New Patient Forms

South Coast Family Medicine

Please correct the errors described below.

We will need to make a copy of Insurance Card and Photo ID
Necesitaremos Hacer Copias De Su Identificacion y Tarjeta de Seguro

PLEASE BRING ALL MEDICATIONS TO ALL APPOINTMENTS
POR FAVOR DE TRAER TODAS SUS MEDICINAS A CADA VISITA

New Patient Information

Apellido
Nombre
Segundo nombre
Direccion de domicilio
Cuidad
Estado
Codigo Postal
Direccion de envio: (Si es different a la direccion de domicilio)
Fecha de nacimiento
Seguro social
Telefono de domicilio
Telefono de trabajo
Alternativo
Correo electronico
Preferencia de Religion (opcional)
Preferencia De idioma
Ocupacion
Empleador
No. de telefono
Direccion de empleador
Cuidad
Estado
Codigo postal
Contacto de emergencia
Relacion al paciente
No. de telefono
Pareinete de sangre que no viva con ustd
No. de telefono
Nombre de Seguro Primario
Nombre de Seguro Secundario

IF YOU ARE NOT THE PRIMARY INSURED PLEASE PROVIDE INFO FOR CARD HOLDER:
Si No Eres La Persona Primaria En El Aseguro Por Favor Proveer la Siguiente Informacion Del Asegurado Principal:

Nombre
Fecha de nacimiento
Seguro Social
Relacion del asegurado y el paciente

Preferred Pharmacy (Please include Name and Address):
Farmacia De Preferencia (Incluya El Nombre y Ubicacion):

Nombre de farmacia
Pedido postal

I hereby consent for the clinic to photograph my care, treatment, and services and allow the clinic to use the photographs for their internal use, for documenting my medical condition or for insurance providers to document my condition for payment purposes.

Yo le doy permiso a la clinica de tomar photografias de mi cuidado, tratamiento, y servicios, la clinica puede usar las photografias para el uso interno para documentar mi condicion medica o para el uso de explicacion de mi condicion medica a las aseguransas para proposito de pago.

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize South Coast Family Medicine or insurance company to release any information required to process my claim.

La información anterior es verdadera a lo mejor de mi conocimiento. Autorizo a mis beneficios de seguro a pagar directamente al médico. Entiendo que soy financieramente responsable por cualquier saldo. También autorizo a South Coast Family Medicine o compañía de seguros para liberar toda la información necesaria para procesar mi reclamo.

Paciente /Padre Del Paciente/Guardian del Paciente
Fecha

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

***PLEASE NOTE: WE DO NOT PRESCRIBE PAIN MEDICATION ON THE FIRST APPOINTMENT***

HEALTH HISTORY QUESTIONNAIRE

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

PERSONAL HEALTH HISTORY

MEDICAL PROBLEMS (PLEASE CHECK)

PREVENTATIVE:

SURGERIES (PLEASE CHECK)

LIST YOUR PRESCRIBED DRUGS AND OVER-THE-COUNTER DRUGS, SUCH AS VITMAINS AND INHALERS

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ALLERGIES TO MEDICATIONS

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HEALTH HABITS AND PERSONAL SAFETY

ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL

Exercise/Diet:

Salt Intake:

Alcohol:

Tobacco:

Drugs:

FAMILY HEALTH HISTORY

Father

Mother

Sibling

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Children

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Grandmother (Maternal)

Grandfather (Maternal)

Grandmother (Paternal)

Grandfather (Paternal)

NOTICE OF PRIVACY PRACTICES FOR SOUTH COAST FAMILY MEDICINE

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.

This practice uses and discloses health information about you for treatment, for administrative purpose, and to evaluate the quality of care that you receive. We are required by law and regulation to protect the privacy of your medical information, to provide you with this notice of our privacy practices the respect to protected health information, and to abide by the terms of the notice of privacy practices in effect. This notice is effective 04/01/2015.

This notice describes our privacy practices. We may change our policies and this notice at any time and have those revised policies apply to all the protected health information we maintain. If or when we change our notice, we will post the new notice in the office where it can be seen. You can request a paper copy of this notice, or any revised notice, at any time.

A. Treatment, Payment, Health Care Operations

Treatment: We are permitted to use and disclose your medical information to those involved in your treatment. For example, your care may require the involvement of a specialist. When we refer you to that physician, we will share some or all of your medical information with that physician to facilitate the delivery of care.

Payment: We are permitted to use and disclose your medical information to bill and collect payment for the services we provided to you. For example, we may complete a claim form that will contain medical information, such as a description of the medical services provided to you, to obtain payment from your insurer or HMO.

Health Care Operations: We are permitted to use or disclose your medical information for the purpose of health care operations, which are activities that support the practice and ensure that quality care is delivered. For example, we may engage the services of a professional to aid this practice in its compliance programs. This person will review billing and medical files to ensure we maintain our compliance with regulations and the law.

