NEW PATIENT FORMS

Demographic Information

Last Name:

First Name:

Previous Name:

Gender:

Male Female

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Work Phone:

Leave Message:

Brief Extended

Through which of your numbers?

Home Cell

Student:

Full Part-Time N/A

Marital Status:

Single Married Divorced Widowed Legally Separated Partner

Patient's Social Security Number:

Date of Birth:

Employment Information:

Employer Name:

Employment Status:

Full-Time Part-Time Self-Employed Retired Not-Employed

Emergency Contact Information:

Emergency Contact Last Name:

First Name:

Relation:

Spouse Child Parent/Guardian Other

Other:

Phone:

Guardian:

Yes No

Primary Insurance Infomation:

Insurance Name:

Phone:

Group#:

Subscriber or Member ID Number:

Guarantor's Date of Birth:

Guarantor Name:

Phone:

SS#:

Secondary Insurance Information:

Insurance Name:

Phone:

Group#:

Subscriber or Member ID Number:

Guarantor's Date of Birth:

Guarantor Name:

Phone:

SS#:

Additional Information

Please check only one from each section.

Race:

White Black or African American Hispanic American Indian / Alaska Native Asian Native Hawaiian Other Refuse to Report

Ethnicity:

Hispanic or Latino Not Hispanic or Latino Refuse to Report

Language:

English Spanish Indian Other

Advance Directive

Advance directives are legal documents that allow you to spell out your decisions about end-of-life care ahead of time.

Patient has declined Advance Directive at this time.

Do Not Resuscitate (DNR) - please give a copy to the receptionist to scan into your record.

Organ or Tissue Donor

Living Will - please give a copy to the receptionist to scan into your record.

Power of Attorney - please give a copy to the receptionist to scan into your record.

Pharmacy Information

Pharmacy phone number is required to expedite refill / new prescriptions.

Pharmacy Name:

Pharmacy Phone:

Pharmacy Address:

Patient's email address (to be web enabled for the portal):

Consent to Treat, Insurance Authorization and Assignment

I voluntarily request Deirdre McMullen M.D., and/or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing is recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I authorize Rocky Creek Family Medicine, PLLC to release any medical and social information acquired during the course of my examination and/or treatment, for the purpose of filing for insurance and other financial coverage, and to provide required information to other medical professionals and facilities for my continuing diagnosis and treatment. I hereby authorize payment of medical benefits directly to Rocky Creek Family Medicine, PLLC. I understand that I am financially responsible for charges not covered by this assignment of benefits, and should the account be referred for collection, I agree to pay reasonable collection and/or attorney's fees.

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

Print Name:

Date:

OFFICE USE:

Entered by:

Memorial Hermann Information Exchange "MHiE"

Patient consent for the use and disclosure of Health Information

Purpose: The MHiE is a health information exchange network developed by Memorial Hermann Healthcare System. Exchange Members include hospitals, physicians and other healthcare providers. Exchange Members are able to share electronically medical and other individually identifiable health information about patients for treatment, payment and healthcare operation purposes. We are an Exchange Member of the MHiE and we seek your permission to share your health information with other Exchange Members via the MHiE. By executing this form, you consent to our use and electronic disclosure of your health information to other MHiE Exchange Members for treatment, payment, and healthcare operation purposes. We will not deny you treatment or care if you decline to sign this Consent, but we will not be able to electronically share your health information with your healthcare providers that participate in the MHiE as Exchange Members if you do not sign this Consent.

Instructions: If you agree to allow us to disclose your health information with other MHiE Exchange Members please complete the relevant portions of and sign this Consent.

Patient Name (Last, First, Middle):

Date of Birth

Information that will be Disclosed; Purpose of the Consent for Disclosure

I, (Patient's Full Name),

hereby consent to the disclosure of my medical, health and encounter information by any and all Memorial Hermann Healthcare System providers (collectively the "Provider") to other participating providers in the MHiE (Exchange Members) who may request such information for treatment, payment or healthcare operation purposes. I understand the information to be disclosed includes medical and billing records used to make decisions about me.

