NEW Patient History Form for the new website

New Patient Registration

Austin Medical Group, PLLC.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Social Security Number
Email
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Marital Status *

Single Married Divorced Widowed Partner
Home Phone Number *

Area Code Phone Number
Cell Phone Number *

Area Code Phone Number
Primary Insurance Information

Insurance Policy Name

Street Address

City State / Province

Postal / Zip Code
Policy Holder Date of Birth

Month Day Year
Date
Policy Number
Group Number
Relationship to Policy Holder
Secondary Insurance Information

Insurance Policy Name

Street Address

City State / Province

Postal / Zip Code
Policy Holder Date of Birth

Month Day Year
Date
Policy Number
Group Number
Relationship to Policy Holder
Pharmacy Information *

Pharmacy Name

Street Address Line 2

City State / Province

Postal / Zip Code
Pharmacy Information *

Pharmacy Name

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number
Emergency Contact Information *

Name of Emergency Contact

Street Address

City State / Province

Postal / Zip Code
Home Phone Number

Area Code Phone Number
Cell Phone Number *

Area Code Phone Number
Relationship to Patient *

BILLING AND COLLECTION POLICY

Any invoices received from our office are due immediately upon receipt. If for any reason you cannot pay the bill in full, we ask that you contact our billing office to set up a payment plan. An interest rate of 1.5% per month may apply to any invoice over 30 days old. If you fail to respond to the bill or fail to cooperate with the terms of your payment plan, your account may be turned over to an outside agency for resolution. If this occurs, you agree to be legally responsible for any and all collection fees which include, but are not limited to, a 33% agency fee (an additional 33% of what you owe) along with any and all attorney and/or court fees.

To avoid problems due to delayed mail, it is your responsibility to notify our office of any changes in your name, address, phone number or insurance coverage.

CREDIT POLICY

We do not offer in-house payment plans for deductibles. All deductibles must be paid in full at the time of service. We accept cash, check, Visa and MasterCard. There is a $35 fee for any returned check.
Signature *

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LATE ARRIVALS, CANCELLATIONS, AND MISSED APPOINTMENTS POLICY

Late arrivals: If you arrive late for a scheduled appointment, you may be asked to reschedule your appointment or wait for an open appointment time on the day's schedule

Cancellations: If you are unable to keep a scheduled appointment, you must call at least two (2) business day's in advance or we may consider you a "no-show."

No-shows: If you miss your appointment, you will be charged $50 fee for a missed appointment, $100.00 fee for missed preventative/wellness/new patient appointment, or a $200.00 fee for a missed procedure/surgery/allergy test. This fee will need to be paid before you are allowed to schedule another appointment. This fee cannot be billed to insurance.

MEDICAL RECORDS AND FORMS

A form to request transfer of your medical records to our clinic is available on our website. To send your records from our clinic to another physician, we need a written request from you. We require an appointment for completion of forms (FMLA, insurance screening, prior authorizations, etc). If forms are sent or dropped off at our office to be completed on your behalf, a fee of $25 will be due before the form can be processed. You should allow at least 7 days for completion of any forms.
Signature *

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PRESCRIPTION REFILLS AND PREAUTHORIZATIONS

Prescriptions are typically given at office visits with enough refills to last until your next follow-up visit. You should inform the medical assistant at the BEGINNING of your visit about any refills you need. Please make sure that the pharmacy on file for you is correct. In the event that a refill is needed sooner, you should contact your pharmacy so the refill can be requested electronically. If your insurance company requires a preauthorization for your medication, you can discuss options for a different medication with your pharmacist or insurance and have them contact us to request a change. We do not have access to your insurance company formulary (list of approved medications). If there is paperwork to be filled out, you may be required to be seen at a regular office visit so the appropriate documentation can be sent to your insurance.

CONTROLLED SUBSTANCE POLICY

Controlled substances include narcotic pain medications, some anti-anxiety medications, attention-deficit medications, and some sleep medications. These medications can be habit-forming if misused and extremely dangerous/lethal when combined with certain other medications.

