IntervalCare New Patient Intake Form

Patient's Full Name

Patient’s Date of Birth*

Date

Sex*

Race/Ethnicity

Primary/Secondary Language spoken*

Home Street Address*

City, State and Zip Code

Home phone number*

Cell Phone

Email address*

example@example.com

What is your preferred contact method?

CellHomePhoneEmail

Text Message Approval?

YesNo

Marital Status*

Will we be your primary care provider?*

If not, please list your primary care provider and their contact information

Preferred Pharmacy Name and Address*

How did you hear about us

Family/Friend/colleagueGoogle

InstagramFacebookPamphletOther

I authorize IntervalCare Medical Services Inc, to give my clinical, personal & financial information, in person or by telephone, in regards to my treatment to:

Name, relationship, and phone number

I DO NOT authorize IntervalCare Medical Services, Inc to share my medical information with family

I understand that I may revoke or change this consent by submitting my request in writing to IntervalCare Medical Services, Inc. You may email your written request to or ask staff to receive a copy of detailed HIPPA Notice of Privacy Practices at info@intervalcaremed.

Parent/Guardian Name

Relationship

Phone Number

Emergency Contact

Same as Responsible Party

Contact Name*

Relationship

Emergency contact phone number*

If 18 years or older, do you have living will, advance directive, or health power of attorney?*

YesNon/a

Insurance Company

If not insured, type "n/a" in any required blanks

Member ID

Group

Primary Policy Holder’s Name

Primary Policy Holder’s Birthdate

Date

Patient’s relationship to policy holder

Secondary Insurance Information (if applicable):

Secondary Insurance Name/Member ID

RELEASE OF MEDICAL INFORMATION - I authorize IntervalCare Medical Services, Inc, to release the medical records concerning my son/ daughter/self to any physician, hospital, or agency involved in the care of the patient listed.

ASSIGNMENT OF MEDICAL BENEFITS - I authorize my insurance carrier to assign all surgical and or medical benefits, if applicable, to IntervalCare Medical Services, Inc. I also authorize release of medical information necessary to process all medical insurance claims.

PAYMENT POLICY - Co-payments are to be collected prior to services received or may be paid after my visit. However, my co-pay fee is due prior to my next visit. IntervalCare accepts Visa, MasterCard, Discover, and American Express. All medical services provided are directly charged to the patient or responsible party. If our physician is contracted with your insurance carrier, we will accept their negotiated rate for the charges billed. However, you will be responsible for any balance deemed patient responsibility/non-payable/non-covered by your insurance and billed accordingly. Payment is expected in full upon receipt of statement or payment arrangements must be made with our billing office.

CANCELLATION POLICY - Our office requests that if an appointment needs to be cancelled that we receive notice no later than 24 hours prior to the appointment. We reserve the right not to refund payment.

REFERRAL POLICY - I understand that it is my responsibility to obtain a referral through my primary care physician's office if required by my insurance company. Failure to do so will result in charges being billed directly to myself.

LABORATORY POLICY-I understand that laboratory testing centers may require demographic information about me and a form of identification provided prior to testing. I also understand that laboratory cost is not included in my visit with IntervalCare Medical Services providers. However, the laboratory may bill my insurance for payment. It is my responsibility to ensure lab cost will be covered by my insurance prior to testing. Otherwise, lab cost may be billed to me for payment.

Please acknowledge:*

I give consent to perform my medical visit via telecommunication as outlined on the telemedicine consent form and agree to IntervalCare Medical Service's HIPAA policy. A copy of the telemedicine consent and HIPAA policy is available for download at www.intervalcaremed.com/patient-forms/ or can be sent to me at my request to IntervalCare Medical Services Inc.

I HAVE READ, UNDERSTAND, AND AGREE TO ABIDE BY THE ABOVE RELEASE OF MEDICAL INFORMATION AND PAYMENT POLICIES.

Patient’s Name*

Guardian’s Name if signing for patient

E-Signature*

Date*

Date

Full Legal Name*

Date of Birth*

Date

Allergies and reaction (food and medication)*

Height (in feet and inches)*

Weight*

Are you currently receiving care for an active condition with another provider?*

If yes, please explain

Current Medications (include OTC medication and vitamins):

List name, dose, and frequency*

Do you drink alcohol?*

If yes, how often?

how many oz per day?

Have you ever/do you currently smoke, vape or chew tobacco?*

If yes, how much (ex. cigarettes/day)?

How long have you been a nicotine user?

Illicit drug use

Past Surgical History: (list all operations and year performed)*

Do you have a history of requiring psychiatric/mental health care?*

YesNo

If yes, when?

Who managed your mental health care?

In the past two weeks, how often have you had little interest in doing things?*

Not at allSeveral DaysMore than half a weekNearly everyday

In the past two weeks, how often have you felt down, depressed, or hopeless*

Not at allSeveral DaysMore than half a weekNearly everyday

Have YOU been diagnosed with any of the following?

Family History (check if applies to your parent, sibling, grandparent)*

I have answered the above questions to the best of my knowledge.

E-Signature*

Photo ID*

Insurance Card (if co-pay is required, it will be due prior to your appointment)

New Patient Information

Permission to Release Medical Information

Primary Insurance Information:

Policies

Medical History