New Patient Information Form

Insurance Coverages / Driver's License (A Copy of your cards is requested)

Authorization To Pay Benefits to Physician: I hereby authorize payment to be paid directly to Eden Internal Medicine, PLLC for surgical and/or medical benefits that are provided either in the office and/or hospital.

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.

Authorization To Release Information: I hereby authorize Eden Internal Medicine, PLLC to release any information acquired in the course of my exam/treatment necessary to process insurance claims.

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.

Eden Internal Medicine, PLLC expects payment of copays, deductibles, and other balances to be paid at the time of service unless payment arrangements have been discussed with the office manager and/or collection personnel. The office participates with several of the manage care programs. The patient has the responsibility to provide the office with their and their spouse's insurance cards at the time of service. If this information is not provided at the time of service and/or in the allotted time required by the insurance company for filing, the patient will be expected to pay for the office visit and any other charges incurred. I understand the responsibilities as a patient, providing Eden Internal Medicine, PLLC with my insurance cards. I also understand that I will be responsible for all copay, deductibles, and balances.

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.

NOTICE OF PRIVACY PRACTICES SUMMARY

THIS NOTICE DESCRIBES HOW YOUR PROTECTED HEAL TH INFORMATION (PHI) MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. IF YOU HAVE ANY QUESTIONS PLEASE CONTACT OUR PRIVACY OFFICER FOR A FULL COPY OF OUR PRIVACY NOTICE. PLEASE READ THIS NOTICE CAREFULLY.

Uses and Disclosures: Eden Internal Medicine, PLLC (hereafter referred to as EIM) is permitted by law to disclose PHI of each patient to provide treatment, to receive payment for that treatment, and for performing healthcare operations. Disclosure of PHI for treatment purposes could be made to physicians and other healthcare providers. PHI may be disclosed to the government, or to other third-party payers for the purpose of obtaining payment for services provided. EIM may also disclose your PHI to carry on normal healthcare operations such as scheduling, appointment reminders, and quality assurance.

Required Authorizations: EIM will not disclose a patient's PHI for any purpose aside from treatment, payment, and healthcare operations without the patient's authorization to disclose the said information. Upon request for such authorization, the patient has the right to refuse and/or revoke any disclosure of his/her PHI.

Privacy Compliance: In accordance with the privacy regulations promulgated under the Health Insurance Portability and Accountability Act, 45CFR Parts 160 and 164 (the "Privacy Regulations"), EIM has adopted privacy policies regarding usage of a patient's PHI.

Additional Information: For additional information regarding EIM's privacy policy or for a full copy of this notice, please contact our Privacy Officer. EIM reserves the right to revise the Privacy Notice giving a new revised date.

PATIENT'S ACKNOWLEDGEMENT/ CONSENT

I understand that as a part of my healthcare, EIM creates and maintains health records describing my health history. I understand that EIM may use this information as:

1. A basis for planning my care and treatment;
2. A means of communication with many health professionals who contribute to my care
3. A means by which a third-party payor can verify that services billed were actually provided; and
4. A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

I have been given the opportunity to read EIM's Privacy Notice which provides a more complete description of information used and disclosed. I understand that I have the right to review the notice prior to signing this authorization. I understand that EIM reserves the right to change its notice and practices. If EIM changes the notice, I can obtain a revised copy by asking the Privacy Officer and/or an employee of EIM. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or other operational activities. EIM is not required to agree to the restrictions requested. If EIM does agree to such restrictions, however, EIM must comply with such restrictions. I understand that I may revoke this authorization in writing, except to the extent that EIM has already taken action.

(name and relationship). I understand I may revoke this authorization at any time.

I do hereby consent to treatment and examination by my physician or other physicians of EIM to provide and perform such medical/surgical care, tests, procedures, drugs, and other services that are considered necessary and beneficial for my health and well being. I am aware that I may request a chaperone if.I deem necessary. I am aware I have the right to refuse a third party in the exam room. I am aware, I may revoke this decision at any time in writing to EIM. If I am a minor and/or unable to make medical decisions, I am aware that I must have the consent of my parents and/or legal guardian.

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.

Please Read Our Payment Policy In Its Entirety Before You Sign

Thank you for choosing Eden Internal Medicine as your primary care provider.

1. SELF PAY: If you do not have insurance, payment in full is due at the time of your visit.
2. INSURANCE: We participate with many insurance plans. You are responsible for providing an up-to-date card at each visit. Failure to provide the correct information may result in the full amount becoming your responsibility. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions regarding coverage.
3. COPAYMENTS: All Co-payments and Co-insurance must be paid at the time of service. This arrangement is part of your contract with your insurance company.
4. NON-COVERED SERVICE: Please be aware that some services you receive may not be covered or considered medically necessary by Medicare or other insurers, this amount will therefore be your responsibility.
5. CLAIM SUBMISSION: We will submit your claims and assist in getting your claims paid. However if your insurance company needs additional information, it is your responsibility to comply with their request. Failure to do so will make the total balance of your responsibility.

Eden Internal Medicine is committed to providing quality healthcare to our patients. If you are unable to abide by our Payment Policy, please speak to either our billing department or office manager prior to your office visit.

I have read and understand the payment policy. I agree to abide by its guidelines. Failure to do so may cause your account to be turned over to collections. This will affect your credit rating for seven (7) years.

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.

MEDICAL HISTORY

2. Check if any blood relative has had any of the following and enter relationship.

3. Have you had any of the following illnesses?

4. Occupational

5. Check which of the following, if any, you are regularly taking

6. Habits

7. Family/Social

Interim Review of System

Current List of Medications and Dosage

List of Hospitalizations/ Surgeries/ Reason

ONLY CHECK THE BLANKS IF THE ANSWER IS "YES"

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.