NEW PATIENT INFORMATION

PATIENT INFORMATION

Date:

Primary care Physician:

Referring Physician:

Last Name:

First Name:

Address:

City:

State:

ZIP:

Home Phone:

Cell No:

Work Phone:

DOB:

SSN:

Employment Status:

Employer Name:

AUTOMATED TELEPHONIC COMMUNICATIONS

May we send automatic tel. reminders/texts for appointments, general lab. or prescription confirmation?

Yes No

If yes, preferred contact No:

Home

Cell

Home

FINANCIAL RESPONSIBLE PARTY

SELF

Name:

Address:

City/ State/ ZIP:

Home Phone:

Cell No:

EMERGENCY CONTACT

Relation to Patient:

Name:

Address:

City/ State/ ZIP:

Home Phone:

Cell No:

INSURANCE INFORMATION

Primary Insurance

Subscriber Dependent

Subscriber No:

Group No:

If dependent, Insured Name:

SSN:

DOB

Secondary Insurance

Subscriber Dependent

Subscriber No:

Group No:

If dependent, Insured Name:

SSN:

DOB

ADDITIONAL INFORMATION

PLEASE NOTE IF A PO BOX ADDRESS WAS PROVIDED FOR GENERAL MAILING, A PHYSICAL ADDRESS IS COMPULSORY FOR ACCEPTING CERTAIN MAIL SUCH AS CERTIFIED OR MEDICATION RECALL LETTERS

Address:

City/ State/ ZIP:

Language; If other:

CONFIDENTIAL CONTACT INFORMATION

Please list all those you give permission for us to discuss your medical condition, appointments, and billing information with.

Add new row

PHARMACY INFORMATION

Please check off the preferred pharmacy

Local Pharmacy

Mail Order Pharmacy

Local Pharmacy Name:

Location:

Mail Order Pharmacy Name:

CONSENT TO ACCESS EXTERNAL PRESCRIPTION HISTORY

: I authorize Sussex Pulmonary and Endocrine Consultants, PA to view the external prescription history via the Rx Hub service for the patient listed below. I understand that prescription history from multiple other unaffiliated medical providers, insurance companies, and pharmacy benefit managers may be viewable by my providers and staff here, and it may include prescriptions back in time for several years.

PRIVACY PRACTICE

: I have read the privacy practice and give my consent to your use and disclosure of my health information.

CONSENT FOR CARE AND TREATMENT

: I do hereby agree and give my consent for Sussex Pulmonary & Endocrine Consultants, PA to furnish medical care and treatment considered necessary and proper in diagnosing or treating my physical and mental condition.

BENEFIT ASSIGNMENT/ RELEASE OF INFORMATION

: I, hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled, including Medicare, Medicaid, private insurance, and third-party payers to Sussex Pulmonary & Endocrine Consultants, PA. A photocopy of this assignment is to be considered as valid as the original. I, hereby authorize said assignee to release all information necessary, including medical records, to secure payment.

: We bill your insurance carrier solely as a courtesy to you. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract, except where we are contracted as preferred provider.

: It is your responsibility to know your insurance policy and initiate a referral when necessary. IF YOU DO NOT HAVE YOUR REFERRAL, YOUR VISIT MAY BE RESCHEDULED OR YOU MAY BE FINANCIALLY RESPONSIBLE FOR THE SERVICES PROVIDED.

: All patients who do not have medical insurance and patients without valid insurance card are considered self-pay. All SELF-PAY PATIENTS are responsible for payment at the time of the visit.

: All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. We accept cash, checks or credit cards.

CANCELLATION

: Please give at-least 24 hours’ notice prior to canceling a scheduled appointment. There will be $ 50 fees for appointments cancelled within 24 hours or missed. These charges will be your responsibility, billed directly to you and payable prior to the next appointment. Failure to pay may result in dismissal from the practice. If you miss three or more cumulative visits, you may be dismissed from the practice. Please help us to serve you better by keeping your regular scheduled appointments.

UNPAID BALANCE

: Balances older than 60 days will be subject to a LATE FEE OF $25. Balances not paid within 90 days will be considered past-due and sent to collection agency. In addition, you will be responsible for all costs of collecting monies owed, including, collection agency fees court costs and attorney fees.

: Any patient with a Financial Past Due Account may be denied a future appointment until balance is paid or a payment arrangement is made. We realize that temporary financial problems may affect timely payment of your account. If such a problem arises, we encourage you to contact us immediately to set up a payment plan.

I have read and understand the above information.

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 / Legal Guardian Signature

Date

PORTAL CONSENT FORM

Sussex Pulmonary and Endocrine Consultants, PA offers secure viewing and communication through its EMR vendor’s (eClinicalworks) secure servers as a service to patients who wish to view parts of their records and communicate with our staff and physicians.

Secure messaging can be a valuable communications tool but has certain risks. To manage these risks, we need to impose some conditions of participation. This form is intended to show that you have been informed of these risks and the conditions of participation, and that you accept the risks and agree to the conditions of participation. By signing below, you confirm that you have read, understand, and agree to comply with our procedures and guidelines for using the Patient Portal. You also agree not to hold Sussex Pulmonary and Endocrine Consultants, PA or any of their staff liable for network infractions beyond their control.

This method of communication and viewing prevents unauthorized parties from being able to access or read messages while they are in transmission. No transmission system is perfect, and we will do our best to maintain electronic security. However, keeping messages secure depends on two additional factors: the secure message must reach the correct email address, and only the correct individual (or someone authorized by that individual) must be able to get access to it.

We need you to make sure we have your correct email address and are informed if it ever changes. You also need to keep track of who has access to your email account so that only you, or someone you authorize, can see the messages you receive from us.

Patient Acknowledgement and Agreement

I acknowledge that I have read and fully understand this consent form and the Policies and Procedures Regarding the Patient Portal. I understand the risks associated with online communications between my physician and me, and consent to the conditions outlined herein. In addition, I agree to follow the instructions set forth herein and including the policies and procedures, as well as any other instructions that my physician may impose to communicate with patients via online communications. All my questions have been answered and I understand and concur with the information provided in the answers.

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

Confidential email, please print clearly:

Patient / Legal Guardian Signature

Date

SUSSEX PEC Representative Signature

Date

Your information will be encrypted.