New Patient Packet

New Patient Packet

Pediatrics
Personal Information
Patient Name

First Name Last Name
Date of Birth

Month Day Year
Date
Age
Social Security #
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Gender
Language
Marital Status
Race / Ethnicity
Financial Responsible Party Information
Responsible Party Name

First Name Last Name
Relationship to Patient
Date of Birth

Month Day Year
Date
Age
Social Security
Insurance Information
Primary Insurance
Policy Number
Group Number
Policy Holder Name
Policy Holder Date of Birth

Month Day Year
Date
Relationship to Patient
Emergency Contact
Emergency Contact Name

First Name Last Name
Phone Number
Please enter a valid phone number.
Relationship to Patient
Reason for Visit
Primary Reason for Visit
Date Symptoms Started

Month Day Year
Date
Were you seen at the Hospital/Urgent Care?
If yes, where?
Other issues you'd like to discuss?
Allergies
Select applicable options

No known food/pet allergy No known medication/drug allergy
Please list any food/pet allergies.
Please list any medication/drug allergies.
Current Medications
Medication, Dosage, & Frequency
Preferred Pharmacy Information
Pharmacy Name
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mail Order Pharmacy
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Statement of Patient Financial Responsibility
Patient Name

First Name Last Name
Date of Birth

Month Day Year
Date
Mercy Grace Private Practice appreciates the confidence you have shown in choosing us to provide for your health care needs. The service you have elected to participate in implies a financial responsibility on your part. The responsibility obligates you to ensure payment in full of our fees. As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. However, you are ultimately responsible for payment of your bill.

You are responsible for payment of any deductible and co-payments/co-insurance as determined by your contract with your insurance carrier. We expect these payments at time of service. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amounts not covered by your insurer. If your insurance denies any part of your claim, or if you or your physician elects to continue past your approved period, you will be responsible for your balance in full.

Should your account fall into a default status due to non-payment, your balance may be eligible for collections. Collections balances should be taken care of immediately to avoid disruption in services. Any account in collections status may be eligible for discharge. Arrangements for any balance should be made immediately.
Initial
I have read the above policy regarding my financial responsibility to Mercy Grace Private Practice for providing rehabilitative services to me or the above names patient. I certify that the information is, to the best of my knowledge, true and accurate. I authorize my insurer to pay any benefits directly to Mercy Grace Private Practice the full and entire amount of my bill incurred by me or above named patient; or, if applicable any amount due after payment has been made by my insurance carrier.
DISCLAIMER: By signing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Patient Signature

Clear
Date

Month Day Year
Date
Guarantor Signature

Clear
Date

Month Day Year
Date
Co-Pay Policy

Some health insurance carriers require the patient to pay a co-pay for services rendered. It is expected and appreciated at the time the service is rendered for the patient at EACH VISIT. Mercy Grace Private Practice does NOT bill for co-pays. Thank you for your cooperation in this manner.
Signature

Clear
Authorization to Bill/Pay

I HEREBY AUTHORIZE MERCY GRACE PRIVATE PRACTICE TO AND ITS AFFILIATES TO RELEASE ANY INFORMATION REQUIRED IN THE COURSE OF MY EXAMINATION OR TREATMENT WHICH INCLUDE HIV, COMMUNICABLE DISEASE OR DRUG ABUSE INFORMATION. I ALSO HEREBY AUTHORIZE PAYMENT DIRECTLY TO THE BUSINESS OF MERCY GRACE PRIVATE PRACTICE AND ITS AFFILIATES FOR THE SURGICAL AND/OR MEDICAL BENEFITS, IF ANY, OTHERWISE PAYABLE TO ME FOR THE SERVICES RENDERED. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES NOT COVERED BY MY INSURANCE. FURTHER, I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED IN THE COLLECTION OF MY ACCOUNT(S) AND WILL PAY ALL FEES INVOLVED SHOULD MY ACCOUNT(S) BE PLACED WITH A COLLECTIONS SERVICE.DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Signature

Clear
Date

Month Day Year
Date
Self-Pay

I agree to pay Mercy Grace Private Practice the full and entire amount for the treatment provided to me.
Initial
Consent for Treatment and Authorization to Release Information
Name

First Name Last Name
Date of Birth

Month Day Year
Date
I hereby authorize Mercy Grace Private Practice through its appropriate personnel, to perform or have performed upon me, or the above-named patient, appropriate assessment and treatment procedures.

I further authorize Mercy Grace Private Practice and its affiliates, to release appropriate agencies, any information acquired in the course of my, or the above named patient’s, examination and treatment.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Patient/Guarantor Signature

Clear
Date

Month Day Year
Date
Cancellation / No Show Policy

We understand there may be times when you miss an appointment due to emergencies or obligations to work or family. However, we urge you to call 24 hours prior to your appointment to cancel. Please initial the following:
If it is necessary to cancel an appointment, a 24 hour notice is required If you miss an appointment or fail to provide 24 hours advanced notice, there will be a charge of $50.00. This charge will not and cannot be billed to your insurance company I understand if I no show for two consecutive appointments, no show for three appointments or cancel for a total of 4 appointments, I may be discharged from care
Our office will notify you in writing, via mail, if you are discharged from care.

I have read and understand the above information and I agree to the terms described:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Patient/Guarantor Signature

Clear
Date

Month Day Year
Date
HIPPA NOTICE OF PRIVACY PRACTICES

I hereby acknowledge that I have been presented with Mercy Grace Private Practice’s HIPAA Notice of Privacy Practices. My signature below is indicative of my acknowledgment and understanding. I am aware that I can obtain a copy of this in the office or on www.mgppaz.com. All of my questions have been answered accordingly.DISCLAIMER: By signing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Signature

Clear
Date

Month Day Year
Date
Release of Information
I Name hereby authorize MGPP to release or discuss any and all information pertaining to myself or my child with Name Relationship to Patient
I authorize MGPP to contact me at HOME WORK CELL

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
May we leave a message on your machine?

Yes No
Signature *

Clear
Should be Empty:

New Patient Packet

Personal Information

Financial Responsible Party Information

Insurance Information

Emergency Contact

Reason for Visit

Allergies

Current Medications

Preferred Pharmacy Information

Statement of Patient Financial Responsibility

Co-Pay Policy

Authorization to Bill/Pay

Self-Pay

Consent for Treatment and Authorization to Release Information

Cancellation / No Show Policy

HIPPA NOTICE OF PRIVACY PRACTICES

Release of Information