Please complete this form as completely and accurately as possible. Please print. Formatted text
List ALL current prescription medications and how often you take them (if none, write none). Medication Name / Total Daily Dosage / Estimated Start Date/Previous Med
Additional Medication
Previous Medication that had been taken:
In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.)
Please sign below that you have read, understand and will abide with this Gregory Narron M.D. and Associates Financial Policy and Consent to 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.
Our automated reminder system has several options. Please let us know the best way to contact you for these friendly reminders. You will receive either a text message or phone message 2 days before your appointment. It will be listed as a “do-not-reply” for texts.
Use the boxes to the left of each option to indicate your preference for receiving appointment reminders. If you prefer not to get appointment reminders please leave blank.
I hereby request that all communications, including voice messages from Gregory Narron, M.D. & Associates, PLLC be directed to the following:
Please list names, relationship and phone numbers of anyone other than the patient that we are allowed to leave message with below:
Additional Name
This request will become effective as of the date below. Any changes to this information must be done by completion of a new Confidential Communications form by the responsible party. By signing the form, I am giving permission to Gregory Narron, M.D. & Associates, PLLC permission to contact me, including leaving messages if necessary concerning confirmation of appointments and to provide information about treatment issues at the above listed numbers.
We are committed to meeting your healthcare needs and keeping your insurance and other financial arrangements as simple as possible. In order to accomplish this in a cost-effective manner for all our patients, we ask that you adhere to our practice’s financial policy. By signing below, you are agreeing to its terms
This authorization will remain in effect until I provide written notice of cancellation to the practice. Authorization for services already rendered cannot be cancelled or refunded. I agree to notify the practice in writing of any changes in my payment or other information.
I agree to pay for the services rendered by GREGORY NARRON M.D. AND ASSOCIATES, PLLC, as indicated below.Payments will be made by Credit Card OR Bank Draft at the time of service, which I authorize you to use:
CREDIT CARD
CHECKING ACCOUNT INFORMATION
**Changes to the Credit Card or Checking information should be reported to the office IMMEDIATELY**
**It is understood that if the patient misses payments, without prior notification and agreement, the practice reserves the right to transfer BALANCE to a collection agency.**
We, at Gregory Narron & Associates, understand that sometimes you need to cancel or reschedule your appointment and that there are emergencies. If you are unable to keep your appointment, please call us as soon as possible (with at least a 24-hour notice). You can cancel/reschedule appointments by calling the following number: 828.274.1415
To ensure that each patient is given the proper amount of time allotted for their visit and to provide the highest quality care, it is very important for each scheduled patient to attend their visit on time. As a courtesy, if you have signed up for the appointment reminders they are automatically made/attempted two (2) business days prior to your scheduled appointment. However, it is the responsibility of the patient to arrive for their appointment on time.
PLEASE REVIEW THE FOLLOWING POLICY:
I have read and understand the No Show/Missed Appointment Policy and understand my responsibility to plan appointments accordingly and notify the practice appropriately if I have difficulty keeping my scheduled appointments
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review if carefully
The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.
As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records for each of the following purposes: treatment, payment, and health care operations.
We may contact you to provide appointment reminders or information about treatment issues, leaving a message if necessary. However, remembering your appointments is your responsibility. If you prefer to be contacted at an alternate address and/or telephone number, please notify our office in writing
We also may communicate with you through email or text, we are making you aware that these communications will not be encrypted. HIPAA allows covered entities and their business associates to communicate e-PHI with patients via e-mails and texts if either (1) the e-mails and texts are encrypted and/or are otherwise secure; or (2) the covered entity or business associate first warns the patient that the communication is not secure and the patient elects to communicate via unsecure e-mail or text, anyway. When it comes to communicating with non-patients, the covered entity or business associate must generally ensure that its e-mail or texts comply with relevant Privacy and Security Rule standards.
Any other uses or disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your earlier authorization.
You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to our Privacy Officer:
We are required by law to maintain the privacy of your protected health information and to provide you with the notice of our legal duties and privacy practices with the respect to protected health information.
This notice is effective as of April 14, 2003, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms and to make new notice provisions effective for all protected health information that we maintain. We will post this information and you may request a written copy of a revised Notice of Privacy Practices from this office.
You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office (see below for the address) or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.
GREGORY NARRON M.D. AND ASSOCIATES5 Kitchin Place, Suite 220 Asheville, NC 28803
THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of Civil Rights200 Independence Avenue, S.W.Washington, DC 20201
I have received a copy of the Notice of Privacy Practices for the above named practice.
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We were unable to obtain a written acknowledgement of receipt of the Notice of Privacy Practices because:
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