New Wave Internal Medicine Clinic

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New Wave Internal Medicine Clinic

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Transcription:

Amber D. Colville, M.D. *Lydia Latour, M.D., * Ashleigh Teates NP-C Dear Patient, Thank you for your interest in becoming a new patient at New Wave Internal Medicine. Please fill out the enclosed paperwork and return it and we will gladly call you to set up an appointment. We do require a one-time $100.00 New Patient deposit by cash or credit card. Cash deposits must be brought to our office before we schedule you an appointment and you will be issued a receipt. Credit card deposits will only be charged if you No Call/No Show for your scheduled appointment and cash will be non-refundable. Please bring your receipt to your New Patient appointment and your cash deposit will be returned. If you have any questions, please call our office. We look forward to seeing you. Thank you, Nikki May New Patient Coordinator

Amber D. Colville, M.D. * Lydia Latour, M.D. New Patient Receipt : Patient Name: Deposit: Cash or Credit Deposit Amount: Name on Card: Credit Card Number:_ Expiration : Security Code: New Wave Rep Patient Signature Deposit Returned New Wave Rep Patient Signature Deposited Charged for No Show NewWave Rep Amount Charged

Amber D. Colville, M.D. *Lydia Latour, M.D. * Ashleigh Teates NP-C. AUTHORIZATION TO RELEASE PATIENT MEDICAL INFORMATION I, give the office of Dr. Amber Colville, Dr. Lydia Latour, & Ashleigh Teates NP-C permission to discuss the results of my lab work, other test and/or information concerning my medical history with: I I Spouse Parent Other (name) (name) (name) I do not want information concerning my medical information discussed with anyone. I give permission to leave a message discussing the results of my lab work, other test and/or information concerning my medical history. D Yes n NO Patient Signature

Amber D. Colville, M.D. *Lydia Latour, M.D. * Ashleigh Teates NP-C. NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I understand that, under Health Insurance Portability & 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 lo: Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly or indirectly. Obtain payment from third-party payers. Conduct normal healthcare operations such as quality assessments and physician certifications. I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosure 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 the Notice of Private 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 options. I also understand you are not required to-agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. Print Patient Name: Patient Signature: Relationship to Patient: : OFFICE USE ONLY I attempted to obtain the patient's signature on this Notice of Privacy Practices Acknowledgement, but was not able to do so as documented below: Reason: Employee: :

Amber D. Colville, M.D. *Lydia Latour, M.D. * Ashleigh Teates NP-C. Assignment of Benefits I assign payment to New Wave in accepting this assignment of benefits for all therapy and applicable and otherwise payable to me but not to exceed the reasonable and customary charge for these services rendered by said group. Agreement of Payment I, the undersigned, do hereby understand and agree that I am responsible for all charges to my account. I further understand that all insurance claims are filed as a courtesy by New Wave Internal Medicine Clinic as per the contractual agreement with my insurance carrier and that I am responsible for any unpaid portion of the account balance. I understand that New Wave will allow sixty (60) days for payment to be made by the insurance carrier at which time I may be held responsible for any unpaid portion of the balance. I understand that there will be a $25.00 No Call/No Show fee if the appointment is not cancelled 24hrs before appointment time and/or if I do not show for my scheduled appointment. I understand this fee will be charged to my account and due at the time of next appointment. This will be my financial responsibility and not that of my insurance carrier. If I am not covered by an insurance carrier, I agree that I am responsible for all charges at the time of services are rendered unless financial agreements have been made in advance. Should my account become past due and is transferred to an attorney and/or collection agency, I understand that I will be responsible for all attorney, court and any other associated fees with the collection of this account. Patient/Responsible Party Signature New Wave Employee

Amber D. Colville, M.D. *Lydia Latour, M.D. * Ashleigh Teates NP-C. Please select one of the following: Race: Ethnicity: I I American Indian or Alaska Native ] Asian ] Native Hawaiian or Other Pacific Islander I I Hispanic Latin Non-Hispanic ] Refuse to Disclose Black/African American White ] Hispanic Primary Language: Other ] Refuse to Disclose Please initial each of the following: I consent to the treatment necessary for the care of named patient. I authorize the release and/or fax transmittal of all medical records to the referring and family physicians and to my insurance company. I have read and fully understand the above consent to treatment, release of medical records and financial agreement. Patient Signature

uuv Last Name PATIENT INFO First Name MiddleName/lnitial Street Address City Zipcode Primary Phone Secondary Phone Work Phone Email Address DOB Age Employer Name Sex Social Security # Employer Address Marital Status (Circle One) Single Widowed Married Other Occupation Divorced EMERGENCY CONTACT INFO Emergency Contact Name Relation to Patient Emergency Primary Number Last Name FINANCIAL RESPONSIBILITY n Same As Above First Name Relation to Patient Social Security # DOB Primary Phone Secondary Phone Employer Name Employer Address Occupation PHARMACY INFO Pharmacy Name Pharmacy Address Pharmacy Phone number INSURANCE - Please provide your insurance card(s) to the receptionist Primary - Policy Holder's Name Policy Holder SSN# Insurance Company Policy Holder DOB Street Address City Zipcode Policy Number Group Number Effective Copay Amount Secondary - Policy Holder's Name Policy Holder SSN# Insurance Company Policy Holder DOB Street Address City Zipcode Policy Number Group Number Effective Copay Amount By signing below you agree that all the information provided is correct and unfalsified : Signature:.

Patient Name Address Amber D. Colville, M.D. *tydia Latour, M.D. * Ashleigh Teates NF-C. MEDICAL RECORD RELEASE FORM City Zip DOB / / Social Security # / / Phone Number ( ) / RELEASE RECORDS FROM Physician Name Address City, Phone Number (_ Fax Number ( ) Zip PLEASE SEND THE FOLLOWING RECORDS Office Notes JX-Rays/Radiology Report Labs Complete Medical Record I understand the following: Except for the Psychotherapy notes(which are not included in my medical records), all records of treatment for mental health, chemical dependency, sickle cell anemia, genetic conditions and AIDS/HIV will be released. I do not want these records released (Please list) If I change my mind, 1 will notify the specified clinic to stop the release of these records. This wilt not apply to records that have already been released. This form will expire in one year after I sign, or sooner (specify here ). The time period noted here may exceed one year only in certain situations specified by law. There may be a fee for releasing records. ($1.00 per page) Once records are released, the clinic or hospital releasing my records cannot prevent them from being released to a third party. At that point, the records may no longer be protected by the state and federal privacy laws. This facility will not release any third party records, we will only release records signed and/or ordered by the facility doctors. Signature Authorized Signature :

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