NEW PATIENT PAPERWORK

PATIENT INFORMATION
Patient Name *
Date of Birth *

Month Day Year
Date
Social Security # *
_ _ _ - _ _ - _ _ _ _
IF PATIENT IS A MINOR, Parent(s) or Legal Guardian Name:

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mobile Number *

Area Code Phone Number
Home Number

Area Code Phone Number
Office Number

Area Code Phone Number
Email *
example@example.com
Marital Status:

Single Married Divorced Widowed
Sex

Male Female
How did you hear about Michael O. LaGrone, MD,

Referral Friends/Family:

INSURANCE INFORMATION

A copy of your insurance card(s) is required prior to your appointment.
Primary Insurance Company: *
Secondary Insurance Company:
Address:
Address:
Phone Number *

Area Code Phone Number
Phone Number

Area Code Phone Number
Subscriber Name: *
Subscriber Name:
Subscriber Employer: *
Subscriber Employer:
Relationship to Patient: *
Relationship to Patient:
Subscriber DOB: *
Subscriber DOB:
Subscriber SS#: *
Subscriber SS#:
ID #: *
ID #:
Group #: *
Group #:
Referral #:
If Applicable
Referral #:
If Applicable
Primary Insurance Card Front

Browse Files

Cancel of
Secondary Insurance Card Front

Browse Files

Cancel of
Primary Insurance Card Back

Browse Files

Cancel of
Secondary Insurance Card Back

Browse Files

Cancel of
Is this visit related to any type of on the job, motor vehicle, or third party accident? *

Yes No
If so, what kind of accident?
Date of accident:

Month Day Year
Date
I hereby authorize the release of requested medical information and/or records to my primary care physician, insurance company, third party review organization, peer review physician, employer or their representatives. I understand that I am responsible for all charges not paid by my insurance company, subject to any contractual limitations between my physician and insurance company or managed care network. I understand that I am responsible for promptly responding to my insurance company to provide any additional information they may request regarding my treatment, pre-existing conditions, accidents or other insurance coverage. Failure to respond in a timely manner may result in my account becoming due and payable, in full, immediately. I will be prepared to present my insurance card and proof of identity (e.g. driver's license) at each visit. I will provide a change of address, telephone number and / or insurance information any time a change occurs.
Signature of Patient, Parent, or Legal Guardian *

Clear
Date *

Month Day Year
Date

PATIENT CONSENT TO TREATMENT
I hereby authorize Michael O. LaGrone, M.D. to render medical evaluations and care to the patient indicated below. I further consent to the performance of any diagnostic procedures, examinations and rending of medical treatments by Michael O. LaGrone, M.D. or his designee as is necessary in the medical staff’s judgment. I understand that the practice of medicine and surgery is not an exact science and acknowledges that no guarantee have been or will be made regarding the results of examinations or treatments in this clinic.
The duration of this consent is indefinite and continues until revoked in writing. I understand that by not signing this consent, the patient will not be provided medical care except in a case of emergency.

The duration of this consent is indefinite and continues until revoked in writing. I understand that by not signing this consent, the patient will not be provided medical care except in a case of emergency.
Patient Name

First Name Last Name
Signature of Patient, Parent, or Legal Guardian *

Clear
Date *

Month Day Year
Date

FINANCIAL POLICY
We are committed to providing you with the best possible care. Since payment of your bill is part of your treatment, we want you to be sure that our financial policies are clearly understood before we begin treatment.

We participate with most insurance plans, but it is your responsibility to call your insurance company to determine whether or not we participate with your particular plan. Please be prepared to provide your insurance card at every visit. Also, tell us if there is a change in your address, telephone number, or insurance coverage at the time of your visit. If your coverage has been terminated prior to your visit with our office, you are responsible for all of the charges incurred. All co-payments and fees are due when services are rendered. We cannot waive your co-payment, as this is an agreement between you and your insurance company. It is your responsibility to know your insurance policy requirements, such as co-payments and deductibles. We will not become involved in disputes between you and your insurance company regarding deductibles or co-payments. This office only files claims with contracted insurance carriers up to three (3) times. If your insurance company has not paid in full, the balance due may become your responsibility. If you do not have insurance, we require full payment at the time of service.

There will be a $25 no-show charge to all patients who do not give 24-hour notice of cancellation. Insurance companies do not cover this charge. If you do not show or do not cancel, this fee will be your responsibility. Anyone with a no-show fee must pay on or before your next visit in order to see one of our providers.

In the event you require an MRI or surgical procedure, a deposit will be required prior to the date of service. Our billing department will contact you once we have verified your deductible, co-payment, and/or co-insurance amounts due for your planned surgical procedure. Our practice will collect the full amount of your expected patient liability prior to your planned surgery. Failure to pay these fees can result in rescheduling or cancellation of your surgery. Please note; our fees are separate from the hospital and the anesthesiologist.

We accept cash, checks, Visa, MasterCard, Discover and American Express. There is a $25 charge for all returned checks. If overpayment occurs, we will credit your account and you may request a refund, as long as there are no other balances owed. Refunds are processed monthly and sent to the original payer in check format only.