I HEREBY SPECIFICALLY AUTHORIZE PROVIDER TO RELEASE ALL TYPES AND CATEGORIES OF PROTECTED HEALTH INFORMATION TO OTHER HEALTHCARE PROVIDERS THAT PARTICIPATE IN THE MHiE FOR TREATMENT, PAYMENT AND HEALTHCARE OPERATION PURPOSES, [INCLUDING BUT NOT LIMITED TO, YOUR ALCOHOL AND TREATMENT RECORDS, YOUR DRUG ABUSE TREATMENT RECORDS, YOUR MENTAL HEALTH RECORDS, AND YOUR HIV/ACQUIRED IMMUNE DEFICIENCY SYNDROME RECORDS, AS APPLICABLE].

No Conditions: This Consent is voluntary. We will not condition your treatment on receiving this Consent. HOWEVER, IF YOU DO NOT SIGN [AND INITIAL] THIS CONSENT, WHERE REQUIRED, YOU CANNOT PARTICIPATE IN THE MHiE.

Effect of Granting this Consent: This Consent permits all MHiE Exchange Members to access your health information. Exchange Members of the MHiE are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

Term and Revocation

This Consent will remain in effect until you revoke it. You may revoke this Consent at any time by completing the MHiE notice of revocation. The MHiE notice of revocation is available by calling 713-456-MHiE (6443). Revocation of this Consent will not affect any action we took in reliance on this Consent before we received your notice of revocation. Revocation of this Consent will also have no effect on your personal health information made available to Exchange Members during the timeframe in which your Consent was active.

Individual's Signature

I have had full opportunity to read and consider the contents of this Consent. I understand that, by signing this Consent, I am confirming my consent and authorization of the use and/or disclosure of my personal health information, as described herein.

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

Full Name:

Date:

If this Consent is signed by a personal representative on behalf of the individual, complete the following:

Personal Representative's Name:

Relationship to Individual:

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.

Include this Consent in the individual's records.

Official Use Only:

FINANCIAL POLICY

Thank you for choosing us as your health care provider. We are committed to your satisfaction. Please assist us in meeting your expectations by reviewing the Financial Policy below.

Forms: You will be asked to complete a registration form which will include your home address, telephone number, social security number as well as the address and telephone number of your insurance company, if applicable. Insurance company information can generally be obtained from a card provided to the company's insured member, and we prefer to make a copy and scan of the card for our records. We also request a copy of your driver's license or other picture identification to include in your record.

Forms of Payment: For your convenience, we accept cash and checks, as well as many credit and debit cards. We must have a copy of your driver's license to accept checks.

Office Visits: All office charges are payable at the time the service is rendered. If you desire, we will provide you with a copy of the superbill documenting the charges and receipts for your visit, which you may use to file for reimbursement with your insurance carrier.

Financial Responsibility for Minors: Unless prior arrangements have been made, charges for a minor child seen in the office will be the responsiblity of the adult accompanying the minor child.

Managed Care Plans: We are contracted with many managed care plans. We will file your insurance in accordance with our agreement with the plan. Any copayment or deductible for which you are responsible must be paid at the time of service.

Although we can assist you in many ways, it is your responsibility to be familiar with the coverage provided by your insurance plan, particularly with respect to preventive care, immunizations, the authorization of any procedures and your primary care physician. Please let us know when you call to make an appointment of any changes in your insurance coverage or plan. It will be your responsibility to make payment for any services not covered by your insurance company. If benefits and eligibility cannot be verified prior to service, you will be required to pay for services in full. Any charges denied by your insurance carrier will be your responsibility.

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

Signature of Patient or Legal Guardian:

Date:

Relationship to Patient:

Print Patient's Name:

Date of Birth:

Print name of Legal Guardian, if any

PATIENT/GUARDIAN MUST BE PROVIDED WITH A SIGNED COPY OF THIS AUTHORIZATION FORM. PLEASE INITIAL IF DECLINING COPY.

HIPAA OMNIBUS RULE

Patient Acknowledgement of Receipt of Notice of Privacy Practices and Consent/Limited Authorization & Release Form

You may refuse to sign this acknowledgement & authorization. In refusing, we may not be allowed to process your insurance claims.

Date:

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.

