NEW PATIENT PACKET

Patient Information

Last Name

First Name

Middle Name

Preferred Name

Date of birth:

SS#:

Primary care physician:

Preferred pharmacy name:

Phone Number

Home address:

City:

State:

ZIP:

Mail to address:

City:

State:

ZIP:

County:

Home Phone:

Cell Phone:

Preferred language:

Email:

Veteran

Yes No Unknown

Religion:

Guarantor information (If guarantor is self, skip to emergency contact)

Parent/guardian presenting minor child for treatment will be listed as the guarantor. If 18 or older, patient will be listed as guarantor and does not have to complete this section. The guarantor will be responsible for any balance due.

Name

Last, First, Middle

Patient relation to guarantor:

Date of birth:

SS#:

Home Phone:

Cell Phone:

Home address:

City:

State:

ZIP:

Country:

Mail to address (if different):

City:

State:

ZIP:

Country:

Emergency contact (Pediatric patients, please list someone other than parent(s)/guardian)

Primary contact name:

Home Phone:

Patient relation to emergency contact:

Cell Phone:

Secondary contact name:

Home Phone:

Patient relation to emergency contact:

Cell Phone:

Employment

Patient employer:

Work Phone:

Ext:

Address:

City:

State:

ZIP:

If retired is select, input date:

(Pediatric patients only) Parent/Guardian & immediate family information

Mother (If the address, phone numbers and employer information are the same as guarantor, please indicate same.)

Full Name

Last, First, Middle

Nickname:

Date of Birth

SS#:

Home address:

(if different from patient)

City:

State:

ZIP:

Employer:

Home phone:

Cell phone:

Work phone:

Father (If the address, phone numbers and employer information are the same as guarantor, please indicate same.)

Full Name

Last, First, Middle

Nickname:

Date of Birth

SS#:

Home address:

(if different from patient)

City:

State:

ZIP:

Employer:

Home phone:

Cell phone:

Work phone:

(Pediatric patients only) Brothers, sisters & other family members

Add new row

Check here if no insurance. And skip to authorization (below).

Accident information

Is visit the result of an accident? (Examples: auto accident, workers compensation, etc.)

Yes No

Type of accident:

Date of accident:

County of accident:

Primary insurance information

SUBSCRIBER: This is the person who carries the insurance. If subscriber is the patient, skip to insurance co. name field.

Subscriber’s name on card:

Date of birth:

Patient relationship to subscriber:

Sex

Male Female

If address and phone number is same as patient, please indicate same.

Address:

City, state, ZIP:

SS#:

Home Phone:

Employer:

Work phone:

Insurance co. name:

Phone:

Policy/Cert #:

Group no.:

Date of birth:

If retired is select, input date:

Secondary insurance information

SUBSCRIBER: This is the person who carries the insurance. If subscriber is the patient, skip to insurance co. name field.

Subscriber’s name on card:

Date of birth:

Patient relationship to subscriber:

Sex

Male Female

If address and phone number is same as patient, please indicate same.

Address:

City, state, ZIP:

SS#:

Home Phone:

Employer:

Work phone:

Insurance co. name:

Phone:

Policy/Cert #:

Group no.:

Date of birth:

If retired is select, input date:

Authorization

I authorize medical evaluation and treatment, and release of information for insurance/medical purposes concerning my illness and treatment. I hereby authorize payment from my insurance company to Prisma Health for services rendered. I will be responsible for any amount not covered by my insurance.

Signature of patient/guardian/guarantor:

Date:

PERMISSION TO TREAT

PATIENT NAME:

ADDRESS:

TELEPHONE:

EMAIL:

SOCIAL SECURITY:

PIM USE ONLY

MRN:

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

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 the treatment directly or indirectly.
Obtain payment from third party payers and your insurance companies.
Conduct normal healthcare operations such as quality assessment and physician certifications.

I have been given a copy of Notice of Privacy Practices by Palmetto Internal Medicine & Primary Care, PA and been given the opportunity to read this notice before signing this consent. I understand that Palmetto Internal Medicine & Primary Care, PA has the right to change its Notice of Privacy Practices from time to time and that I may contact this facility at any time to obtain a current copy of the 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 healthcare operations. I also understand that Palmetto Internal Medicine & Primary Care, PA is not required to agree to my requested restrictions, but if it does agree, then it is required to abide by these restrictions.

I understand that I have the right to revoke this consent in writing at any time. I understand that revocation of this consent will not affect any action taken by Palmetto Internal Medicine & Primary Care, PA in reliance on this consent before its revocation. I understand that Palmetto Internal Medicine & Primary Care, PA may decline to treat me or continue to treat me if this consent is revoked.

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/GUARDIAN SIGNATURE

Date:

RELATIONSHIP TO PATIENT

Authorization for Disclosure of Medical Information

Patient Full Nam e (PRINT)

DOB

MRN

PIM USE ONLY

Authorization for Disclosure of Medical Information: The privacy of your medical information is important. We will discuss your medical condition with person(s) you designate.

DO YOU W ANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM THE PROVIDER MAY DISCUSS YOUR MEDICAL CONDITION? IF YES, WHOM? (Check and complete one)

YES - The provider may discuss my medical condition with the following family member or other individual: NO The provider may not discuss my medical condition with any family member or other individual.

You m ay revoke/ cancel or modify/ change the above designation, but the revocation or modification must be in writing.

NOTE: This designation does not give the above named individuals the right to make health care decisions for you. If at any time you are unable to consent to care or treatment, we will follow the procedure set forth in the South Carolina Adult Health Care Consent Act.

Communication: Please provide phone number(s) where we can reach you (by providing a number you also authorize Prism a Health to leave you voicemails at the number(s) listed):

Home:

Cell:

Work:

Note: An automated appointment reminder system m ay call the number listed in our data base.

