaedic Center – New Patient Forms ? v11.11.2014 3
HOW YOUR MEDICAL INFORMATION WILL BE USED AND DISCLOSED:
We will securely store your medical information on a computer for use as part of rendering patient
care. For example, your medical information may be used by the health care professional treating
you, by the business office to process your payment for the services rendered and by the
administrative personnel reviewing the quality and appropriateness of the care you receive.
We may also use and/or disclose your information in accordance with federal and state laws for the
following purposes:
We may contact you to provide appointment reminders or information about treatment
alternatives or other health-related benefits and services that may be of interest to you.
? We may disclose medical information when required by the United States Department of
Health and Human Services as part of an investigation or determination or the Hospital's
compliance with relevant laws.
? Unless you object, we will include general information, including your name, location in the
clinic, your condition described in general terms and your religious affiliation in a directory of
individuals located in the clinic. The directory information, except for your religious
affiliation, will be released to people who ask for you by name. Your religious affiliation may
be given to members of the clergy, even if they do not ask for you by name.
? Unless you object, we may disclose to family members, other relatives or close personal
friend the medical information directly relevant to such person's involvement with your care.
? Unless you object, we may use or disclose your medical information to notify a family
member, a personal representative or another person responsible for your care of your
location, general condition or death.
? We may disclose your medical information to a public or private entity for the purpose of
coordinating with that entity to assist in disaster relief efforts.
? We may use or disclose your information for public health activities, including the reporting
of disease, injury, vital events and the conduct of public health surveillance, investigation
and/or intervention. We may disclose your medical information to a health oversight agency
for oversight activities authorized by law, including audits, investigations, inspections,
licensure or disciplinary actions, administrative and/or legal proceedings.
? We may disclose your medical information in the course or certain judicial or administrative
proceedings. We may disclose your medical information for law enforcement purposes or
other specialized government functions.
? We may disclose your medical information to a coroner, medical examiner or a funeral
director.
? If you are an organ donor, we may disclose your medical information to an organ donation
and procurement organization.
? We may disclose your medical information for certain research purposes.
? We may use or disclose your medical information to prevent or lessen a serious threat to
health or safety or another person or the public.
? We may disclose your medical information as authorized by laws relating to workers'
compensation or similar programs.
Mississippi Sports Medicine and Orthopaedic Center
& The Therapy Center for Mississippi Sports Medicine
Mississippi Sports Medicine and Orthopaedic Center – New Patient Forms ? v11.11.2014 4
We will not use or disclose your medical information for any other purpose without your written
authorization. Once given, you may revoke your authorization in writing at any time.
YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION:
You have the following rights with respect to your medical information.
? The right to request restrictions on certain uses and disclosures of your medical information.
We are not required to agree to your requested restriction, but if we do, we will honor it.
? The right to receive communications from us in a confidential manner.
? The right to inspect and copy your medical information. This right is subject to certain
specific exceptions, and you may be charged a reasonable fee for any copies of your records.
? The right to request an amendment of your medical information. We may deny your request
for certain specific reasons, and, if denied, we will provide you with a written explanation for
the denial and information regarding further rights you would have at that point.
? The right to receive an accounting of the disclosures of your medical information made by
the clinic in the six years prior to your request, except for disclosures for treatment, payment
or clinic operational purposes, and for other certain specifications disclosure types.
? The right to request a paper copy of this notice of Privacy Practices for Protected Health
Information.
? The right to complain to the clinic and/or to the United States Department of Health and
Human Services if you believe that the Hospital has violated your privacy rights. To complain
to the clinic, please contact: The Administrative Department of the clinic in question. If you
choose to file a complaint you will not retaliated against in any way.
If you would like further information regarding your rights or the uses and disclosures of your
medical information you may contact our administrator, Mr. Robert R. Lodes at:
Mississippi Sports Medicine Clinic & Orthopaedic Center, PLLC
1325 East Fortification Street, Jackson MS 39202
Phone: 601-354-4488 Fax: 601-914-1849
Patient Acknowledgement of Receipt of Notice of Privacy Practices
Published by:
OHIO CLERK OF COURTS ASSOCIATION
Printed 11/2006
A GUIDEBOOK FOR NOTARIZING
OHIO TITLE DOCUMENTS
Compliments of:
Gerald E. Fuerst, Clerk of Courts
Automobile and Watercraft Department
1261 Superior Ave
Cleveland, Ohio 44114
216 - 443 - 8900
Automobile and Watercraft Title Office Locations
Main Office
1261 Superior Ave.
Cleveland, OH. 44113
Ph: 216 - 443-8900
Hours:
Monday – Friday 9:00am to 4:30pm
Southgate Branch
21100 Southgate Park Blvd., Ste. 101
Maple Hts., OH 44137
Ph: 216 - 475-6855
Hours:
Monday - 8:30am - 4:30pm
Tuesday - 8:30am - 4:30pm
Wednesday - 8:30am - 4:30pm
Thursday - Closed
Friday 8:30am - 4:30pm
Saturday 8:30am - 1:00pm
Parma Branch
12100 Snow Rd., Ste. 15
Parma, OH. 44130
Ph: 440-888-7050
Hours:
Monday – 9:00am to 4:30pm
Tuesday 9:00am to 1:30pm
Wednesday 8:30am to 6:30pm
Thursday – Friday 9:00am to 4:30pm
Great Northern Branch
5069 The Arcade
Great Northern Shopping Center
North Olmsted, OH. 44070
Ph: 440-777-4060
Hours:
Monday 9:00am to 4:30pm
Tuesday 8:30am to 6:30pm
Wednesday – Closed
Thursday – Friday 9:00am to 4:30pm
Saturday 8:30am to 12:30pm
Introduction
A Certificate of Title is one of the most notarized documents in the State of Ohio.
It is an important legal document, as it officially signifies ownership of a motor
vehicle or watercraft vessel.
The following guideline was compiled by the Ohio Clerk of Courts Association
and is provided as a courtesy to you. This booklet serves as a general guideline;
it does not cover every specific aspect of notarizing certificates of title. If you
have any questions concerning the notarization of titles or title-related documents,
please contact your local county Clerk of Courts' Title Office for guidance.
Notarizing an Ohio Title – General Guidelines
• Do not take the acknowledgment on any instrument wherein blanks are left to be
filled in later. The legal instrument must be completely prepared before notarization is
completed.
• When selling a vehicle or watercraft, owner(s) on the front of the title must sign and
print their name(s) as it appears on the face of the title.
• Assignments of ownership must be in the form of legal names:
- Clifton J. Smith (not CJ Smith)
- Richard L. Jones Jr. (not Dick Jones)
• Do not, under any circumstances, white out or scribble out any errors on the title
assignment; this will void the title and a replacement must be issued.
• If someone signs the back of a title on behalf of a company or other entity, they must
state their position with that entity:
- ABC Trucking Company, John F. Rees, Fleet Mgr.
- Dixie Candy Corp, Dennis T. Dix, Owner
- Abel Family Trust, Carol A. Abel, Trustee
- Estate of Mary Scott, James E. Scott, Executor
• If the seller or buyer is under 18 years of age, the custodial parent or guardian must fill
out a notarized minor consent form (available from the Clerk of Courts' Title Office).
The minor must bring this consent form—along with the certificate of title—to the
Clerk of Courts' office, or the parent/guardian must appear in person with the minor at
the time of transfer. The guardian must provide the court document indicating that
they are the legal guardian of the minor.
• If you take the acknowledgment from a person appointed as power of attorney, the
notarized power of attorney form (available from the Clerk of Courts Title Office)
must be surrendered at the time of transfer of ownership.
- A Durable Power of Attorney is acceptable
- A Health Care Power of Attorney is not acceptable
• If you take the acknowledgment from a person appointed by the Court, the Court
Order must bear the Judge's signature and seal, and must be surrendered at the time of
transfer of ownership:
- Court Order appointing Executor, Fiduciary, Guardian, etc.
- Letter of Authority to Transfer
- Relief from Administration of Estate
• The Ohio ORC #4505.02 requires each applicant to present an official photo ID.
Please contact your local Clerk of Courts' Title Office if you have additional inquiries.