B. Disclosures That Can Be Made Without Your Authorization: There are situations in which we are permitted to disclose or use your medical information without your written authorization or an opportunity to object. In other situations, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization, in written, to stop future uses and disclosures. However, any revocation will not apply to disclosures or uses already made or that rely on that authorization.

  • We may disclose your medical information for public health activities. Public Health Activities are mandated by the government for the collection of information about disease, vital statistics (like births and deaths), or injury by a public health authority. We may disclose medical information if authorized by law, to a person who may have been exposed or may be at risk for contracting or spreading disease. We may disclose your medical information to repost reactions to medications, problems with products, or to notify people of recalls of products that may be using.
  • HIPAA privacy regulations permit the disclosure of information relating to victims of abuse, neglect, or domestic violence.
  • We may disclose your medical information to a health oversight agency for those activities authorized by law. Example, of these activities are audits, investigations, licensure applications and inspections, which are all government activities undertaken to monitor the health care delivery systems and compliance with other laws, such as civil rights law.
  • We may release your medical information when the disclosure is required by law.
  • We may disclose your medical information in the course of judicial or administrative proceeding in response to an order of the court or other appropriate legal process.
  • We may disclose your medical information to police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.
  • We also may release your medical information if we believe the disclosure is necessary to prevent or lessen an imminent threat to the health or safety of a person.
  • We may release your medical information to a correctional institution or law enforcement official if you are an inmate threat or under custody of law enforcement, in order to provide you with medical care.
  • We may disclose your medical information for specialized government functions such as discharge from military service, authorized national security and intelligence activities, protective services for the President, other government officials, or foreign head of state.
  • When a research project and its privacy protections have been approved by an institutional review board, we may release medical information to researchers for research purposes.
  • We may release medical information to organ procurement organization for the purpose of facilitating organ, eye, or tissue donation if you are a donor.
  • We may release your medical information to a coroner or medical examiner to identify a deceased person or a cause of death.
  • Further, we may release your medical information to a funeral director when such a disclosure is necessary for the director to carry out his duties.

C. Your Right Under Federal Law
The U.S. Department of Health and Human Service created regulations intended to protect patient privacy as required by the Health Insurance Portability and Accountability Act (HIPAA). Those regulations create several privileges that patients may exercise.

Requested Restrictions:

  • You may request that we restrict or limit how your protected health information is used or disclosed for treatment, payment, or health care operations. We do NOT have to agree to this restriction, but if we agree, we will comply with your request except under emergency circumstances.
  • You may also request that we limit disclosure to family members, other relative, or close personal friends who may or may not be involved in your care.
  • To request a restriction, submit the following in writing: (a) the information to be restricted, (b) what kind of restrictions you are requesting (i.e., on the use of this information. Disclosure of information, or both), and (c) to whom the limits apply. Please send the request to the address and person listed at the end of this document.

Receiving Confidential Communication by Alternative Means: We may contact you by telephone, mail, or both to provide appointment reminders, information about treatment alternatives, or other health-related benefits and services that may be of interest to you. You may request that we send communications of protected health information by alternative means or to an alternative location. This request must be made in writing to the person listed below. We are required to accommodate only reasonable requests. Please specify in your correspondence exactly how you want us to communicate with you and the contact and address information.

Inspection and Copies of Protected Health Information: You may inspect and/or copy health information that is within your medical record that is used to make decisions about your care. Texas laws requires that requests for copies be made in writing, and we ask that request for inspection of your health information also be made in writing. Please send your request to the person listed at the end of this document. There are certain situations in which we are not required to comply with your request. Under these circumstances, we will respond to you in writing, stating why we will not grant your request and describe any right you may have to request a review of your denial. Texas law requires us to be ready to provide copies within 15 days of your request. We will inform you when the records are ready or if we believe access should be limited. HIPAA permits is to charge a reasonable cost-based fee for copying your chart.

Amendment of Medical Information: You may request an amendment of your medical information in the designated record set. Any such request must be made in writing to the person listed at the end of this document and must explain your reason for the amendment. We will respond within 60 days of your request. We may deny your request for the following reasons: the information was not created by this practice or the physicians in this practice, the information is not part of the records used to make a decision about you, the information is not available for inspections because of an appropriate denial, or the information is accurate and complete.

If we refuse to allow an amendment, we will inform you in writing and you are permitted to include a statement in your chart about the information at issue in your medical record. If we approve the amendment, we will inform you in writing, allow the amendment to be made and tell others that we not have the correct information.

According of Certain Disclosure: HIPAA privacy regulations require us to provide at our request, an accounting of disclosures that are either for treatment, payment, health care operations, or made via an authorization signed by you or your representative. Please submit any request for and accounting to the person at the end of this document. If you request a list of disclosures more than once in 12 months, we are allowed to charge a reasonable fee.

Complaints: If you are concerned that your privacy rights have been violated, you may contact the person listed below. You may also send a written complaint to the U.S Department of Health and Human Services. We will not retaliate against you for filling a complaint with us or the government.

