New Patient Form

Patient Registration

Patient Name:

Date of Birth:

Address:

Social Security #

City/State/Zip:

Gender:

Female Male

Home Phone:

Cell Phone:

Marital Status:

Race:

Ethnicity:

Language:

Employed By:

Work Phone:

Email Address:

Guarantor Information

(Insurance Policy Holder)

Guarantor Name:

Date of Birth:

Address:

Social Security #:

City/State/Zip:

Gender:

Female Male

Home Phone:

Cell Phone:

Marital Status:

Race:

Ethnicity:

Language:

Employed By:

Work Phone:

Email Address:

Notice to Patients

Abundant Health! Family Medicine providers are not providers for claims regarding accidental injuries as a result of motor vehicle accidents or a work-related injury/workers comp claim. If you are a victim of a motor vehicle accident or work-related injury and your appointment with our office is in any way a result of that accident, please take this form to the front desk so that we may remove your appointment from the schedule database.

By signing this document, you are attesting that your injuries that we are evaluating in our office are not related to motor vehicle accident or a work-related injury/workers comp claim.

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

Name

DOB

Signature

Date

Statement of fact:

I, the above signed patient attest to a statement of fact regarding my injury. I acknowledge that knowingly or willfully falsifying medical information will result in an immediate collection based upon the care provided. In addition, I will be personally responsible for the debt incurred during my visit and agree to pay a $200.00 additional processing fee per visit during which the false or misleading information was provided.

Financial Policy

Welcome! Thank you for choosing Abundant Health Family Medicine as your health care provider. We look forward to providing excellent medical care and forming, a long-term professional relationship with you. As part of that professional relationship, we feel it is important to provide you information that will allow you to understand our financial policy.

If you have medical insurance, that relationship is between you, your employer and your insurance company. As a courtesy, we will file a claim with your insurance for our services. Ultimately you are financially responsible for the services rendered by our providers.

It is always the patient's responsibility to know their insurance carriers benefits and policy. Please provide your current insurance information at the time of your visit. Failure to provide the correct insurance information in a timely manner, could result in the claim being denied by your insurance company. In the case of non-payment by the insurance carrier, patient is ultimately responsible for payment. Please make sure to bring your current insurance card to each visit.
Before you receive services at our office, you must verify that we are participating providers with your insurance. If we are not participating providers and you still want to be seen, you will need to pay for the service in full at the time of the visit.
Please be aware that some or perhaps all of the services rendered in our office may not be covered fully by your insurance company.
You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.
If your insurance plan includes a copay, we are required to collect the copay at the time of service.
Coinsurance and/or deductibles are due at time of service. we will estimate the amount owed based on the information from your insurance company. If additional amounts are owed after the insurance company has paid the claim, you will be responsible for the difference, regardless of our initial estimate.
It is your responsibility to provide us with your most current medical billing information.
You will be asked at each visit to verify your insurance information as well as your current mailing address and phone number.
If you have an account balance, we will send a statement to the most recent billing address you have provided. If you have questions about your statement, please contact our office at (830) 620-7744.
Payment in full is due upon receipt of your statement. Balances not paid in full within 30 days of statement issue date will be deemed past due. Past due accounts will be subject to a $10.00 re-billing fee.
Past due accounts may be referred to an independent collection agency for further collection activity.
If you are unable to pay your balance in full, you must contact our office to discuss a payment plan. Once payment arrangements have been made, it is your responsibility to fulfill that agreement. Failure to follow the payment plan schedule may result in your account being referred to an independent collection agency / or termination of care with our clinic.
A minimum of 24 hours cancellation notice is required for appointments. A $25.00 "No show" fee will be applied for failure to cancel or reschedule an appointment at least 24 hours prior to your appointment time. All "no show" fees must be paid in full prior to being seen at your next visit. You are responsible for any no-show fees you are charged; your insurance company will not be billed. If you incur (3) no show charges within a one-year time period, you may face dismissal from the practice.
A $50.00 fee will be applied to the original balance for checks returned by your financial institution.*
Abundant Health Family Medicine has an on-call provider available after hours care requiring diagnosis and treatment of our medical condition.
Patients with past due accounts, who have not previously made payment arrangements, will be required to meet in person with a member of our staff prior to making any routine or preventive appointments.
If the patient has insurance coverage with which this office has a contractual agreement, we will bill the insurance for services rendered. In the case of non-payment by the insurance company, the patient/guardian understands they are responsible for payment.
The providers at Abundant Health Family medicine made decisions regarding your health based on medical judgment. This may mean that they recommend laboratory test, x-rays, or procedures that may not be covered by your health plan (if you have one). Please be familiar with your health insurance benefits. The time to address your coverage/cost is before the services/procedure(s) are performed.

I, the undersigned patient/guardian, or responsible party have read and understand Abundant Health Family Medicine's policies.

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

Signature of Patient/Guardian or Personal Representative

Date

Name of Patient or Personal Representative

Date

Relationship to Patient

Emergency Contact Information

First Contact

Address

Home Phone Number

Cell Phone Number

Relationship

Second Contact

Address

Home Phone Number

Cell Phone Number

Relationship

General Consent for Treatment

Patient Name:

Date of Birth:

I voluntarily consent to evaluation and treatment by the Physician, Physician Assistant, or family Nurse Practitioner on staff at Abundant Health! Family Medicine clinic. I understand that the practice of medicine is not an exact science and that no guarantees have been made to me as to the results of treatments or examination by the staff.