1
Table of Contents
General Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Assignment of an Ohio Title. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-3
Application of an Ohio Title. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-5
Power of Attorney. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-7
Odometer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Additional Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-16
Assignment of an Ohio Title
3
Assignment of an Ohio Title
1. Selling price
2. Date of Sale/Delivery
3. Minor? (consent form required)
4. Buyer(s) legal name and address
5. Odometer reading as shown on vehicle
6. IF odometer is 5 digits and rolled over, place(X) in box
(in excess of mechanical limits)
7. IF odometer is broken or any other discrepancy exists, place(X) in box
8. Check appropriate box, if applicable
9. Printed name(s) of seller(s)
10. Signature of seller(s)
11. Address of seller(s)
12. Person(s) name who signed in front of you
13. Notary Date
14. Commission expiration date
15. Printed name of Notary Public
16. Signature of Notary Public
17. Notary Seal
2
Application for an Ohio Title
5
Application for an Ohio Title
1. Type of Title
2. Buyer(s)' legal name
3. Buyer(s)' Social Security Number
4. Buyer(s)' physical address
5. County of residence
6. Purchase price
7. N/A (Dealer sale only)
8. N/A (Dealer sale only)
9. N/A (Dealer sale only)
10. If sale is exempt from tax, place (X) in box
11. Reason for exemption
12. N/A (Dealer sale only)
13. N/A (Dealer sale only)
14. Condition of vehicle/watercraft
15. Lienholder's name and address (if applicable)
• If no liens – state "none"
16. Minor? (consent form required)
17A. Buyer(s)' signature
17B. Buyers' acknowledgment of mileage
18. Choose (X) printed or (X) non-printed
19. Person's name who signed in your presence
20. Notary Date
21. Commission expiration date
22. Signature of Notary Public
23. Notary Seal
4
7
Power of Attorney Form
• Power of attorney forms for certificates of titles must be notarized
• A power of attorney form must always accompany the title and becomes part
of the permanent title record
• A power of attorney form may only be used for one transaction
• An executor of an estate or trustee cannot give power of attorney to someone
else to sign on their behalf
Please contact your local Clerk of Courts' Title Office
if you have additional inquiries.
6
Additional Forms
The following pages contain samples of other title-related forms that may be
required to transfer an Ohio Certificate of Title.
If used, these forms must also be completed entirely and notarized.
Please contact your local Clerk of Courts' Title Office
if you have additional inquires.
9
Odometer Statement
• The seller of a motor vehicle is statutorily required to state the true mileage of
the vehicle at the time the title is assigned to the buyer (see feature #5).
• Mileage stated as "in excess" of its mechanical limits should only apply to a
5-digit odometer (see feature #6) (For additional information, refer to assignment
of title p.2).
• Vehicles that register 6 digits on the odometer should not be "in excess" of
their mechanical limits
• An odometer that is broken, inoperable or replaced should be marked as "non
actual" (see feature #7) (For additional information, refer to assignment of
title p. 2)
8
10 11
State of Ohio - Seller's Affidavit
Erasures or Alterations Void This Statement
ODOMETER READING DISCLOSURE STATEMENT
Notice to Transfer: You are required by law to enter all information required herein,
including the odometer reading of the motor vehicle in the affidavit immediately
following. The making of a false statement under oath or affirmation is in violation of
Section 2921.13 of the Revised Code and is punishable by six months imprisonment
and a fine of up to one thousand dollars, or both .
• TYPE OR PRINT IN INK
State of Ohio, ________________County SS: Date __________________, 20____
Year _______________________ Mfr's Serial No.__________________________
Make ______________________
Purchaser's Name ___________________________________________________
I (we) certify that the mileage registered on this vehicle at the time of assignment is
_______________ miles.
• CHECK ONE OF THE FOllOWING STATEMENTS. I (WE) CERTIFY THAT:
I:l To the best of my (our) knowledge, the Odometer reading reflects the actual mileage;
I:l The Odometer reading reflects mileage in excess of the designed mechanical limit
of 99,999 miles.
I:l To the best of my (our) knowledge, the Odometer reading is not the actual mileage
and should not be relied upon .
• CHECK ONE OF THE FOllOWING. I (WE) CERTIFY THAT, WHilE IN MY (OUR) POSSESSION:
I:l The Odometer of this vehicle was not altered, set back, or disconnected;
I:l The Odometer of this vehicle was repaired or replaced.
x_____________________________
TRANSFEROR'S SIGNATURE
Sworn to before me and subscribed in my presence this _____________day of
____________ , 20_____ . My commission expires,
_________________20____.
SEAL
All information must be
entered before notarization.
__________________________________________
(CLERK, DEPUTY CLERK OF COURTS - NOTARY)
1153
12 13
14 15
This booklet intended to serve as a general guideline for notarizing Ohio Title
Documents.
Your county Clerk of Courts' Title office can assist you in answering more
specific questions, or in addressing items specific to your county of residence.
16
Notes
