New Patient Packet

Last name

First Name

Middle Name

Please upload PDF files of your Insurance Card(s) (Front & Back)

Add file

Please upload a file

Please upload a PDF file your Driver's License (Front)

Add file

Please upload a file

Please upload your Covid-19 Immunization Card (Front & Back)

Add file

Please upload a file

Date of Birth

Current Height

Current Weight

SSN #

Email address

Address

City

State

Zip

Primary or referring Dr.

Employer

Home Phone

Cell Phone

Work Phone

Pharmacy Name and Location

Language

Race

Ethnicity

Insurance

ID #

Group #

Emergency Contact

Relationship

Home Phone

Cell Phone

Prince Shah, M.D & Kevin D. Stuart, M.D are separate solo practices that share a medical record system and provide coverage for each other's patients. IF you obtain continued medical care at this facility, it is taken as implied consent to the above arrangement.

AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN: I hereby authorize payment directly to you, for all medical and or surgical benefits, if any, otherwise payable to me for services rendered. I understand that I am responsible for all charges whether or not paid by insurance.

AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize the doctor to release any information acquired in the course of my examination and treatment necessary to secure the payment of the insurance benefits. I also, AUTHORIZE RELEASE OF ANY MEDICAL INFORMATION, TO referred Physician's office as necessary, for my care and treatment.

Please Check to confirm you have read the HIPPA compliance

Please Check to confirm you have read the Financial Interest for GEC

Please Check to confirm you have read the Pharmacy consent form

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.

Signature

Date

Medical History Questionnaire

General State of Health?

Excellent Good Poor Fair

Are you allergic to Any Medications

Yes No

Please List

Do you have any other Allergies?

Yes No

Please List Allergies

Do you have sleep apnea?

Yes No

Have you had Surgery in the past?

Yes No

Please List

Prescriptions

Over the counter (Aspirin, Motrin, Etc.)

DOES ANYONE IN YOUR FAMILY HAVE:

Relationship

Type

List Date

Do you drink alcohol?

Non-Drinker Socially

(1-2 Times a week)

Regular

(Almost Everyday)

Excessive

If you selected Excessive, please explain here

Do you smoke tobacco

Current Past Never Smoked Other

If you selected Other, please explain here

Do you vape

No Yes

If yes, please detail what product and how frequently

Marijuana use

No Yes

If yes please detail type/amount and frequency

Any other substance abuse

No Yes

If yes please detail which one, and when last used

Signature

Date

Patient Contact List

Authorization to speak with spouse, relative, or person of your choice. Allows persons listed to speak with staff/physician regarding your health information. Please list contacts below if interested.

Check here if you DECLINE patient contact list

Last Name

First Name

Middle Name

Phone #

Relationship

Last Name

First Name

Middle Name

Phone #

Relationship

Consent to use Patient Portal

Last Name

First Name

Middle Name

Address

Email address

Purpose of this Form

Prince Shah, M.D offers secure viewing and communications as a service to patients who wish to view parts of their records and communications with our staff. Secure messaging can be valuable communications tools but has certain risks. In order to manage these risks, we need to impose some conditions of participation, and that you accept the risks and agree to the conditions of participation.

A secure web portal is a kind of webpage that uses encryption to keep unauthorized persons from reading communications, information, or attachments. Secure messages and information can only be read by someone who knows the right password or pass-phrase to log in to the portal site. The portal may allow you to compose, pick up, and reply to secure messages or view information sent to you through a Web site hosted by our electronic records company.

How the Secure Patient Portal Works

How to Participate in our Patient Portal

Once this form is agreed to and signed, we will send you an email notification that tells you how to register for the first time, The notification will give you the the-URL (internet address) of the website where you can log in. By clicking on the URL you will activate your Internet browser, which will open the Web site. You will then be able to login using the user name and password provided. Next, you will be able to look in your "message box'' and see any new or old messages or view other parts of your electronic record. Because the connection channel between your computer and the Web site uses "secure sockets layer" technology, you can read or view information on your computer, but it is still encrypted in transmission between the Web site and your computer.

You can view more clinic-specific information, including our privacy policy, or access to the portal through www.healthportalsite.com It is our intent to offer this as a free service, but we reserve the right to change this policy if needed in the future. We will provide adequate notice should this happen in the future.

Protecting your Private Health Information and Risks

This method of communication and viewing utilizes the best commercial means available to attempt to prevent unauthorized parties from being able to access or read messages while they are in transmission. Nevertheless, users should be aware that electronic transmissions by their nature carry a risk of interception. Keeping message secure depends on two additional factors: the secure message must reach the correct email address, and only the correct individual (or someone authorized by that individual) must be able to get access to it. Only you can make sure these two factors are present. We need you to make sure we have your correct email address, and that we are informed if it changes. You also need to keep track of who has access to your email account; so that only you, or someone you authorize, can see the messages you receive from us. If you pick up secure messages from a Web site, you need to keep unauthorized individuals from learning your password. If you think someone has learned your password, you should promptly go to the Web site and change it.

Conditions of Participating in the Patient Portal

Access to this secure web portal is an optional service, and we may suspend or terminate it at any time and for any reason. If we do suspend or terminate this service we will notify you as promptly as we reasonably can. You agree not to hold Prince Shah, M.D liable for network infractions beyond our control.

Before you were given this form, we provided you with our policies and procedure using this web portal. We need you to understand comply with these, and by signing this form below you will acknowledge that they were explained to you and that you agree to comply with them. If you do not understand or do not agree to comply with our policies and procedures, do not sign the form. If you have any questions we will gladly provide more information.

Patient Responsibilities

In return for access to the patient portal, you agree not to:

transmit any electronic information that violates the rights or privacy of any party,
use the web portal in any way that violates local, state or federal law,
transmit material that Is obscene, defamatory, abusive, slanderous, hateful, or otherwise likely to result in harm to others, or
Intentionally distribute viruses or other harmful computer code.

Kevin D. Stuart, M.D & Prince Shah, M.D are separate solo practices that share a medical record system and provide coverage for each other's patients.

Signature

Date

Your information will be encrypted.