There is a $25 charge for completion and release of forms for third party forms, including but not limited to disability and FMLA. Form services must be paid in full prior to completion. Patients requesting copies of medical records will be required to pay a $25 fee for copying medical records and x-rays. Images can be burned on a disc for an additional $10.

I have read, understand, and agree to the above financial policy. I understand that charges not covered by my insurance company, as well as applicable co-payments and deductibles, are my responsibility. I understand that it is my responsibility to contact my insurance carrier(s) if they do not respond to payment requests made on my behalf.
Signature of Patient, Parent, or Legal Guardian *

Clear
Date *

Month Day Year
Date

PATIENT RESPONSIBILITY AGREEMENT FOR CONTROLLED SUBSTANCE PRESCRIPTIONS
Controlled substance medications (i.e., narcotics, tranquilizers and barbiturates) are very useful, but have a high potential for misuse and are, therefore, closely controlled by local, state and federal governments. They are intended to relieve pain, thus improving function and/or ability to work. Our providers are dedicated to restoring functional use in an efficient and functional manner.

You are responsible for the controlled substance medications prescribed to you. This includes safeguarding the medication from other family members and ensuring it is out of the reach of children. If your prescription is lost, misplaced, stolen or if you “run out early”, please understand that medication will not be replaced. Refills will not be made if you “run out early”, “lose a prescription”, or “spill or misplace” your medication. You are responsible for taking the medication in the dose prescribed and for keeping track of the amount remaining.

Driving a motor vehicle may not be allowed while taking controlled substance medications and it is your responsibility to comply with the laws of the state while taking the prescribed medications.

Refills of controlled substance medications will only be made only during regular office hours, Monday through Friday. Refills will not be made at night, on weekends, or during holidays. Refills will not be made as an “emergency” such as on Friday afternoon because you suddenly realize you will run out tomorrow. You must call at least 24 hours ahead if you need assistance with a refill.

Michael O. LaGrone, M.D. is not a chronic pain specialists. Narcotic medications are prescribed only for acute pain or for post-surgical pain and then only for a limited time. If you require long-term narcotic medication, you will be referred to or consult with a pain specialist or your primary care physician.

If you violate any of the above conditions, your prescription for controlled substance medications may be terminated immediately. If you are involved in obtaining controlled substance medications from another individual, forging or altering a controlled substance prescription, or using non-prescribed illicit (illegal) drugs, your prescription for controlled substance medications will be terminated immediately and you may also be reported to all of your physicians, medical facilities, and appropriate authorities.

All prescriptions for controlled substance are to be filled at the same pharmacy (provided below) by only one physician. You are required to notify our office of any changes.
Pharmacy Name *
Pharmacy Phone Number *

Area Code Phone Number

Pharmacy Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

I have read this contract and I fully understand the consequences of violating this agreement.
Patient Name (please print)
Signature of Patient, Parent, or Legal Guardian *

Clear
Date *

Month Day Year
Date

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE
The Health Insurance Portability and Accountability Act (HIPAA) is a federal government regulation designed to ensure that you are aware of your privacy rights and of how your medical information can be used by our staff in providing and arranging your medical care.

By signing below, you acknowledge that you have received the attached Notice of Privacy Practices prior to any service being provided to you by the office of Michael O. LaGrone, M.D, P.A., and you consent to the use and disclosure of your medical information as set forth herein except as expressly stated below.

Download a copy Michael O. LaGrone, MD, PA NOPP

I hereby request the following restrictions on the use and/or disclosure (specify as applicable) of my information:
Patient Name: *
Patient Date of Birth: *

Month Day Year
Date
Signature of Patient, Parent, or Legal Guardian *

Clear
Date: *

Month Day Year
Date
If Legal Representative, relationship to Patient:

PATIENT PERMISSION FOR RECORD DISCLOSURE
I hereby give permission to Michael O. LaGrone, M.D., P.A. to disclose and discuss any information related to my medical and financial condition(s) to/with the following:
Name

First Name Last Name
Relationship to Patient
Phone Number

Area Code Phone Number
Name

First Name Last Name
Relationship to Patient
Phone Number

Area Code Phone Number
The duration of this authorization is indefinite unless otherwise revoked in writing. I understand that requests for medical information from persons not listed above will require a specific authorization prior to the disclosure of any medical information.
Signature of Patient, Parent or Legal Guardian

Clear
Date

Month Day Year
Date

PATIENT INFORMATION

INSURANCE INFORMATION

PATIENT CONSENT TO TREATMENT

FINANCIAL POLICY

PATIENT RESPONSIBILITY AGREEMENT FOR CONTROLLED SUBSTANCE PRESCRIPTIONS

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

PATIENT PERMISSION FOR RECORD DISCLOSURE

NEW PATIENT/NEW COMPLAINT HISTORY FORM

Conservative Treatments:

Present and Past Medical History:

Review of Systems: