Established Patient Paperwork

Please Note:

In order for West Park Primary Care to stay contracted with your insurance and we accept you as a patient, please be aware that Insurance has QUALITY MEASURES example: Colon screen, Mammograms, Annual well exams and diabetic eye exams, etc. It is important that you please help our office by keeping all of your follow up appointments and keeping your Annual well/360 exams up to date and calling us for an appointment.

Medications: When the doctor sends in refills or a new prescription, please go to the pharmacy and pick the medicine up, or please tell the provider you DO NOT want this , so we do not get penalized for you not picking up prescribed medication. Call your pharmacy for all refills, pharmacy will send us notification.

We ask that you update your records every year, this is so we can stay in contact with you for your medical needs, you will be ask yearly to up date records.

Please make sure your bring all medication bottles to each and every appointment so we can ensure accuracy on your medications.

When going to the ER or being admitted to the Hospital, please call our office for a follow-up appointment.

When changing address, Insurance or phone numbers, please notify us when checking in for your appointment.

Please arrive 15 minutes early for Established patients and 30 minutes early for New Patients and please bring your paperwork with you with driver license and Insurance card.

NO SHOW FEE: please remember, if you have an appointment then we can't schedule other patients that may need an appointment, please call 24 hours in advance for cancellations or a $25.00 fee will be applied to your account.

Referrals: You must have at least a 3 month visit in order to update an existing referral, for all NEW Referrals, you must have an office visit.

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.

REQUIRED - Please complete all pages!

Emergency Contacts

Insurance Information

It is the patient's responsibility to ensure their claims are paid timely and we have the correct and up to date Insurance information to bill/submit your claim on your behalf. It is also your responsibility to ensure our practice and providers are your Primary Care Provider listed with your insurance. Please make sure you have ONLY ONE primary insurance, coordination of benefits should be up to date. All none paid visits will be your responsibility, or account will go to collections.

Please be aware we do not prescribe narcotics at this facility.

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.

Consent for Treatment & HIPPA

I authorize and direct West Park Primary Care including Elias Kanaan M.D, Hunganh But M.Dand Richard T. Cain NP to perform quality care upon me.

I acknowledge that the practice of medicine is not an exact science and no guarantee has been made to me as to the outcome of the procedure and/or treatments.

I grant consent without duress, confusion or pressure from West Park Primary Care, physicians, staff and Colleagues.

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.

We understand that YOUR medical & health info is personal, we are committed to protecting your info & the care you receive from WPPC. HIPPA is the federal health privacy law that requires a signed waiver that authorizes IVPPC to release YOUR health info. This Person or Persons have the right to call and ask about any health/appointment related questions on your behalf.

Please list spouse, family member or care giver that you would like to have access to your COMPLETE medical record with name, date of birth and contact phone number of each person.

Please List any person/person's YOU DO NOT want to have any information on your behalf.

Acknowledge of review of privacy practices

I have reviewed the notice of Privacy policies (HIPPA), which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document and entitled to request changes to this information at any time.

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.

Patient Financial Policy

To reduce confusion and misunderstandings between our patients and practice, we have adopted the following financial policies. If you have any questions regarding these policies, please ask for the billing department. We are dedicated in providing the best possible care and services to you and your family and regard your complete understanding of your financial obligations pertaining to your insurance, may it be deductibles, co-pays and coinsurance.

As per patient insurance we as a provider have an obligation to collect all fees that your insurance will not cover, this is part of the contract that we agreed to sign in order to take your insurance. We accept Cash and credit cards ONLY. No checks please.

You are expected to pay all fees up front, if for any reason you have a visit with the provider and discuss issues that were not scheduled, we will balance bill you and you will be required to pay on your next visit, please call our office for payment arrangements before your account goes to collections. We will work with Patients that work with us.

Please remember we bill your claims/visits as a courtesy, it is still the patient's responsibility to make sure all claims/visits are paid.

NOTE: IF patient is a minor child, parents or legal guardians are responsible for child. All children under the age of 18 must be accompanied by a parent or guardian, guardians must have appropriate paperwork for proof of guardianship.

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 & Billing Records Release

This release is used for the request of your medical records from other providers and/or hospitals.

to disclose the following information from the health records for the purpose of continuation of medical care.

I understand this authorization may be revoked at any time, except to the extent that action has been taken in reliance on authorization. Unless otherwise revoked, this authorization will expire l year from the date authorization was signed. The facility, its employees, officers, and physicians are hereby release from legal responsibility for disclosure of the above information to the extent indicated and authorized herein.

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.

Medication List