Patient Registration Form

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Please be advised that due to the upcoming compliance date of December 31, 2010 for the Red Flags Rule patients of Earl V. Wilkinson, M.D., Earl V Wilkinson, MD, LLC medical practice are subject to comply with policies that the practice uses to identify, detect, and respond to Red Flags. The following is a description of an enforced procedure designed to protect our patients and the practice.

    1. When a patient calls to request an appointment, the patient will be asked to bring the following at the time of the appointment:
    a. Driver's license or other photo ID;
    b. Current health insurance card; and
    c. Utility bills or other correspondence showing current residence if the photo ID does not show the patient's current address. If the patient is a minor, the patient's parent or guardian should bring the information listed above.
    2. When the patient arrives for the appointment, the patient will be asked to produce the information listed above. This requirement may be waived for patients who have visited the practice within the last six months.
    3. If the patient has not completed the registration form within the last six months, registration staff will verify current information on file and, if appropriate, update the information.
    4. Staff should be alert for the possibility of identity theft in the following situations:
    a. The photograph on a driver's license or other photo ID submitted by the patient does not resemble the patient.
    b. The patient submits a driver's license, insurance card, or other identifying information that appears to be altered or forged.
    c. Information on one form of identification the patient submitted is inconsistent with information on another form of identification or with information already in the practice's records.
    d. An address or telephone number is discovered to be incorrect, non-existent or fictitious.
    e. The patient fails to provide identifying information or documents.
    f. The patient's signature does not match a signature in the practice's records.
    g. The Social Security number or other identifying information the patient provided is the same as identifying information in the practice's records provided by another individual, or the Social Security number is invalid.

Below are links for a Patient Registration form and a HIPPA Privacy Notice. These files are in PDF format and require an acrobat 7.0 or later reader to open them. You can download an acrobat reader for FREE by visiting adobe's website here:


All new patients must fill out a new patient registration form that applies to them based on age or requiring a legal guardian. The notice of assignment of benefits to a provider and privacy practices must be completed and returned to the practice along with the completed new patient registration form. Please remember to bring cash or check for any required copayments. The practice does not accept credit cards.


Required:Please select 1 of the 3 New Patient Forms that applies to the patient

New Patient Adult Registration Form (18 years of age and above)

New Patient Minor Registration Form (Under 18 years of age)

New Patient Registration Form (Patient present with Legal Guardian)

Required:Please select the Notice of Assignment of Benefits to a Provider and Privacy Practices

Notice of Assignment of Benefits to a Provider and Privacy Practices

Optional: Please select the link below to read about HIPPA Privacy

HIPPA Privacy Notice

Optional: Please select the appropriate links regarding record release

Authorization form requesting medical records to be released to Dr. Earl Wilkinson

Authorization form requesting medical records from Dr. Earl Wilkinson be released and sent outside Earl V Wilkinson, MD, LLC medical practice


Red Flags Rule Compliance date: December 31, 2010

In November 2007, the Federal Trade Commission (FTC) issued a set of regulations, known as the "Red Flags Rule," requiring that certain entities develop and implement written identity theft prevention and detection programs to protect consumers from identity theft. While the American Medical Association (AMA) is committed to the protection of patients and physicians, the Red Flags Rule did not specifically state whether physician practices were subject to the Red Flags requirements. In response to FTC staff indications that the FTC intends to apply the Rule to physician practices, the AMA expressed its concerns and successfully delayed implementation of the Rule until December 31, 2010. The AMA is continuing its efforts to persuade the FTC that physicians are not "creditors," and therefore should not be subject to the Red Flags Rule.

What is the purpose of the Red Flags Rule?

The Red Flags Rule requires certain entities to develop and implement policies and procedures to protect against identity theft. Identity theft occurs when someone uses another's personal identifying information (e.g., name, Social Security number, credit card number, or insurance enrollment or coverage data) to commit fraud or other crimes. In the case of physician practices, of particular concern is medical identity theft. Medical identity theft occurs when someone uses a person's name and sometimes other parts of their identity-such as insurance information-without that person's knowledge or consent to obtain or make false claims for medical services or goods. Medical identity theft can also result in erroneous entries into existing medical records and can involve the creation of fictitious medical records in the victim's name.

Who has to comply with the Red Flags Rule?

The Rule applies to any institution considered a "creditor." A creditor is defined as "any person who regularly extends, renews, or continues credit; any person who regularly arranges for the extension, renewal, or continuation of credit; or any assignee of an original creditor who participates in the decision to extend, renew, or continue credit." The FTC, however, considers physicians who accept insurance or allow payment plans to be creditors and therefore subject to the Red Flags Rule.

The FTC takes the position that physicians extend credit by allowing deferred payment until services are rendered and insurance is collected. The AMA does not believe the FTC interpretation is consistent with the intent or scope of the enabling legislation and is continuing efforts to avoid application of the Rule to physician practices. Physician practices who accept insurance or allow payment plans are covered under the Red Flags Rule and must have adequate policies and procedures in place by December 31, 2010, or they may face a penalty of up to $2,500 per "knowing violation."

How does the Rule differ from HIPAA privacy and security rules?

HIPAA is intended to protect personal health information (PHI) for security and privacy purposes. PHI as defined by HIPAA is covered by the Red Flags Rule, but the Rule extends to other sensitive information:

    Credit card information
    Tax identification numbers: Social Security numbers, business identification numbers and employer identification numbers
    Insurance claim information
    Background checks for employees and service providers

What is a "red flag?"

A Red Flag is a pattern, practice, or specific account activity that indicates the possibility of identity theft. The FTC identifies the following as red flags:

    Alerts, notifications or warnings from a consumer reporting agency
    Suspicious documents and/or personal identifying information, such as an inconsistent address or nonexistent Social Security number
    Unusual use of, or suspicious activity relating to, a patient account
    Notices of possible identity theft from patients, victims of identity theft or law enforcement authorities

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