Signature: I hereby authorize the disclosure of my medical information as described above

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/ Patient’s Representative Signature:

Date:

Time:

PRINT Name (if Patient’s Representative):

Relationship to Patient (if Patient’s Representative):

PIM Representative:

Date:

Time:

Financial Policy

Please read this financial policy carefully. If you have any questions about this policy, any member of our staff will be glad to assist you.

The following are the conditions for services provided by Palmetto Internal Medicine & Primary Care for the patients whose name appears above.

PROOF OF INSURANCE: Please bring your insurance card to every appointment. We participate with a large variety of insurance plans. If you are not insured by a plan that we participate with, a payment in full is expected at each time of service. It is your responsibility to ensure that we have your correct information and up to date copy of your insurance card.

SELF-PAY PATIENTS: We understand not all patients can afford insurance, that is why we offer self-pay prices at a discount rate. For all self-pay patient’s, it is required that you pay up front before every visit and before any service is done.

CO-PAYMENTS, DEDUCTIBLES & CO-INSURANCE: All co-payments, deductibles, co-insurance, & outstanding balances must be paid at the time of service. If you have a deductible, we collect a portion of the deductible up front. You will be required to pay the whole balance on your next visit. If you do not have your copay/co-ins/deductible on the date of service, YOU MAY BE REQUIRED TO RESCHEDULE.

CLAIMS SUBMISSION: We will submit your claims and assist you in any way we can to help get your claims paid. Your insurance plan may request information directly from you, it is your responsibility to reply in a timely manner. Remember, your insurance benefits is a contract between you and your insurance plan.

COMPLETION OF MEDICAL FORMS: There may be a charge for completion of forms such as disability, FMLA, etc.

COPIES OF MEDICAL RECORDS: There is a charge for completion of this process; SC Sec. 44-7-325 for Health Care Facilities

Clerical fee not to exceed $25.00
$0.65 per page for the first 30 pages, if there are more than 30 pages, the price is reduced to $0.50 per page.
$15.00 for an itemized bill

A special handling fee of $10 will be charged if records must be delivered within 48 hours of requested date.

NO SHOW APPOINTMENTS: We understand that there may be times you cannot make your scheduled appointments. If need be, you can cancel your appointments via MyChart, our automated reminder system, and by calling our office. We ask that you at least give a 24-hour cancellation notice before your scheduled appointment. If a 24-hour notice is not given, your appointment will be counted as a No-Show. As a courtesy we are no longer charging No-Show fees, but after 4 No-Show or missed appointments you will be dismissed from Palmetto Internal Medicine and Primary Care.

For more information on our No-Show Policy please read our Cancellation and No-Show Policy.

COLLECTION POLICY: If no resolution can be made within sixty (60) calendar days, delinquent actions will be forwarded to a collection agency/or to small claims court and possible discharge from the practice. If you are unable to pay your balance promptly, please call us at 864-277-8300 to make payment arrangements. We will attempt to contact you by phone before your account is forwarded.

QUESTIONS: We are here to help if you should have any questions regarding your statement. **Knowing your insurance benefits is your responsibility. Please contact your insurance plan with questions you may have regarding your coverage**

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/Personal Representative Signature:

Date:

PRINT name of Personal Representative:

Lab Policy

At Palmetto Internal Medicine and Primary Care, we pride ourselves in offering the best healthcare possible to our patients. By doing this, our providers may at times desire for you to have labs drawn, whether for preventative or diagnostic care.

Although we feel like these labs are a very important part of your healthcare, these labs may not be covered by some insurance companies, and as the insured that is your responsibility to know your benefits. In the event that your labs are not covered by your insurance company you will receive a bill from Palmetto Internal Medicine, LabCorp, or both.

By signing this form, you are accepting the responsibility for any uncovered expenses associated with these labs.

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/GUARDIAN SIGNATURE

Date:

RELATIONSHIP TO PATIENT

Cancellation and No-Show Policy

Thank you for trusting your medical care with Palmetto Internal Medicine and Primary Care. When you schedule an appointment with us, we set aside enough time to provide you with the highest quality care. Our goal is to provide quality medical care in a timely manner. To do so we have had to implement an appointment cancellation policy. Should you need to cancel or reschedule an appointment please contact our office as soon as possible, no later than 24 hours prior to your scheduled appointment. This gives us time to schedule other patients who may be waiting for an appointment. Please read our Cancellation and No-Show Policy below:

Effective June 29th, 2023, any established patient who fails to show or cancels/reschedules an appointment without a 24-hour notice will be marked as a No-Show.
Any patient that continuously cancels or reschedules their appointment will not be rescheduled.
As a courtesy, and to help patients remember their scheduled appointments, we send out phone call, text message, and email reminders 2 days prior to your appointment.

Our No-Show Policy occurrence is as follows:

1st No-Show occurrence, you will be given a verbal warning by one of our clerical staff.
2nd No-Show occurrence, you will receive a letter from our office notifying you that our No-Show policy has been violated.
3rd No-Show occurrence, you will receive a phone call from our practice manager about the violation.
4th No-Show occurrence, you will be discharged from the practice and notified by letter.

Our practice firmly believes that good physician/patient relationship is based upon understanding and good communication. We understand that there are times when you miss an appointment due to emergencies or obligations for work, or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting needed medical care.

I have read and understood Palmetto Internal Medicine’s Cancellation/No Show Policy and understand my responsibility to plan appointments accordingly and notify Palmetto Internal Medicine appropriately if I have difficulty keeping my scheduled appointments.

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 Name (Please Print)

Date of Birth:

Signature of Patient or Patient Representative

Date:

Patient MRN:

Your information will be encrypted.