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

Please print your name:

Legal Representative:

Description of Authority:

Your comments regarding Acknowledgements or Consents:

How do you want to be addressed when summoned from the reception area:

First Name Only

Proper Sir Name

Other

Other:

Please list any other parties who can have access to your health information: (This includes step parents, grandparents and any care takers who can have access to this patient's records):

Name:

Relationship:

Name:

Relationship:

I authorize contact from this office to confirm my appointments, treatments & billing information via:

Cell Phone Confirmation

Home Phone Confirmation

Work Phone Confirmation

Text Message to my Cell Phone

Email Confirmation

Any of the Above

I authorize information about my health be conveyed via:

Cell Phone Confirmation

Home Phone Confirmation

Work Phone Confirmation

Text Message to my Cell Phone

Email Confirmation

Any of the Above

I approve being contacted about special services, events, fund raising efforts or New Health Info on behalf of this Healthcare Facility via:

Phone Message

Text Message

Any of the Above

None of the above (opt out)

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.

Office Use Only

As Privacy Officer, I attempted to obtain the patient's (or representatives) signature on this Acknowledgement but did not because:

It was emergency treatment

I could not communicate with the patient

The patient refused to sign

The patient was unable to sign because:

Other (please describe):

Signature of Privacy Officer:

Physician/Patient Memorandum of Understanding

Thank you for choosing our care team for your medical care. We appreciate the trust and confidence you have placed in us. Our goal is to provide YOU with high quality, personal medical care, which is responsive to your individual needs and values. In order for this goal to be achievable, it is important that we (the Physician and the Patient and/or the Patient's caregiver) each commit to satisfying certain responsibilities, as follows:

PHYSICIAN RESPONSIBILITIES

I will listen effectively, provide YOU with explanations as to health care matters, and otherwise encourage a way of life of open, full and honest communication between us.
I will provide YOU with information regarding the different treatment plan for YOUR acute or chronic condition to enable YOU to select the plan appropriate for YOU.
I will provide convenient options (telephone, voice mail, and email) for non-urgent communications between YOU and my practice team for scheduling office visits and follow up visits, and for obtaining test results and referrals.
I will provide YOU telephone availability for urgent communications, 24 hours per day, and 7 days per week by a medical provider in the office.
As technology develops, every effort will be made to provide convenient options (e-consultations, secure email) for non-urgent communications between YOU and I and/or my team, including post-hospital support, follow up visits and consultations.
I will coordinate a multidisciplinary approach to YOUR health care by referring YOU to other clinicians and health care institutions when appropriate.
I will coordinate and integrate care provided by other health care professionals, other clinicians and health care institutions effectively so as to avoid duplication, delay and error.
I will provide flexible and expanded office hours, schedule YOUR appointments within a reasonable time, and see YOU as closely as reasonably possible to YOUR scheduled appointment time.
I will furnish YOU with test and treatment results promptly and correctly.
I will provide YOU with information and recommendations regarding preventative care, maintaining wellness, self-management direction and counseling.
The health care team in my practice will send YOU reminders of the need for follow up care, preventative care and compliance with treatment plans.
I will keep clinical information in a system that allows for ready search, retrieval and information transfer while protecting privacy and confidentiality, including participating in the development and maintenance of standardized electronic health records and patient registries.
My practice team will be trained in the responsibilities described above.

YOUR RESPONSIBILITIES

Communicate openly, fully, freely and proactively with my Medical Provider and staff.
Be an active participant in the development with my Medical Provider of a treatment plan for my or the patients acute or chronic condition, and follow agreed-upon treatment plans.
Provide Medical Provider with feedback regarding my or the patients treatment plan.
Appear on time for appointments, procedures and other medical tests at my Medical Providers office, and timely submit materials, samples and information as requested by Medical Provider.
Schedule and attend follow-up appointments at intervals suggested by my Medical Provider.
Follow my Medical Provider and other health care professionals' recommendations with respect to maintenance or improvement of my or the Patient's health and wellness.
Participate in developing and maintaining a comprehensive Patient health record by authorizing delivery and circulation of my or the patients clinical information to and from clinicians and health care institutions.

Please take the time to carefully read and understand each of our respective responsibilities. To show that you accept and agree with them, please sign your name below. Thank you once again!

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

Signature of Patient or Legal Guardian:

Date:

Relationship to Patient:

Print Patient's Name:

Date of Birth:

Print Name of Legal Guardian (if applicable):