ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
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1 MRN: DATE RECEIVED: ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES By signing this document, I acknowledge that I have reviewed and/or received a copy of the Notice of Privacy Practices, which provides a more complete description of how my protected health information (PHI) may be used or disclosed. I understand that Holston Medical Group (HMG) reserves the right to change their notice and information practices and that I may view a copy of the current Notice on HMG s website, in any of their offices, or by a request in writing. I also understand that Holston Medical Group participates in the OnePartner Health Information Exchange (OnePartner HIE) and may make my medical information available electronically, or may electronically transmit my medical information to a third party, in order to fulfill provider obligations to release my medical information in the future. Print Patient Name Patient Signature (if applicable) Authorized Representative Signature Patient Date of Birth Date Relationship to Patient I understand that my protected health information will only be verbally communicated to those individuals listed below. Those individuals will be required to provide the last four (4) digits of my Social Security Number, along with my date-of-birth, before any information will be discussed with them. List the individuals that you want protected health information verbally discussed with: FOR INTERNAL USE ONLY: Reason Acknowledgement Could Not Be Obtained: Employee Signature Date Holston Medical Group complies with applicable Federal civil laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Holston Medical Group does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. NC_
2 Patient: MRN: Communicating with Your Primary Care Office Access to Your Physician and Staff Your Holston Medical Group (HMG) health care team can be reached either by telephone or electronically through our patient portal, Follow my Health. If you wish to communicate electronically, you may sign up at any office location on our website at your convenience. Please remember, electronic communication is for routine matters and never should be used for emergencies. It is not appropriate to communicate with your health care team through social media, such as Facebook, or texting. Your privacy is important to us and these are not secure methods of communication. Any questions or concerns should be directed to the patient portal or office during normal business hours. After Hours Care HMG is dedicated to serving our patients 24 hours a day, 7 days a week. The most effective way to serve you is during regular clinic hours, but we understand acute illnesses can occur at any time. Your Primary Care Provider s telephone message will direct you on how to contact the HMG Physician on Call. HMG Urgent Care Please use the Emergency Room only in a true emergency (i.e. chest pain, shortness of breath, stroke-like symptoms). To avoid long wait times in the ER, come to our Urgent Care clinics for routine health concerns such as colds, ear aches, flu symptoms, sprains and strains, etc. We have two locations conveniently located in Bristol and Kingsport. For hours and specific information call (423) (Kingsport) or (423) (Bristol). Prescription Refills To avoid delays and busy phone lines, the best time to obtain your medication refills is at your office visit. While we realize there may be a need to request a refill via telephone or patient portal, please allow at least 48 hours for all refill request before checking with your pharmacy. Sample medication will only be distributed during normal business hours. Monthly refills of any controlled medications (pain medication, anxiety, etc) will only be given during an office visit within regular business hours. Signature: Date: Witness: Date: Holston Medical Group complies with applicable Federal civil laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Holston Medical Group does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. NC_
3 Holston Medical Group believes that part of good healthcare practice is to establish and communicate a financial policy to our patients. We are dedicated to providing the best possible care for you, and we want you to have an understanding of our financial policy. 1. PAYMENT is expected at the time of your visit. Just as we make every effort to accommodate you when you are in need of medical care, we expect that you will make every effort to pay your bill promptly. Payment is due at the time services are provided or upon receipt of a statement from our billing office. We will accept cash, check, debit, credit or health savings accounts. You may also make a payment online through our patient portal, myhmg. Payment will include any unmet deductible, co-insurance, co-payment amount or non-covered charges from your insurance company. If you do not carry insurance, or if your coverage is currently under a pre-existing condition clause payment in full is expected at the time of your visit. For visits under a global or a follow up trauma visit (from a procedure performed by an HMG physician) or for ongoing rehabilitation treatment plans, you will only be responsible for your co-payment if applicable based on your insurance. We do ask for a copy of your current insurance card at the time of your visit to ensure we properly file your claim. 2. SURGERY PATIENTS: You may be responsible or required to pay a percentage of surgery charges prior to any surgeries or procedures. This will be determined by information given to us by your insurance company in regard to patient percent responsibility. 3. INSURANCE: We participate with several insurance plans and will file your claims on your behalf. It is your responsibility to ensure coverage for services prior to your visit. You will be responsible for the complete charges for any non-covered services provided. In addition, all co-payments, deductibles or non-covered charges will be due at the time of service.you must provide proof of insurance at each visit so we can ensure proper billing to your benefit plan. If there is an overpayment on your account, we will refund any overpayment to you after overpayment credit is applied to any outstanding account balance(s). We do not bill third party payors, but will be happy to provide a copy of the original claim if requested. 4. HIGH-DEDUCTIBLE PLANS: Under these plans, your insurance company will provide you a discount off our billed charges, but you are responsible for the entire amount due until you meet your deductible. We will accept cash, check, debit, credit or you may use your health savings account. 5. RETURNED CHECKS will incur a service charge which may vary from time to time as determined by our financial institution. 6. ACCOUNTING PRINCIPLES: If there is an overpayment on your account, we will refund any overpayment to you after overpayment credit is applied to any outstanding account balance (s). Payment and credits are applied to the oldest charges first, except for insurance payments which are applied to the corresponding date of service 7. FORMS FEES: Medical records, except those involving worker s compensation cases, will be billed at the rates listed below: Simple Forms (completed within 2 business days) DURING an office visit: No Charge AFTER an office visit: $5 / form Examples of Simple Forms: Handicap tag/sticker, work re-entry forms, immunization, medication, sports, concussion clearance, WIC, Home Bound Status Short form, Disability Short Form, Bank Loan Form, Foster Parent Health Form, College & Camp Forms Complex Forms: $25 (completed within 10 business days) Examples of Complex Forms: FMLA (per illness per year), Disability Long Form, Home Bound Status Long Form.
