New Patient Forms

Patient Information

Name:

Today's Date:

Mailing Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Work Phone:

Date of Birth:

Age:

Social Security Number:

Guarantor (if applicable):

Relationship to Patient:

Guarantor's Address:

City:

State:

Zip Code:

Who may we contact in case of emergency?

Phone Number:

Who referred you today?

Insurance Information

Medicare Number:

Insurance Company:

Address:

City:

State:

Zip Code:

Policy Number:

Group Number:

Policyholder Name:

Relationship to Patient:

Please upload a copy of the front and back of your insurance card:

Add file

Please upload a file

Assignment of Insurance Payment

I hereby authorize payment of medical benefits directly to Julia Harre, M.D.. I understand that regardless of insurance coverage, I am ultimately responsible for any charges incurred as the result of service(s) provided.

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.

Date

Patient/Parent/Guardian Signature:

Authorization to Release Medical Information

I authorize release of any medical information to my insurance company, legal counsel, Worker's Compensation insurance company or liability insurance company for the purpose of pre-certification or to process my insurance claim(s). I also authorize the release of my medical records to my physician(s)

Date

Patient/Parent/Guardian Signature:

Patient Portal

Would you like access to the patient portal?

Yes No

If yes, please provide your email address:

Medical Information

Who do we thank for referring you to our office?

General Physician:

Reason for Visit Today:

Medication(s) you are currently taking:

Significant Past Medical History:

Allergies (include medications):

Is there a family history of skin disease? (Please list):

Have you ever had prolonged bleeding after an injury?

Yes No

Have you ever had a reaction to anesthesia?

Yes No

Do you smoke?

Yes No

Do you drink alcohol?

Yes No

Are you on a blood thinner?

Yes No

Do you have a pacemaker or defibrillator?

Yes No

Have you ever had or do you now have:

Hepatitis

Yes No

Cancer

Yes No

Heart Disease

Yes No

Diabetes

Yes No

Tuberculosis

Yes No

Notice of Privacy Practices Acknowledgement

I understand that, under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
Obtain payment from third party payers.
Conduct normal healthcare operation such as quality assessments and physicians certificates.

I have read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree than you are bound to abide by such restrictions.

Patient Name:

Relationship to Patient:

Signature:

Date

Office Use only

I attempted to obtain the patient's signature in acknowledgement on this Notice of Privacy Practices Acknowledgement, but was unable to do as document below:

Date

Initials:

Reasons:

Your information will be encrypted.