The physicians at Austin Medical Group do not prescribe chronic pain medications. If your condition warrants repeated use of pain medications, you will be referred to a Pain Management Specialist.

The physicians at Austin Medical Group do not prescribe benzodiazepines (anxiety meds) for long-term use. If your condition warrants repeated use of such medications, you will be referred to a Psychiatrist.

Refills for these controlled substances are subject to a $10 administrative fee if there is no office visit at the time the refill is being picked up. Patients prescribed controlled substances agree to urine drug screening on an annual basis; additional urine drug screens may be required at the prescribing physician’s discretion.
Signature *

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DateTime

Frequently asked Questions regarding HIPAA
In a constantly changing healthcare environment, AUSTIN MEDICAL GROUP is committed to educating their patients about healthcare issues that affect them. As a result, they have provided general information about the Health Insurance Portability and Accountability Act (HIPAA) of 1996 for your review. AUSTIN MEDICAL GROUP is complying with HIPAA regulations and will be happy to answer any additional questions you might have.

WHAT IS THE PRIVACY RULE?

The Privacy Rule is part of the HIPAA regulation of 1996. The Privacy Rule establishes a federal requirement that doctors, hospitals or other healthcare providers and health plans obtain a patient’s written consent before using or disclosing a patient’s personal information to carry out treatment, payment or other healthcare operations.

WHAT IS PROTECTED HEALTH INFORMATION (PHI)?

Protected health information (PHI) means any personal health information as defined by law, including demographic information collected by a healthcare provider or other entity that could potentially identify the individual. PHI includes all medical records and other individually identifiable health information held or disclosed by AUSTIN MEDICAL GROUP regardless of how it is communicated (e.g. electronically, written, or verbally.)

WHAT IS TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS (TPO)?

TPO refers to the treatment, payment or healthcare operations of AUSTIN MEDICAL GROUP. In other words, quality patient care; ensure that the physician is paid for services; and, operate the business. Some examples of these activities are the use of PHI by the physician and clinical staff to treat a patient; Use of PHI by administrative staff for strategic planning and internal management activities.

WHY DO I HAVE TO SIGN A CONSENT FORM?

In order to use or disclose your PHI, AUSTIN MEDICAL GROUP is required to obtain a signed consent form from you to directly treat you or carry out healthcare payment and business-related activities. AUSTIN MEDICAL GROUP is not required to obtain your prior consent in an Emergency, when AUSTIN MEDICAL GROUP is required by law to treat you, or when there are substantial communicable barriers. AUSTIN MEDICAL GROUP reserves the right to refuse to treat you if you do not sign the consent form.

WHAT IS THE DIFFERENCE BETWEEN CONSENT AND AUTHORIZATION FORMS?

In order to use or disclose your PHI for specific purposes, other than direct treatment, payment, or healthcare operations, AUSTIN MEDICAL GROUP is required to obtain a signed authorization form from you. For example, if you request AUSTIN MEDICAL GROUP to disclose PHI to a third party, you must sign an authorization form. This authorization form is more detailed than a consent form and has a specific expiration date.

Patient Receipt of "Notices of Privacy Practices"
AUSTIN MEDICAL GROUP has provided information regarding the NOTICE OF PRIVACY PRACTICES. This notice describes the practice’s commitment to privacy, my rights to privacy and how AUSTIN MEDICAL GROUP may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations.

By signing this form, I am acknowledging that I have reviewed the NOTICE OF PRIVACY PRACTICES which explains how my medical and personal information will be used and disclosed, I understand that I am entitled to receive a copy of this document upon request.
Signature *

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DateTime
Should be Empty:

	Mother	Father	Sister	Brother	Maternal Grandmother	Maternal Grandfather	Paternal Grandmother	Paternal Grandfather
Deceased ?
Stroke
Blood Clot
Cancer (Type)
Heart Problems
Diabetes
High Blood Pressure
High Cholesterol
Lung Problems
Thyroid Problems
Other
NO KNOWN HISTORY

New Patient Registration

Patient History Form

Frequently asked Questions regarding HIPAA

Patient Receipt of "Notices of Privacy Practices"