NEW PATIENT INFORMATION

PLEASE READ:

ALL PROFESSIONAL SERVICES RENDERED ARE CHARGED TO THE PATIENT, NECESSARY FORMS WILL BE COMPLETED TO HELP EXPEDITE INSURANCE CARRIER PAYMENTS, HOWEVER, THE PATIENT IS RESPONSIBLE FOR ALL FEES, REGARDLESS OF INSURANCE COVERAGE. IT IS ALSO CUSTOMARY TO PAY FOR SERVICES WHEN RENDERED UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN ADVANCE WITH OUR OFFICE BOOKKEEPER.

INSURANCE AUTHORIZATION AND ASSIGNMENT

I request that payment of authorized Medicare/Other Insurance Company benefits be made either to me or on my behalf to HIGH DESERT FAMILY MEDICINE for any service furnished me by that party who accepts assignment/physician. Regulations pertaining to Medicare assignment of benefits may apply.

I authorize any holder of medical or other information about me to release to the Social Security Administration and CMS or its intermediaries or carriers any information needed for this or a related Medicare claim/other Insurance Company claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. I understand it is mandatory to notify the health care provider of any other party who may be responsible for paying for my treatment. (Section 112B of the Social Security Act and 31 U.S.O, 3801 -3612 provides penalties for withholding this information)

Acknowledgment of Receipt of Privacy Notice - I have been presented with a copy of this provide's Notice of Privacy Policies detailing how my information may be used and disclosed as permitted under federal and state law, I understand the contents of the notice, and subject to the following restriction(s) concerning my personal medical information, I agree to the disclosures named in the Notice.

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.

FAMILY HISTORY: (please select appropriate answer)

Has any blood relative ever had:

ALLERGIES - Are you allergic to:

INJURIES - Have you had any:

TRANSFUSIONS - Have you had:

WEIGHT:

Personal History (please select appropriate answer)

ILLNESSES - Have you ever had:

SURGERIES (Please Include date)

Habits - Do you:

Women ONLY:

Menstrual History:

List any drugs, medications or vitamins you are taking:

New Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operations

understand that as part of my health care, High Desert Family Medicine originates and maintains paper and/OR electronic records describing my health history, symptoms, examination and lest results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:

• A basis for planning my care and treatment
• A means of communication among the health professionals who contribute to my care
• A source of information or applying my diagnosis and surgical information to my bill
• A means by which a third-party payer can verify that services billed were provided
• A tool for routine health care operations such as assessing quality and reviewing the competence of healthcare professionals

I understand and have been provided with a Notice of Privacy Policies that provides a more complete description of Information uses and disclosures, I understand that I have the following rights and privileges:

• The right to review the notice prior to signing this consent
• The right to object to the use of my health information for directory purposes, and
• The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations

I understand the High Desert Family Medicine is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon, I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

I further understand that High Desert Family Medicine reserves the right to change their notice and practices and prior to Implementation, In accordance with Section 164.520 of the Code of Federal Regulations. Should High Desert Family Medicine change their notice, they will send a copy of any revised notice to the address I've provided (whether U.S. mail or, If I agree, email).

I wish to have the following restrictions to the use or disclosure of my health Information:

I hereby consent for Dr. Daniel Skotte, associates and staff at High Desert Family Medicine to treat me and access my patient health information during the course of my treatment, I understand that as part of this organizations treatment, payment, or health care operations, It may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax.

I fully understand and accept the terms of this consent.

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.