New Patient Information Form

Friedman Family Practice

Please correct the errors described below.

Patient Information

Primary Insured Party

Emergency Contact Information

Which Pharmacy You Do Use?

Consent to Treatment


I voluntarily consent to receive medical and health care services that may include diagnostic procedures examinations and treatment.

Financial Responsibility and Assignment of Benefits

I understand that I am responsible for payment in full or any co-payment at the time services are rendered, as indicated by my insurance plan. I understand that any amounts not paid by my insurance are my responsibility. Should I not respond within a 90 day period for any unpaid balances, the amount will be turned over to a collection agency including all additional fees, legal or otherwise, as allowed by the state of Texas.
Billing policy available upon request.

Medical Records Disclosure

I authorize the employees of Bradley Friedman MD PA to disclose my (or my child’s) medical records to the following individuals

Privacy Practices Acknowledgement

I have been provided an opportunity to review the notice of Privacy Practices (HIPAA): (available on the website, in-office clipboard and upon request)

TREATMENT OF MINORS

Minors cannot be seen at Friedman Family Practice without the legal guardian’s consent. Grandparents, Stepparents, and childcare practitioners must have written consent to treat from the legal guardian.

PATIENT PORTAL USER AGREEMENT

PATIENT PORTAL USER AGREEMENT
We are pleased to provide a Patient Portal in partnership with our electronic medical records provider, EClinicalWorks for the exclusive use of established patients. The Patient Portal is designed to enhance patient – physician communication. All users must be established by a previous office visit.
We strive to keep all of the information in your records correct and complete. If you identify any discrepancy in your records, you agree to notify us immediately. Additionally, by using the Patient Portal, the user agrees to provide factual and correct information.
The Patient Portal provides access to the following services:
• Request appointments • Request prescription refills • View your medical records
• Receive educational material • View current and past statements • Send messages to clinical staff
• Receive health maintenance reminders
The Patient Portal is not intended to provide internet based diagnostic medical services. The following limitations also apply: • No internet based triage and treatment requests. Diagnosis can only be made and treatment rendered after the patient is SEEN by the physician. • No emergent communication or services. Any emergent conditions should be handled by calling the office directly, going to an urgent care clinic or emergency room or calling 911 should the emergency be life threatening. • No requests for narcotic/controlled medications will be accepted. • No requests for new prescriptions or refills for conditions for which you are not being treated by our clinic will be accepted. • It may take 72 hours to receive a response to an email request. If you do not receive a response within 72 hours you should contact the office at (972) 668-0821. • If you lose your password or username, you may request a new one through the web portal or in person at the office by providing valid identification. • Always remember to log out and close your browser when you are finished accessing password protected Patient Portal services. This prevents someone else from accessing your personal information. YOU SHOULD NEVER USE A PUBLIC COMPUTER TO ACCESS THE PATIENT PORTAL.
This Patient Portal is provided as a courtesy to our patients. While some offices charge for this convenience on an annual basis, we are focused on providing the highest level of service and health care. However, if abuse or negligent usage of the Patient Portal persists, we reserve the right, at our discretion, to terminate Patient Portal offering, suspend user access and modify services available through the Patient Portal. The Patient Portal is provided in partnership with EClinicalWorks, our EHR software vendor and provider. That data is HIPAA compliant with high level encryption that exceeds the HIPAA standards. While we believe that the IT infrastructure and data are safe and secure, it does not guarantee unforeseen adverse events cannot occur. To the extent possible, our office has undergone rigorous IT implementation and security standards exceeding industry recommendations.
Please read our HIPAA policy for information on how private health information is used in our office. All patients have signed a HIPAA agreement form. If you do not recall having signed a HIPAA agreement or need to reacquaint with the HIPAA policy, we will be happy to provide you with a copy.
Once you have signed the Patient Portal User Agreement and have provided our office with a legitimate email address that is secure, you will be given our system generated unique user identification and password. The site may be accessed in two ways:
1. Directly by going to this URL: https://mycw8.eclinicalweb.com/fmdl/jsp/login.jsp
2. Our website: www.FriedmanFP.com and clicking on Patient Portal tab
Patient Acknowledgement and Agreement:
I acknowledge that I have read and fully understand this consent form. I have been given risks and benefits of the Patient Portal and agree that I understand the risks associated with online communications between my physician and myself, and consent to the conditions outlined herein. I acknowledge that using the Patient Portal is entirely voluntary and will not impact the quality of care I receive should I decide against using the Patient Portal. In addition, I agree to adhere to the policies set forth herein, as well as any other instructions or guidelines that my physician may impose for online communications. I have been given an opportunity to ask questions related to this agreement and all of my questions have been answered to my satisfaction.

