Patient Information Form

PATIENT INFORMATION

First Name

Middle Initial

Last Name

Suffix

Sex

Male Female

Date of Birth

SSN (Optional)

Cell Phone

May we leave a message?

Yes No

Home Phone

May we leave a message?

Yes No

Work Phone

May we leave a message?

Yes No

Email address

May we email you?

Yes No

*Please note: Email address is necessary to sign up for FREE online personal health records. Please ask us for details.

HOME or MAILING ADDRESS:

Street

City

State

Zip

Preferred Method of Communication

Cell Home Work

Payment Information

Self Pay Insurance

INSURANCE DETAILS: (Please provide insurance card with your photo ID)

Payer

Member ID

Group ID

Payer Claims Address

Payer Phone Number

LOCAL PHARMACY:

Pharmacy Name

Pharmacy Phone Number

Pharmacy Address

MAIL ORDER PHARMACY:

Pharmacy Name

Pharmacy Phone Number

Pharmacy Address

DEMOGRAPHICS:

Preferred Language

English Spanish Vietnamese Other

If other, please specify.

Ethnicity/Race

Declined American Indian or Alaska Native Asian Hispanic/Latino African American Native Hawaiian or Pacific Islander White Other

If other, please specify.

NEXT OF KIN INFORMATION OR EMERCENGY CONTACT:

Patient Relationship to Next of Kin

Next of Kin Name

Primary Phone Number

Secondary Phone Number

ADDRESS

Same as above OR

Street Address

CURRENT MEDICATIONS:

Add new row

MEDICAL HISTORY:

Other

ALLERGIES:

Drug and Reaction

SURGICAL HISTORY:

Add new row

FAMILY HISTORY:

Heart Attack

Stroke

Diabetes

High Blood Pressure

Cancer

Sudden Death

Other

SOCIAL HISTORY:

TOBACCO USE

Are you a

Current Smoker Former Smoker Never Smoked

If so, how long?

ALCOHOL USE

Did you have a drink containing alcohol in the past year?

Yes No

If yes, how often did you have a drink containing alcohol in the past year?

Never Monthly or less 2 to 4 times a month 2 to 3 times per week 4 or more times a week

How many drinks did you have on a typical day when you were drinking in the past year?

1 or 2 3 or 4 5 or 6 7 to 9 10 or more

How often did you have six or more drinks on one occasion in the past year?

Never Less than monthly Monthly Weekly Daily or almost daily

PREVENTATIVE CARE:

Last Bone Density (DEXA)

Last Colonoscopy/Results

Last Physical Exam

Last Diabetic Exam/Result

Last Mammogram/Result

Last Pap Smear/Result

Last Menstrual Period

Pregnancies

Kids

Hepatitis C Screening

HIV Screening

RELEASE OF MEDICAL INFORMATION

Please check all that apply and list name(s) of spouses, child(ren) and others involved in care as applicable.

You have permission to leave information on my home answering service regarding my medical care and test results.
You have permission to leave information on my mobile phone regarding my medical care and test results.
You have permission to send information via text (SMS) on my mobile phone regarding my medical care and rest results.
You have permission to speak with the individuals listed below involved in my medical care.

Name

Relationship

Phone

Upon request, I may limit the amount of time that this consent for release of information is valid. I may revoke this authorization, in writing at any time. I understand that the revocation will not apply to information that has already been released. I understand that authorizing the disclosure of this information is voluntary

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 Name

DOB

Signature

Date

Statement of Patient Financial Responsibility

Patient Name

DOB

Premier NW Houston Medical Group (the “Practice”) appreciates the confidence you have shown in choosing us to provide for your health care needs. The service you have elected to participate in implies a financial responsibility on your part. The responsibility obligates you to ensure payment in full of our fees. As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. However, you are ultimately responsible for payment of your bill.

You are responsible for payment of any deductible and co-payment/co-insurance as determined by your contract with your insurance carrier. We expect these payments at time of service. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amounts not covered by your insurer. If your insurance carrier denies any part of your claim, you will be responsible for your balance in full.

I agree to pay my costs incurred by the Practice in collecting any amounts due including, without limitation, collection agency fees and attorney’s fees.

I have read the above policy regarding my financial responsibility to the Practice, for providing medical services to me or the above named patient. I certify that the information is, to the best of my knowledge, true and accurate. I authorize my insurer to pay any benefits directly to the Practice, the full and entire amount of bill incurred by me or the above named patient; or, if applicable any amount due after payment has been made by my insurance carrier.

Patient Signature

Date

Guarantor Signature

(If guarantor is not the patient, Must sign)

Date

Co-Pay Policy

Some health insurance carriers require the patient to pay co-pay for services rendered. It is expected and appreciated at the time the service is rendered for the patients to pay EACH VISIT. Thank you for your cooperation in this matter.

Patient/Guarantor Signature

Date

Consent for Treatment and Authorization to Release Information

I hereby authorize the Practice, through its appropriate personnel, to perform or have performed upon me, or the above named patient, appropriate assessment and treatment procedures.

I further authorize the Practice, to release to appropriate agencies, any information acquired in the course of my or the above named patient’s examination and treatment.

Patient/Guarantor Signature

Date

Cancellation / No Show Policy

We understand there may be times when you miss an appointment due to emergencies or obligations to work or family. However, we urge you to call 24-hours prior to canceling your appointment.

I understand if I no show for two consecutive appointments, no show for three appointments or cancel for a total of four appointments, I may be discharged from care.

The Practice will notify you in writing, via certified mail, if you are discharged from care. I have read and understand the above information, and I agree to the terms described.

Patient/Guarantor Signature

Date

Self-Pay

I do not have health insurance and will be responsible for services rendered here at the Practice. I agree to pay the Practice, the full and entire amount of treatment given to me at each visit.

Patient/Guarantor Signature

Date

HIPAA Information

I have been made aware of HIPAA information and I can review them on www.premiernwhoustonmedicalgroup.com at any time. I may receive a hardcopy of this information upon my request.

Patient/Guarantor Signature

Date

Your information will be encrypted.