Questions and Contact Person for Requests: If you have any questions regarding the privacy notice, any complaints or concerns regarding this practice or any requests (pursuant to the rights describe above) please contact:

SOUTH COAST FAMILY MEDICINE
6182 Dunbarton Oak Dr., Suite B
Corpus Christi, Texas 78414
Ph: (361) 452-9320 Fax: (361) 452-9321

Patient Policies

As a patient of South Coast Family Medicine, I understand that the following policies are currently in effect:

  1. I understand that South Coast Family Medicine, and any providers associated with the clinic has the right to refuse service.
  2. I understand that a $30.00 fee will be assessed on all returned checks. Returned checks will have to be paid in cash within 10 days of notification. I also understand if outstanding checks are not resolved within the 10 days limit, I may be dismissed from the practice.
  3. I understand payment is due at time services are rendered, unless prior payment arrangements are made with office. This includes any deductibles, copayment, or co-insurance amounts. Any balances not paid by my insurance carrier are my responsibility to resolve. I further understand that balances due must be paid in a timely manner to avoid further collection actions.
  4. I understand that if I am involved in any accident causing bodily injury, the providers at South Coast Family Medicine will not see me for any reason pertaining to such injuries and am I to go through a third party such and an insurance company or law firm to address my injuries.
  5. I give permission to be seen and treated by a medical student / nurse practitioner student who is under the supervision of a licensed medical provider.
  6. I am to present proof of my insurance coverage at every office visit.
  7. I understand that if I am habitually noncompliant with prescribed medications, medical diagnostic orders or adherence to agreed-upon treatment plans, South Coast Family Medicine is not to be held responsible and I may be dismissed from the practice.
  8. I understand that South Coast Family Medicine has the right to dismiss me from the practice at any time if I display rude, disruptive or unreasonably demanding behavior. Furthermore, I understand that I may be dismissed from South Coast Family Medicine I am involved in a sentinel incident (verbal threat, violence, criminal activity) or seductive behavior towards any staff member.
  9. I am responsible in notifying South Coast Family Medicine of any changes of name, address, and phone numbers within 30 days of made changes.
  10. I understand if I am more than 15 minutes late for my schedule appointment I may be asked to reschedule for another day.
  11. I understand that I may be charged per phone conversation by South Coast Family Medicine and any associates for any outstanding balance.
  12. I understand that all outstanding balances are due in full prior to next scheduled appointment unless payment agreement has been arranged.
  13. I understand that I am to allow at least 5-7 business days for my prescription’s refills and/ or paperwork I may need to complete by my provider. I also understand that there may be a $15.00 fee to complete such paper work and forms that are requested at any other time that is not during a scheduled visit.
  14. If I am a self-pay patient (without insurance coverage) and receive orders for diagnostic testing (i.e. X-rays, labs, or other medical orders) all must be performed prior to next scheduled appointment. I also understand that no medical treatment nor medication refills will be received on behave of South Coast Family Medicine and their providers until medical orders are carried out.
  15. Finally, I understand that if any detrimental effects result from lack of following medical diagnostics orders provided South Coast Family Medicine and their rendering providers are not responsible for any untoward or detrimental effects.

My signature confirms I have read and understand the above office policies and have had an opportunity to ask question regarding any concerns I may have about these policies.

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

**This document may be obtained in Spanish version, per patient request. / Este documento puede ser obtenido en Espanol**

Notice of Privacy Acknowledgement

I have received a copy of the South Coast Family Medicine Notice of Privacy Acknowledgement. I understand that South Coast Family Medicine has the right to change its Notice of Privacy Practices from time to time and that I may contact South Coast Family Medicine at any time to obtain a current copy of the Notice of Privacy Practices.

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

FOR OFFICE USE ONLY

AUTHORIZATION FOR DISCLOSURE OF CONFIDENTIAL INFORMATION

Authorizes South Coast Family Medicine, to release the following information to:

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Confer orally with person(s) listed below about my medical conditions: (family member, caregiver, etc)

This Authorization shall be valid from the date of signature. The patient can revoke this authorization in writing at any time.

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Permission to Release Medical Records

Please release my records:

To:
South Coast Family Medicine
6182 Dunbarton Oak Dr., Suite B
Corpus Christi, Texas 78414

Office: (361) 452-9320
Fax: (361) 452-9321

Permission is hereby granted for RELEASE OF INFORMATION

***REQUIRED***

Please initial the following:

I recognize the information disclosed may contain mental health information that is protected by state and federal laws. I consent to the disclosure of this information.

I recognize the information released may contain drug/alcohol information that is protected by federal law. I consent to disclosure of such information.

I recognize the information disclosed may contain information regarding sexually transmitted disease or HIV/AIDS testing. I consent to disclosure of this information.

You have the right to revoke this authorization at any time, except to the extent that South Coast Family Medicine has already acted based on this authorization. To revoke this authorization, you must submit a request in writing to South Coast Family Medicine at the above address.

This authorization does not have an expiration date.

Your information will be encrypted.

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