Physician Assistant (PA)/Nurse Practitioner (NP)

Consent for Treatment

This facility has on staff Physician Assistants (Robin Isaacks PA, Lindsay Svehla PA) and a Nurse Practitioner (Kristy Moore NP) to assist in the delivery of medical care.
A physician assistant or nurse practitioner is not a doctor. A physician assistant/nurse practitioner is a graduate of a certified training program and is licensed by the state board. Under the supervision of a physician, a physician assistant/nurse practitioner can diagnose, treat and monitor common acute and chronic diseases as well as provide health maintenance care.
“Supervision” does not require the constant physical presence of a supervising physician, but rather overseeing the activities of and accepting responsibility for the medical services provided.
A physician assistant/nurse practitioner may provide such medical services that are within his/her education, training and experience. These services may include:
• Obtaining histories and performing physical exams
• Ordering and/or performing diagnostic and therapeutic procedures
• Formulation a working diagnosis
• Developing and implementing a treatment plan
• Monitoring the effectiveness of therapeutic interventions
• Assisting at surgery
• Offering counseling and education
• Supplying sample medications and writing prescriptions (where allowed by law)
• Making appropriate referrals
I have read the above, and hereby consent to the services of a physician assistant or nurse practitioner for my health care needs.
I understand that at any time I can refuse to see the physician assistant or nurse practitioner and request to see a physician. I understand that my appointment will likely need to be rescheduled to accommodate my request.

Controlled Substance Policy

It is the policy of this office that we do not routinely prescribe controlled substances such as narcotics (Vicodin, Percocet, Norco etc.) or benzodiazepines (valium, xanax, ativan, etc.). There are occasions where controlled substances are warranted however, they will only be prescribed in a very limited quantity and will not be refilled. These substances will also not be prescribed over the phone. If you have a condition that you feel requires either large quantities of such medications or long term use of such medications, we will be happy to refer you to the appropriate specialist for your condition. We cannot provide refunds for patients who are seen but feel they require larger dosages, quantities, or refills of controlled substances.
By initialing below, I acknowledge that I have read and understood the controlled substance policy of Bradley Friedman M.D. P.A. and Friedman Family Practice.

Missed Appointment Policy

I hereby acknowledge that it is the policy of Bradley Friedman M.D. P.A. that should I fail to show up for an appointment and do not notify the office at least three hours prior to the appointment, I will be billed a “missed appointment” fee of $40.

At Friedman Family Practice, we are dedicated to providing you with the best medical care available. In order to do that, we will need your assistance in providing us with necessary information. This information will be kept confidential and is protected by law. The information provided is used for the purpose of providing services to you and is shared with your insurance company for the purpose of reimbursement. If any type of lab work is done, this same information will be provided to the lab provider as well. We will not release your information to any other facility or person unless requested by you in writing.
We will file with your insurance if we are a participating provider under the plan for which you are enrolled. Any out of pocket expense, co-pay, deductible, or co-insurance is the responsibility of the patient, and is due at the time of service. If we are not a participating provider on the plan you are enrolled, payment will be due at the time of service. We accept various forms of payment. If a check will be used as payment, your driver’s license must be provided.
** Unfortunately, we are not always aware of the particular details of each insurance plan. Therefore, please be sure you are aware of any exclusions and/or provisions with your plan. Any service not covered by the insurance will be the responsibility of the patient. Your insurance is a contract between you, your employer, and the insurance company. We file your claims as a courtesy but ultimately, medical charges are the responsibility of the patient.
If you have any questions or concerns with these policies, please feel free to contact our office.
Information on patient concerns for TSBME and TDI available upon request
By typing in my name in below in lieu of my signature (as the responsible party/legal guardian), I certify that I have read and understood all of the information above and agree to the policies of Bradley Friedman M.D. P.A. (Friedman Family Practice). This form must be completed prior to services being rendered. It will become part of your permanent record with our office.

Your information will be encrypted.

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