HPW New Patient Registration Form

New Patient Registration Form

HealthPoint Wellness
Name*

First NameMiddle InitialLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Home Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Primary Phone Number

HomeWorkCell
Date of Birth*

MonthDayYear
Social Security #
Referring Doctor
Primary Care Doctor
Employment Status
Employer Name
Marital Status
Preferred Language

Optional Data
Race
Optional
Ethnicity
Optional

Emergency Contact Information
Do you have an Emergency Contact?*

YesNo
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.
Relationship to Patient
ex. Spouse

Medical Insurance Information
Primary Insurance Company*
Policy Holder Name*

SelfOther (List Name)
Policy #*
Group ID*
Policy Holder Date of Birth

MonthDayYear
Patient Relationship to Policy Holder
Do you have Secondary Insurance?*

YesNo
Secondary Insurance Company
Policy Holder Name

SelfOther (List Name)
Secondary Ins. Policy #
Secondary Ins. Group ID
Policy Holder Date of Birth

MonthDayYear
Patient Relationship to Policy Holder

Communication Preferences

These communications may include information such as visit guidelines, appointments, instructions regarding recommendations, and billing information.
Please check one of the options below regarding communication preferences:*

YES, you may share my health information with the individuals listed below:NO, I prefer that the provider or staff speak to only myself, personality, regarding any medical information.
Name

First NameLast Name
Relation

Add Name
Name

First NameLast Name
Relation

Add Name
Name

First NameLast Name
Relation

Message Preferences

These messages may include information such as visit guidelines, appointments, instructions regarding recommendations, and billing information.
Please check one of the options below regarding message preferences:*

YES, you may leave messages on my voicemailNO, please do not leave messages on my voicemail
If yes, choose which locations below:

on Cell Phoneat Homeat Work

Notice of Privacy Practices
EFFECTIVE DATE: Jan 1, 2021

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.

Your health record is the physical property of HealthPoint Wellness LLC. The information contained in the record, however, belongs to you. You have the right to:

A. Request a restriction or limitation on the medical information we use or disclose about you for your treatment, payment or health care operations. For example, you may request that a particular procedure be kept confidential and not shared with other providers. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment of your care, like a family member or friend or when we notify a family member, personal representative or other person responsible for your care to inform them of your location and general condition. We are not required to agree to your requested restrictions. If we disagree, we will comply with your request unless the information is needed to provide you emergency treatment.

B. Obtain a copy of this Notice by requesting one from HealthPoint Wellness LLC.

C. Inspect and obtain a copy of your health care record by submitting a request in writing to HealthPoint Wellness LLC.

D. Amend your healthcare record if you feel that medical information that we have about you is incorrect or incomplete by requesting, in writing, that an amendment be made. You must provide a reason that supports your request.

E. Obtain a report of all of the disclosures of your health information that we have made.

F. Request that we communicate with you about your medical information in a certain way or at a certain location within reasonable time limits.

G. Revoke your authorization to use and disclose medical information about you, except to the extent that we already used or disclosed your medical information.

OUR RESPONSIBILITES REGARDING YOUR MEDICAL INFORMATION

We are required by law to:

A. Maintain the privacy of your health information.

B. Provide you with this Notice, which describes our legal duties and privacy practices with respect to information we collect about you and a revised copy of the Notice if it is amended or otherwise changes.

C. Abide by the terms of this Notice.

D. Notify you if we are unable to agree to a requested restriction.

E. Accommodate reasonable requests that you have made to have us communicate your health information to you in a certain way or at a certain location.

WE RESERVE THE RIGHT TO CHANGE THIS NOTICE. We reserve the right to make the revised and changed notice effective for medical information that we already have about you, as well as any information we receive in the future. We will post a copy of the current notice in the HealthPoint Wellness LLC office. The notice will contain the effective date on the first page. Each time you register at HealthPoint Wellness LLC for health care services, we will offer you a copy of the current Notice in effect.

Patient Consent, Acknowledgment, & Authorization Form
RELEASE OF MEDICAL RECORD:
In order to ensure proper follow-up and continuity of care, I hereby authorize all physicians, hospitals and other medical facilities to release to HealthPoint Wellness LLC, my medical history, laboratory reports, x-rays, films, and any other material regarding medical consultations I received.

