New Patient Form (Newborn

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

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:

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 carrier's 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, the 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 the 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 to address your urgent medical concerns. A $20.00 fee may be assessed for 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.

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 of Patient/Guardian or Personal Representative

Date

Relationship to Patient

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.

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 of Patient/Guardian:

Date:

Mid-Level Provider Consent Form

This practice utilizes Physicians Assistants (PAs) and Nurse Practitioners (FNPs) to provide healthcare. 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.

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 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.

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.

Patient/Parent/Legal Guardian Signature:

Date:

Release of Information

I (we) the undersigned patient and/or responsible party hereby authorize this office, its agents/employees to release and disclose all or part of the patients/ medical records to any entity, which is, or may be liable for all or part of the provider charges.

I (we) authorize the release and disclosure or any and all medical records to any other entity including by not limited to referring physicians, hospitals or other health care providers which may be of assistance in the opinion of this office, in providing for the treatment of patient.

I (we) authorize the release of records necessary as assist in reimbursement of benefits to which I (we) may be entitled. I (we) authorized this office and/or its employees to release via fax machine medical records which are needed in order to provide patient with the most appropriate medical care.

I (we) authorize the release of my x-rays, labs, and medical results to be left on my answering machine if I am unavailable.

Yes No

I (we) the undersigned patient and/or responsible party hereby authorize this office to release medical, billing, and appointment information to the following family members in lieu of myself:

Add another person

Emergency Contact Information

In case of an emergency, please contact the following person or persons on my behalf:

First Contact:

Relationship:

Home Phone Number:

Cell Phone Number:

First Contact:

Relationship:

Home Phone Number:

Cell Phone Number:

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.

Patient/Parent/Legal Guardian:

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 needed

I authorize Abundant Health Family Medicine to release information to

I authorize Abundant Health Family Medicine to obtain information from

Add new row

Purpose for this request: (check one)

Transfer of care Upcoming appointment Insurance verification Other

If other, specify

Type of records requested: (check one)

Imaging reports Recent visit notes Laboratory results Other

If other, specify

I understand that:
My right to healthcare treatment is not conditioned on this authorization. I may cancel this authorization at any time 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

Child Health Inventory (Birth - 12 Years)

Please bring in a record of your child's vaccinations for us to copy

Date

DOB

Age

Name

Concerns

Do you have any particular concerns regarding your child?

Prenatal and Birth History

Birth weight

Height

Was your baby?

Early Late

If yes to either, how many weeks?

Was your baby born at home?

Yes No

Mother's age at the time of pregnancy?

Number of pregnancies

Number of living children

Month prenatal care was started

At any time during this pregnancy did you

Have bleeding

Have flu or other infections?

Have persistent vomiting?

Need drugs other than vitamins or iron?

Have high blood pressure?

Have other illness or accidents?

Were you or your doctor worried about this pregnancy?

Did you use alcohol or street drugs during this pregnancy?

Were you on WIC?

How long was the labor?

Were there any difficulties with labor?

Yes No

If yes, explain

Has your child had a tuberculosis (TB) skin test?

Yes No

If yes, date?

Is your child foreign-born?

Yes No

Has your child had close contact with a TB Infectious

Yes No

Development

At what age did your child

Smile or respond

Sit Alone

Roll over

Take 10 steps alone

Crawl

Potty train - pee

Joint words

Have her first period

Potty train - poop

Social

Who lives with your child? (name, relationship, age)

Do you see your child as different in any way compared to other children his/her age?

Yes No

If yes, in what way?

Does your child have trouble getting along with teachers in school?

Not in school yet

Yes

Does your child have trouble learning?

Not in school yet

Yes

Does your child need extra help in math or reading?

Not in school yet

Yes

Does your child have trouble getting along with other children?

Yes

Has your child shown aggressive verbal, physical or sexual behavior?

Yes

Within the last 12 months, has your child been in a relationship in which there were threats, pushing, grabbing, hitting, kicking, breaking things, or other hurting?

Yes

Nutrition

List what your child has had to eat and drink in the past 24 hours:

List the number of servings your child has of these foods each day:

Milk

Bread/Pasta/Grains

Fruits/Vegetables

Meat

Mark number of meals your child eats each day:

Is your child a fussy eater?

Yes No

Does your child eat too much?

Yes No

Do you give vitamins or iron?

Yes No

Is/was your child on WIC?

Yes No

Health History

Has your child ever been hospitalized?

Yes No

If yes, explain and give dates:

List any health problems/surgeries your child has had:

List any medication your child is currently taking, including over-the-counter and herbal medications:

List any food/medication your child is allergic to:

Dental

Does your child take fluoride drops or tablets or use fluoridated water?

Don't know

Yes

Do your child's teeth get brushed daily?

Yes

Are your child's teeth flossed daily?

Yes

Does your child visit the dentist at least once a year?

Yes

Family History

Safety

Does your child use an age-appropriate car seat / seat belt?

Yes No

Does you have a properly working smoke detector in your home?

Yes No

Do you have Ipecac on hand in case of accidental poisoning?

Yes No

Do you know how to help your child if he/she is choking?

Yes No

If your child is riding a bicycle, does he/she use an approved bicycle helmet to prevent head injury?

Yes No Doesn't ride

Have you taught your child about personal safety and what to do If someone bothers or attempts to molest him/her?

Yes No

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 updated 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

Name / Signature:

Date:

Your information will be encrypted.

New Patient Form (Newborn - 12 Years old)

Patient Registration

Guarantor Information

Financial Policy

General Consent for Treatment

Mid-Level Provider Consent Form

HIPAA Compliance Patient Consent Form

Release of Information

Emergency Contact Information

Authorization for Release of Medical Information

Child Health Inventory (Birth - 12 Years)

Concerns

Prenatal and Birth History

Development

Social

Nutrition

Health History

Dental

Family History

Safety

Information Update

Patient or Guardian