1. New Patient Packet

Community Family Practice, PA - New Patient & Information Change Form
Patient Information-use full legal name
Date ______________________________
Last Name____________________________ First Name ______________________________ Middle Initial _______
Address ________________________________________________________________________________________
City ________________________________________ State ___________ Zip_______________________
Home Phone ________________________________ Cell Phone __________________________________________
Date of Birth __________________________
Age ________ Sex ______________
Marital Status __________
Pharmacy Name & Location:_______________________________________________________________________
Employer Name __________________________________________ Work Phone ___________________________
SS# ___________________________ Email Address ____________________________ DL#__________________
Emergency Contact Name ____________________________________Emer Contact Phone ___________________
Please tell us how you heard about us
Guarantor Information-Complete this section if patient is child under 18 or insurance is
through your spouse/partner
Relationship to patient:
Spouse_____________
Parent ____________ Other___________
Last Name____________________________ First Name ______________________________ Middle Initial _______
Address ________________________________________________________________________________________
City ___________________________________ State _______________ Zip __________________
Children under 18, mothers maiden name __________________________________________________________
Home Phone ________________________________ Cell Phone __________________________________________
Date of Birth ______________________ Age ________ Sex ________ SS# _______________________________
Employer Name
Work Phone
Insurance Information
Primary Insurance Name ____________________________________________ Insured Name _____________________________________
Policy Number _______________________________________ Group # _______________________ Effective Date ___________________
Claim Address & Phone Number ______________________________________________________________________________________
Secondary Insurance Name ___________________________________________ Insured Name ___________________________________
Policy Number _______________________________________ Group # _______________________ Effective Date ___________________
Claim Address & Phone Number
Patient Privacy Directive
OK to leave message at home Yes___ No____
Person(s) who may have access to my medical information:
Name _________________________________ Relationship _______________________ Phone _________________
Name
Relationship
Phone
**Please read & sign back of form***
PATIENT REGISTRATION FORM
DISCLOSURES & CONSENTS
Patient Name: ___________________________________________________________ Date of Birth: _______________________
First Name
M.I.
Last Name
ASSIGNMENT OF INSURANCE BENEFITS:
I hereby authorize direct payment of my insurance benefits to MedicalEdge Healthcare Group or the physician individually for
services rendered to my dependents or me by the physician or under his/her supervision. I understand that it is my responsibility to
know my insurance benefits and whether or not the services I am to receive are a covered benefit. I understand and agree that I will
be responsible for any co-pay or balance due that MedicalEdge is unable to collect from my insurance carrier for whatever reason.
MEDICARE/MEDICAID/CHAMPUS INSURANCE BENEFITS:
I certify that the information given by me in applying for payment under these programs is correct. I authorize the release of any of
my or my dependent’s records that these programs may request. I hereby direct that payment of my or my dependent’s authorized
benefits be made directly to MedicalEdge Healthcare Group or the physician on my behalf.
AUTHORIZATION TO RELEASE NON-PUBLIC PERSONAL INFORMATION:
I certify that I have received and read a copy of the MedicalEdge Healthcare Group Patient Information Privacy Policy. I hereby
authorize MedicalEdge Healthcare Group or the physician individually to release any of my or my dependent’s medical or incidental
non-public personal information that may be necessary for medical evaluation, treatment, consultation, or the processing of
insurance benefits.
AUTHORIZATION TO MAIL, CALL OR E-MAIL:
I certify that I understand the privacy risks of the mail, phone calls, and e-mail. I hereby authorize a MedicalEdge Healthcare Group
representative or my physician to mail, call or e-mail me with communications regarding my healthcare, including but not limited to
such things as appointment reminders, referral arrangements, and laboratory results. I understand that I have the right to rescind
this authorization at any time by notifying MedicalEdge Healthcare Group to that effect in writing.
LAB/X-RAY/DIAGNOSTIC SREVICES:
I understand that I may receive a separate bill if my medical care includes lab, x-ray, or other diagnostic services. I further
understand that I am financially responsible for any co-pay or balance due for these services if they are not reimbursed by my
insurance for whatever reason.
CONSENT TO TREATMENT:
I hereby consent to evaluation, testing, and treatment as directed by my MedicalEdge physician or his or her designee.
PATIENT SIGNATURE: _____________________________________________________________ DATE: ______________________
GUARANTOR SIGNATURE: _________________________________________________________ DATE: ______________________
(If different from patient)
GUARANTOR NAME (Please Print): _______________________________________________________________________________
Confidential Proprietary Information
New Pt Reg Form Dec 2004
Community Family Practice, PA
Authorization for Release of Information – Compound Release
Name of Patient ________________________________________________
Date of Birth ______________
Community Family Practice, PA is authorized to release protected health information about the above named patient in the
following manner and to identified persons.
Entity to Receive Information.
Check each person/entity that you approve to receive information.
