Associates in Family Practice Patient Intake Forms

Emergency Contact #1-

Emergency Contact #2-

Financially Responsible Party- If patient is under the age of 18, the parent or guardian bringing patient in will be listed as the guarantor:

*If patient is under 18 and someone other than the parent/guardian is bringing the child in, please ask our receptionist for the Transport and Accompany Minor Authorization form.*

Primary Medical insurance

Secondary Medical insurance

Medical History Form

Health Maintenance Screening Test History:

Women’s Health:

Current/Past Health Conditions:

Please fill in the options below for all that apply:

Disease/Condition

Current/Past Specialists:

Specialist:

Additional Health Information:

Tobacco Use:

Alcohol Use:

Caffeine Use:

Family Medical History:

Family History Check all that apply:

Review of Symptom:

Check any that you are currently experiencing or have recently experienced:

Patient Consent Form:

The department of health and human services has established a “Privacy Rule”, to ensure that personal health care information is protected. The Privacy Rule was also created to provide a standard for certain health care providers to obtain their patient’s consent for use and disclosure of health information about the patient to carry out treatment, payment, or health care operations.

As our patient we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take responsible precautions to protect your privacy. When it is appropriate and necessary, we provide the necessary information to only those we feel need your health care information about treatment, payment, or health care operations, to provide health care that is in your best interest.

We also want you to know that we support your full access to your medical records, with the appropriate HIPPA compliant, signed documentation. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients) and may have to disclose personal health information about treatment, payment, or health care operations. These entities are most often not required to obtain patient consent.

You may refuse to consent to the use of disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse service to treat you, should you choose to refuse to disclose your personal health information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied in this or previously signed consent.

If you have any objections to this form, please feel free to ask to speak with our HIPPA Compliance Office. You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you’ve reviewed our policy notice.

Thank you for being one of our valued Patients.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Authorization of Treatment

I hereby authorize Associates in Family Practice to examine, test and treat me or my dependent for a medical condition. I understand that no guarantees have been made to me regarding treatment or examination. In case of an emergency in which I cannot be reached, I authorize Associates in Family Practice to treat my dependent.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Insurance Authorization

I hereby authorize Associates in Family Practice to furnish information to my insurance carrier(s) concerning treatment and I hereby assign to the physician(s) all payments for the medical services rendered to myself or my dependents. I understand that I am responsible for any amount NOT covered by insurance.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Financial Policy

This is an agreement between Associates in Family Practice and the Patient/Guarantor named below. By signing this agreement, you are acknowledging that you understand our insurance and financial policies and are agreeing to pay for all services that are received.

• Initial Visit

Please provide us with your insurance care and billing information if you would like us to bill your insurance for you. PAYMENT IN FULL IS REQUIRED AT THE TIME OF EACH VISIT.

• Health Insurance and Workers’ Compensation

We bill your insurance company as a courtesy to you. Each insurance company has its own rules for determining how much they will pay for each claim. We will try to answer any questions you have about your insurance; however, your policy is a contract between you and your insurance company. It is your responsibility to know your insurance policy and be familiar with your coverage, co-pay, and deductibles. We do not accept assignment on out-of-state workers’ compensation claims, and we will require that you pay for any charges not covered by insurance on out-of-state claims. If your insurance company denied your claim, you are responsible for payment in full.

• Personal Injury, Auto Accidents and Third Party

We require payments at the time of service. We do not bill liability insurance carriers or your attorney for charges incurred due to personal injury cases.

• Medicare and Medicaid

We participate with Medicare. You are required to pay the amount allowed by Medicare. If you have a secondary supplemental policy, we will bill this for you. Medicare does not pay for routine and some other routine services. If they don’t pay, you are required to pay for this service in full. We participate with Medicaid and will bill them directly. They do not pay for school sports physicals.

• Payment and Late Charges

Unless we approve other arrangements in writing, the balance on your statement is due upon receipt. If payment is not received, we reserve the right to refuse future appointments on delinquent accounts. If your account becomes past due, we will take the necessary action to collect this debt. All unpaid accounts are subject to collection procedures and additional costs. Unpaid delinquent accounts are sent to our collection agency, in which case, you will need to pay/clear the full amount through their department before you can be scheduled.

• Payment Options

You may pay by cash, check or credit/debit cards. Returned checks will receive a $20.00 service fee.

I have read, understand, and agree to comply with these policies. I acknowledge receipt of Associates in Family Practice’s Notice of Privacy Practices (HIPPA).

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

(Medicare Only)

Medicare Blanket Signature Authorization

I request that payment of authorized Medicare benefits be made either to me or on my behalf of Associates in Family Practice for any service furnished to me by that Physician/Supplier. I authorize any holder of the medical information Administration and its agents any information needed to determine these benefits payable for related services.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.