Signature of Patient/Guardian:

Date:

Mid-Level Provider Consent Form

This practice utilizes Physicians Assistants (PAs) and Nurse Practitioners (FNPs) to provide health care. PAs and FNPs are educated, licensed, and nationally certified providers that work in conjunction with supervising Physician. There is on-going communication between the Physician and the Mid-Level providers regarding patient care. If at any time a patient requests an appointment with the Physician, this request will be granted at the first availability.

I have read the above information regarding Mid-Level Providers. I hereby give my consent of treatment.

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

Signature of Patient/Guardian:

Date:

HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient's rights section describing your rights under the law. You ascertain by your signatures that you have reviewed our notice before you sign this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

The HIPAA, (Health Insurance Portability and Accountability Act of 1996) law allows for the use/disclosure of patient health information. You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with restriction, but if we do, we shall honor this agreement.

By signing this form, you consent to our use and disclosure of your protected healthcare information. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The practice reserves the right to change the privacy policy as allowed by law.
The patient has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
The practice may condition receipt of treatment upon execution of this consent.

Patient/Parent/Legal Guardian Signature:

Date:

Authorization for Release of Medical Information

Patient's Name

Date of Birth

Address

City/State/Zip

Patient's Phone Number

Date of Request

Date of Needed

I authorize Abundant Health! Family Medicine to release information to I authorize Abundant Health! Family Medicine to obtain information from

Name of Provider or Facility

Address

City/State/Zip

Phone/Fax

Purpose for this request

Transfer of care Upcoming appointment Insurance verification Other

If other, please specify.

Type of records requested: (Check one)

Complete medical records Imaging reports Recent visit notes Laboratory results Other

If other, please specify.

I understand that:

My right to healthcare treatment is not conditioned on this authorization. I may cancel this authorization at anytime by submitting a written request to the office. This request will be valid for one year from the date signed. There may be a charge for the requested records.

Signature of Patient/Parent/Guardian

Date:

New Patient Intake Form

Name:

DOB:

Reason for Visit Today:

How did you learn about our practice?

Newspaper

Internet

Friend/Relative

Other

If Other, please specify:

Name of person who referred you:

If cancer, please specify type:

If Sexually Transmitted Disease, please specify type:

FOR WOMEN ONLY:

Date of:

Last Menstrual Period

Last Pap Smear

Last Mammogram

Last Bone Density

Age of First Period

Abnormal Pap Smears?

Abnormal Mammograms?

Abnormal Bone Density?

# of pregnancies

# of live births

# of miscarriages

# of abortions

# of living children

Family History: Have any of your family members had any of the following problems?

Heart Disease/Attack

Family Member(s):

Stroke

Family Member(s):

Diabetes

Family Member(s):

High Blood Pressure

Family Member(s):

High Cholesterol

Family Member(s):

Thyroid Disease

Family Member(s):

Depression

Family Member(s):

Other Mental Illness

Family Member(s):

Alcohol or Drug Addiction

Family Member(s):

Asthma

Family Member(s):

Autoimmune Disease

Family Member(s):

Osteoporosis

Family Member(s):

Migraines

Family Member(s):

Breast Cancer

Family Member(s):

Colon Cancer

Family Member(s):

Prostate Cancer

Family Member(s):

Lung Cancer

Family Member(s):

Ovarian Cancer

Family Member(s):

Uterine Cancer

Family Member(s):

Skin Cancer

Family Member(s):

Other Cancer

Family Member(s):

Any other illness in the family not listed?

Vaccines: (Date of Last):

Flu Vaccine

Shingles Vaccine

Pneumonia Vaccine

Tetanus Vaccine

TB Screen

Social History:

Marital Status:

Highest Level of Education:

Occupation:

Number of Children and Ages:

Health Habits:

Do you smoke currently?

Yes No

If so, how much? (cig/day)

# of years smoking

If no, did you smoke in the past?

Yes No

# of years?

Cig/day?

Quit Date:

Are you exposed to smoke?

Yes No

Any other tobacco use?

Yes No

Type:

Cigars

Chewing Tobacco

Vaping/E-cigs

Other

Do you drink caffeine?

Yes No

If so, how much per day?

Do you drink alcohol?

Yes No

What kind?

Beer

Wine

Liquor

If so, how many drinks per week?

Have you ever had a problem with alcohol in the past?

Have you ever used street drugs?

Yes No

Which Ones?

If yes, are you still using?

Yes No

Are you sexually active (in the last year)?

Yes No

If yes, how many partners?

Which birth control do you or your partner use?

Do you wear a seatbelt?

Yes No

Do you have a working smoke alarm in your home?

Yes No

Do you have a living will (Do Not Resuscitate order, Power of Attorney)?

Yes No

Do you exercise?

Yes No

If so, what type and how often?

Is there concern for your safety? (emotional, physical, or sexual abuse)

Yes No

Preferred Pharmacy?

Who was your last doctor and when were you last seen?

Information update

Due to our most recent update to better assist our patients with appointment reminders, we are requesting that you provide an email address and update cell phone number. With this information we will be able to email your appointment reminder as well as text. This feature will allow you to respond to the text or email. This will save you time from having to call in or being placed on hold. By signing this form you are giving us consent to send you reminders of healthcare services and marketing.

Email:

Preferred phone number:

Patient or guardian

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

Signature:

Date