Description of information to be released. Check each that can be
given to person/entity on the left in the same section.
o Voice Mail
o Spouse: _____________________________
o Parent: ______________________________
o Other:
o Results of lab tests/x-rays
o Financial
o Medical
o Appointment reminders
o Breach notification
o Other_______________________________
o Text communication – Provide number *
o Appointment reminder
o Patient Portal Notifications
o Other: ____________________________________
____________________________________
*For text communication to occur, accept the disclosure below:
o For text communication I understand that if information is not sent in an encrypted manner there is a risk it could be accessed
inappropriately. I still elect to receive text communication as selected.
o Photo of patient received from patient or legal guardian o May be posted in office
o Photo taken by staff (Example: pre/post procedure)
o May be posted on website
o Other
o Other________________________________
Patient Rights:
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I have the right to revoke this authorization at any time.
I may inspect or copy the protected health information to be disclosed as described in this document.
Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be
protected by federal or state law.
I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.
This authorization will remain in effect until revoked by the patient.
_________________________________________________________ Date ___________________
Signature of Patient or Personal Representative
*Description of Personal Representative’s Authority (attach necessary documentation)
__________________________________________________________________________________
Revised August 2015
HIPAA Notice of Privacy Practices
Community Family Practice, PA
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Uses and Disclosures
Treatment. Your health information may be used by staff members or disclosed to other health care professionals
for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example,
results of laboratory tests and procedures will be available in your medical record to all health professionals who
may provide treatment or who may be consulted by staff members.
Payment. Your health information may be used to seek payment from your health plan, from other sources of
coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For
example, your health plan may request and receive information on dates of service, the services provided, and the
medical condition being treated.
Health Care Operations. Your health information may be used as necessary to support the day-to-day activities
and management of [name of practice]. For example, information on the services you received may be used to
support budgeting and financial reporting, and activities to evaluate and promote quality.
Law Enforcement. Your health information may be disclosed to law enforcement agencies who support
government audits and inspections, to facilitate law-enforcement investigations, and to comply with governmentmandated reporting.
Public Health Reporting. Your health information may be disclosed to public health agencies as required by law.
For example, we are required to report certain communicable diseases to the state’s public health department.
Research
Provider may disclose your medical information to people preparing to conduct a research project (for example, to
help them look for patients with specific medical needs) so long as the medical information they review is not
removed from the premises of this practice. Provider may also disclose the medical information of decedents for a
research project, so long as the information is necessary for the research.
Other uses and disclosures require your authorization. Disclosure of your health information or its use for any
purpose other than those listed above requires your specific written authorization. If you change your mind after
authorizing a use or disclosure of your information you may submit a written revocation of the authorization.
However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that
occurred before you notified us of your decision to revoke your authorization.
Additional Uses of Information
Appointment Reminders. Your health information may be used by our staff to send you appointment reminders. If
you would like this office to communicate your health information to you in a confidential manner, please indicate
your wishes on the ‘Acknowledgement of Receipt of HIPAA Notice of Privacy Practices’ form.
Information about treatments. Your health information may be used to send you information that you may find
interesting on the treatment and management of your medical condition. We may also send you information
describing other health-related products and services that we believe may interest you.
Individual Rights
You have certain rights under the federal privacy standards. These include:
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The right to request restrictions on the use and disclosure of your protected health information;
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HIPAA Notice of Privacy Practices
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The right to request restrictions on disclosure to a health plan if you paid out of pocket, in full, for
items or services;
The right to receive confidential communications concerning your medical condition and treatment;
The right to inspect and copy your protected health information;
The right to amend or submit corrections to your protected health information;
The right to receive an accounting of how and to whom your protected health information has been
disclosed; &
The right to receive a printed copy of this notice.
Practice Duties
We are required by law to maintain the privacy of your protected health information and to provide you with this
“Notice of Privacy Practices”.
We are also required to abide by the privacy policies and practices that are outlined in this notice.
Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in
our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we
will provide you with the most recently revised notice on any office visit. The revised policies and practices will be
applied to all protected health information we maintain.
Requests to Inspect Protected Health Information
You may generally inspect or copy the protected health information that we maintain. You have the right to access
your protected health information in electronic format where it is available. As permitted by federal regulation, we
require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form
to request access to your records by contacting this practice. Your request will be reviewed and will generally be
approved unless there are legal or medical reasons to deny the request.
Complaints
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter or
placing a call outlining your concerns to:
HIPAA Privacy Officer
PhyServe, Inc. on behalf of MedicalEdge Healthcare Group, P.A.
9229 LBJ Freeway
Dallas, TX 75243
(972) 792-3803
If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a
letter describing the cause of your concern to the same address. You may also submit complaints to the Secretary of
Health and Human Services.
You will not be penalized or otherwise retaliated against for filing a complaint.
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Payment Policy
Thank you for choosing us as your primary care provider. We are committed to providing you
with quality and affordable health care. Because some of our patients have had questions
regarding patient and insurance responsibility for services rendered, we have been advised to
develop this payment policy. Please read it, ask us any questions you may have, and sign in the
space provided. A copy will be provided to you upon request.