4 8. MISSED APPOINTMENTS: If you fail to cancel a previously scheduled appointment at least 24 hours in advance, you may be charged a fee as outlined below: Established office visit: $20 Allergy Testing: $75 New patient visit or consultation: $100 GI Procedure: $250 This charge cannot be billed to the insurance company. Failure to pay a no show fee will be treated according to our policy on unpaid balances, with the exception of collection accounts. This charge is not applicable to patients with Medicaid/TennCare insurance coverage. After 2 no-show appointments in a rolling calendar year, you may be discharged from the practice, at the discretion of the responsible provider and management. Medical care will not be withheld for a medical emergency for thirty days from date of dismissal. 9. UNPAID BALANCES: All outstanding balances shall be due within 30 days of the date of service. At that time, all past due balances in their entirety must be paid prior to the time of your next visit. Balances that remain outstanding for a period of 90 days or more may be referred to a collection agency and could affect your credit. 10. FINANCIAL DISMISSAL: Patients who do not make payment arrangements risk being dismissed from the practice. Holston Medical Group reserves the right to dismiss patients for delinquent financial accounts on personal balances. If dismissed, medical care will not be withheld for a medical emergency for thirty days from date of dismissal. 11. BILLING QUESTIONS: We will be happy to help you resolve your balance and can be reached at (423) , Monday Friday 8:00AM 5:00PM.
5 MRN#: Date Received: Holston Medical Group believes that part of good healthcare practice is to establish and communicate a financial policy to our patients. We are dedicated to providing the best possible care for you, and we want you to have an understanding of our financial policy. I have read, understand and agree to the Financial Policy as provided to me. I understand that charges not covered by my insurance company, as well as applicable co-payments, deductibles and any charges older than 30 days from the date of service are my responsibility. I authorize Holston Medical Group to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim. I authorize my insurance benefits be paid directly to Holston Medical Group. By signing below, I indicate my agreement with the policy as provided to me. Date Signature Printed Name Holston Medical Group complies with applicable Federal civil laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Holston Medical Group does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
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PATIENT INFORMATION NAME (LAST, FIRST, MIDDLE) SSN# BIRTH SEX ADDRESS CITY, STATE & ZIP CODE EMAIL: MAILING ADDRESS (IF DIFFERENT FROM ADDRESS) CITY, STATE & ZIP CODE HOME PHONE CELL PHONE OTHER PHONE
M F Last Name First Name Middle Initial Gender. Home Phone: Work Phone: Cell Phone: Physical Address: Mailing Address (if different):
Welcome to Patient Information: Date of Birth: M F Last Name First Name Middle Initial Gender Home Phone: Work Phone: Cell Phone: Physical Address: Mailing Address (if different): Employer: Occupation:
UnitedHealthcare Choice Plus Health Savings Account (HSA) Plans User Guide
UnitedHealthcare Choice Plus Health Savings Account (HSA) Plans User Guide Tips for Healthy Saving and Spending CHOOSE HEALTH. SPEND WISELY. We are committed to offering you a comprehensive benefits program
Our office is located at 501 Darby Creek Road, Suite 21 in Lexington. This is just off Man- O-War Blvd, between Palumbo Drive and Mapleleaf.
COMPLETE, SIGN AND RETURN THIS ENTIRE PACKET OF INFORMATION PLEASE MAIL TO OFFICE AFTER COMPLETION DO NOT FAX Our office is located at 501 Darby Creek Road, Suite 21 in Lexington. This is just off Man-
Quick Patient Registration Form Patient Information:
Quick Patient Registration Form Patient Information: Legal First Name: MI: Legal Last Name: Sex: M F Date of Birth: Primary Language: Marital Status: Married Single Partner Divorced Widowed Race: Ethnicity:
Statement of Financial Responsibility
: Patient Intake Form Patient Name: (Last) (First) (M): Cell Phone Home Phone Work Phone Mailing Address: City: State: Zip: Home Address: City: State: Zip: (If Different) Email How did you hear about us?