INSURANCE AUTHORIZATION/ASSIGNMENT RELEASE:
I request that payment of authorized medical benefits be made to HealthPoint Wellness LLC for any services provided to me. This assignment of benefits includes Medicare, state medical assisted agency programs, commercial insurance, managed care plans, and any third party payer benefits that I may have. I authorize the use of this signature on all my insurance claim submissions.

I authorize any holder of medical and other information about me to release to Medicare and its agents, any insurance company, any third party payer, state medical assistance agency, or any other governmental or private payer responsible for paying such benefits, any information required to determine these benefits for related services.

I authorize a copy of this authorization to be used in place of the original.

FINANCIAL RESPONSIBILITY:
I am responsible for all the financial obligations of health services, and for the reimbursement and payment of claims from my insurance company. I understand that I am responsible for any amount not covered by insurance. I also understand that if a payment becomes more than 90 days past due, I will be responsible for the balance due on my account as well as any and all reasonable attorney fees and costs of collections in the event of default.

ELECTRONIC HEALTH RECORD ACCESS/COMMUNICATION INFORMED CONSENT:
I hereby request access to HealthPoint Wellness LLC's Patient Portal and understand that in order to gain access to HealthPoint Wellness Patient Portal I will be given a confidential password. I agree to keep it confidential and not share it with anyone else. I understand that my use of HealthPoint Wellness Patient Portal is subject to certain terms and conditions. I agree to review HealthPoint Wellness Patient Portal terms and conditions before accessing HealthPoint Wellness Patient Portal and further agree that by accessing HealthPoint Wellness Patient Portal I am agreeing to abide by the HealthPoint Wellness Patient Portal terms and conditions.

I agree to abide by the guidelines for the HealthPoint Wellness Patient Portal electronic communication, as outlined below. HealthPoint Wellness Patient Portal is not intended for critical or time sensitive communication. I understand that I am to contact the hospital, office, or physician directly for any urgent or emergent situations. My failure to adhere to the following guidelines may result in termination of the HealthPoint Wellness Patient Portal access. When using HealthPoint Wellness Patient Portal I agree to never use HealthPoint Wellness Patient Portal to communicate information related to behavioral/mental health, chemical dependence, such as alcohol and substance abuse or workers’ compensation injuries or disabilities.

I understand that the hospital, office, or provider or a designated staff member will maintain certain activities with HealthPoint Wellness Patient Portal as part of the practice medical record, use reasonable and appropriate security practices to protect electronic patient information and prevent unauthorized access (password protection, encryption, proxy authorizations, etc.) and share HealthPoint Wellness Patient Portal communications with hospital or office staff and other healthcare providers as needed.

I understand that e-mail is not a confidential means of communication. I agree to waive any rights that I may have against HealthPoint Wellness LLC, any affiliated organization, or physician, or the supplier or operator of HealthPoint Wellness Patient Portal, for any loss of information due to technical failures and/or unintended breach of confidentiality, due to unauthorized access to my information, as a result of my decision to communicate with my physician in this manner.

VISIT CONSENT/RELEASE:
I understand that this wellness visit is designed to determine preventive health recommendations only, and is not an examination to detect and/or treat any health issues or diseases. I further understand, it is my responsibility, and at my own discretion, whether to follow-up on any health recommendations that were provided by HealthPoint Wellness LLC and I hereby release HealthPoint Wellness LLC, as well as their staff, from any, and all liability, which may arise from my failure to seek necessary healthcare, regular or otherwise.

CONCIERGE CONSENT & AUTHORIZATION:
I authorize HealthPoint Wellness and its providers to disclose necessary protected health information to affiliated institutions in order to provide health concierge/navigator services or accommodate other applicable healthcare orders. This includes, but is not limited to, demographics, visit notes, medical records, wellness guidelines, and health history. Additionally, by signing this form, I allow the Health and Wellness Concierge/Navigator or affiliated personnel to contact me in the future by phone, text, email, and/or mail regarding my wellness visit recommendations.

RECEIPT OF NOTICE OF PRIVACY PRACTICES:
I have received the Notice of Privacy Practices from HealthPoint Wellness LLC.
Check the boxes below to confirm your agreement and authorizations to corresponding documents.*

I have read and understand the Notice of Privacy PracticesI have read and agree to the terms presented in the Patient Consent, Acknowledgment, & Authorization Form
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

New Patient Registration Form

Optional Data

Emergency Contact Information

Medical Insurance Information

Communication Preferences

Message Preferences

Notice of Privacy Practices

Patient Consent, Acknowledgment, & Authorization Form