1. Insurance. We participate in most insurance plans, including Medicare. If you are not
insured by a plan we do business with, payment in full is expected at each visit. If you are
insured by a plan we do business with, but do not have an up-to-date insurance card,
payment in full for each visit is required until we can verify your coverage. Knowing your
insurance benefits is your responsibility. Please contact your insurance company with any
questions you may have regarding your coverage.
2. Co-payments and deductibles. All co-payments and deductibles must be paid at the time of
service. This arrangement is part of your contract with your insurance company. Please
help us by paying your co-payment at each visit.
3. Non-covered services. Please be aware that some – and perhaps all – of the services you
receive may be non-covered or not considered reasonable or necessary by Medicare or
other insurers. You must pay for these services in full at the time of visit.
4. Proof of insurance. All patients must complete our patient information form before seeing
the doctor. We must obtain a copy of your driver’s license and current valid insurance to
provide proof of insurance. If you fail to provide us with the correct insurance information
in a timely manner, you may be responsible for the balance of a claim.
5. Claims submission. We will submit your claims and assist you in any way we reasonably can
to help get your claims paid. Your insurance company may need you to supply certain
information directly. It is your responsibility to comply with their request. 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.
6. Coverage changes. If your insurance changes, please notify us before your next visit so we
can make the appropriate changes to help you receive your maximum benefits. If your
insurance company does not pay your claim in 45 days, the balance will automatically be
260 Merrimon Avenue, Suite 200
Asheville, North Carolina 28801
Phone (828) 254-2444
Fax (828) 254-0660
billed to you.
7. Nonpayment. If your account is over 60 days past due, you will receive a letter stating that
you have 30 days to pay your account in full. Partial payments will not be accepted unless
otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your
account to a collection agency and you will be discharged from this practice. If this is to
occur, you will be notified by regular mail that you have 30 days to find alternative medical
care. During that 30-day period, our physician will only be able to treat you on an
emergency basis.
8. Missed appointments. Our policy is to charge $20.00 for missed appointments not canceled
within a reasonable amount of time. These charges will be your responsibility and billed
directly to you. Please help us to serve you better by keeping your regularly scheduled
appointment.
Our practice is committed to providing the best treatment to our patients. Our prices are
representative of the usual and customary charges for our area.
Thank you for understanding our payment policy. Please let us know if you have any questions
or concerns.
I have read and understand the payment policy and agree to abide by its guidelines:
______________________________________
Signature of Patient or Responsible Party
260 Merrimon Avenue, Suite 200
Asheville, North Carolina 28801
______________________
Date
Phone (828) 254-2444
Fax (828) 254-0660
Thepatientportalisasecurewebportalthatallowsyouasapatienttoaccessmedical
recordsviatheinternet.Thisisnotmandatoryforourpatients,butisanoptionalservicethat
weoffer.Westrivetokeepalloftheinformationinyourrecordscorrectandcomplete.Ifyouidentify
anydiscrepancyonyourrecord,youagreetonotifyusimmediately.Additionally,byusingthePatient
Portal,theuseragreestoprovidefactualandcorrectinformation.
ThePatientPortalcanprovidethefollowingservices:
1. Medicationrefillrequest.
2. Communicationoflaboratoryresultsfromstafftopatient.
3. Reviewapatient’smedicalsummary,medicationlist,treatmenthistoryandvisitationdates.
4. Limitedcommunicationregardingongoingtreatment.
ThePatientPortalisprovidedasacourtesytoourvaluedpatients.Whilesomeofficeschargeforthis
convenienceonanannualbasis,wearefocusedonprovidingthehighestlevelofserviceandhealth
care.However,ifabuseornegligentusageofPatientPortalpersists,wereservetherightatourown
discretiontoterminatePatientPortaloffering,suspenduseraccessormodifyservicesofferedthrough
thePatientPortal.
IfyouareinterestedinparticipatinginthePortal,pleasereadthefollowingpolicy
carefullyandsignatthebottomofthepage:
1. Weareofferingthepatientportalasaconveniencetoyouatnocost.Wedonot
sellorgiveawayanyprivateinformation,includingemailaddresses,withoutyour
writtenconsent.
2. Pleasenotethattheportalisnotcheckedorupdatedonweekends.
3. Wedonotrefillcontrolledsubstancesovertheportal.
4. Ifyoufindyouarenotreceivingemailsfromus,pleasecheckyourJUNKemail
folderbeforecontactingus.
5. Byusingthispatientportal,youagreetoprotectyourpasswordfromany
unauthorizedindividuals.Itisyourresponsibilitytonotifyusshouldyourpassword
bestolen.YouagreetonotholdCommunityFamilyPracticeresponsibleforanynetwork
infractionsbeyondourcontrol.
Yoursignaturebelowconfirmsthatyouhavereadandfullyunderstandourpoliciesfor
onlinecommunicationandwishtoparticipateinourpatientportal.
Name_____________________________________________
Emailaddress____________________________________________________
Signature_______________________________________Date________________