DIABLO DERMATOLOGY 3436 Hillcrest Ave., Suite 150, Antioch, CA (925) MEDICAL HISTORY
Patient Name: DIABLO DERMATOLOGY 3436 Hillcrest Ave., Suite 150, Antioch, CA 94531 (925) 754-6767 MEDICAL HISTORY Date: Referred by: Self Family/Friend Doctor Doctor s Name: 1. Are you aware of being allergic
Charles T. Murphy, DPM. Podiatric Medicine and Surgery. Patient Registration
Charles T. Murphy, DPM Podiatric Medicine and Surgery Patient Registration Patient Name: Billing Address: Permanent Address: Responsible Party Name: City, State, Zip: City, State, Zip: Home Phone: ( )
ADULT PATIENT REGISTRATION
PATIENT NAME: (LAST) (FIRST) (M) CELL: ( ) HOME: ( ) PERSONAL E-MAIL: (FOR PATIENT PORTAL) DATE OF BIRTH: / / AGE: GENDER: MALE FEMALE SOCIAL SECURITY: - - MARITIAL STATUS: SINGLE MARRIED WIDOW(ER) OTHER
Patient Registration Form Please complete all the information below in print, please do not leave any questions blank. Thank You!
Patient Registration Form Please complete all the information below in print, please do not leave any questions blank. Thank You! PATIENT INFORMATION: Last Name: First Name: Middle: Date of Birth: Home
Advanced PT, LLC 200 W Douglas Ave, Ste 1040 Wichita, KS (866)
200 W Douglas Ave, Ste 1040 Wichita, KS 67202 (866) 412-5554 Welcome to Advanced PT, LLC. We are honored that you have chosen us as your therapy provider. Our goal is to provide the highest quality of
Please complete entire form
Please complete entire form Patient Name: (Last) (First) (M) Address: City: State: Zip: DOB: Age: Sex: M F Social Security #: (If Using Insurance this is required) Home Phone: Cell Phone: Work Phone: Marital
JUST US KIDS PEDIATRICS NEWBORN HISTORY FORM
JUST US KIDS PEDIATRICS NEWBORN HISTORY FORM DATE: PATIENT NAME: D.O.B BIRTH HISTORY WAS YOUR BABY FULL TERM? PRE-TERM? ADOPTED? IF PRE-TERM, HOW MANY WEEKS? IF ADOPTED, AT WHAT AGE? TYPE OF DELIVERY:
WELCOME TO SPORTS CONDITIONING AND REHABILITATION
WELCOME TO We are pleased you have chosen, (SCAR) for your physical therapy needs. We know there are many choices and we appreciate your confidence in us. You will find we provide unsurpassed individualized
PATIENT AGREEMENT ACCESS ENTERPRISE, LLC d/b/a ACCESS FAMILY MEDICINE
PATIENT AGREEMENT ACCESS ENTERPRISE, LLC d/b/a ACCESS FAMILY MEDICINE This is an Agreement entered into on, 20, between Access Enterprise, a Nebraska Limited Liability Company, d/b/a Access Family Medicine
It is very important to bring the following to your first visit:
Dear New Patient: Welcome and thank you for choosing Capital Digestive Care! The enclosed packet contains important information for your upcoming appointment as well as our new patient registration forms.
RESPONSIBLE PARTY (Complete only if patient is a minor or otherwise not financially responsible): Name: DOB: / / SSN: - -
Date / / Chart # PATIENT INFORMATION: Name: DOB: / / SSN: - - Address: Phone (H) ( ) - Gender: M F Phone (C) ( ) - Race: *OK to leave message with personal health information on voicemail of above phones:
NO-FAULT PATIENT INFORMATION *** PLEASE COMPLETE ALL INFORMATION REQUESTED FOR OUR RECORDS *** Date:
NO-FAULT PATIENT INFORMATION *** PLEASE COMPLETE ALL INFORMATION REQUESTED FOR OUR RECORDS *** Date: Last Name: MI: First Name: DOB : SEX : SS # : Address: City: State Zip Code: Phone (Home): Phone (Cell):
ROCKWALL SURGICAL SPECIALISTS
PATIENT REGISTRATION FORM Patient s name (Last, First, Middle Initial) Sex (M or F) Date of Birth Address City State Zip Home Phone Cell Phone Email Marital Status Social Security Number Driver s License
PATIENT INFORMATION. Last Name: First Name: Middle Initial: Sex: M F Preferred Name: Date of Birth (MM/DD/YYYY): Height: Weight: Mailing Address:
PERSONAL INFORMATION PATIENT INFORMATION Last Name: _ First Name: _ Middle : Sex: M F Preferred Name: Date of Birth (MM/DD/YYYY): Height: _ Weight: Mailing Address: City: State: Zip: Social Security #:
MR #: Patient Name: Page: 1 of 4 MAX MOTION PHYSICAL THERAPY PATIENT DATA SHEET. May we send you text messages relating to your care with us?
MR #: Patient Name: Page: 1 of 4 MA MOTION PHYSICAL THERAPY PATIENT DATA SHEET First: MI: Last: Date of Birth: Age: Gender: Male Female Mailing Address: Physical Address: May we send you text messages
ROCKWALL SURGICAL SPECIALISTS
ROCKWALL SURGICAL SPECIALISTS Dr. David Ritter Dr. Ashley Egan Dr. Jon Harris Phone (972) 412-7700 Fax (972) 412-7710 PATIENT REGISTRATION FORM Patient s name (Last, First, Middle Initial) Sex (M or F)