Established Patient Packets

PATIENT INFORMATION

EMERGENCY CONTACT INFORMATION

ACCOUNT INFORMATION

The Primary Insurance Holder (the person that pays for the insurance plan which is called the policy holder):

INSURANCE INFORMATION

The patient’s insurance card must be presented at the time of your appointment for each visit. Insurance won’t be billed until a copy of the card is received. COPAYS are due at the appointment. Failure to pay the copay will result in a $10 fee. Self-Pay patients and out-of-network patients are required to pay for the visit in full at the time of service. The patient authorizes Family Practice Associates to release information to the insurance company in order for current and future claims to be processed. Patients 18 years and older will be responsible for the account unless we received signed notification from your responsible party.

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.

HIPAA Privacy Authorization Form

Authorization for Use or Disclosure of Protected Health Information

AUTHORIZATION: I authorize Family Practice Associates to use and/or disclose certain Protected Health Information (PHI) about me to the following individuals. (Please print full name.)

Your initials are required to withhold the following information:

I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations. The medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I direct. I understand that treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization. I may revoke this authorization at any time by notifying FAMILY PRACTICE ASSOCIATES, in writing, of my desire to revoke it. The notice will not apply to actions taken by the requesting person/entity prior to the date FAMILY PRACTICE ASSOCIATES receives the request.

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.

REQUIRES PATIENT SIGNATURE:

I acknowledge that I have received a copy of the NOTICE OF PRIVACY PRACTICES regarding my health information.

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.

I acknowledge that I have received a copy of the NOTICE OF OFFICE AND FINANCIAL POLICIES.

As part of our electronic health record standard, would you be willing to state your race and ethnicity? This is an important part of your medical history. Some medical conditions are more prevalent in certain races, such as diabetes, hypertension and cancer