Medical Physicians Group PLLC - New Patient Info (UPDATED

Signature
Notice of Medical Record Charge

Please note that it will cost $1 to $2 per page plus postal fees for any medical request. You may get access to medical records free on https://medical1688.patientlogon.com and you can get your lab request with Quest, LabCorp, etc. It is your (patient's) responsibility to pay your bill if insurance does not pay for it. If you do not pay for your bills, and your bills are sent to collection, you will need to pay for the cost of collection in addition to your financial responsibilities. By signing below, you agree to provide your email address and to access your electronic medical record (EMR).
Sign
Health Insurance Portability and Accountability Act (HIPPA) Acknowledgement

I have received the HIPAA information. I understand that Medical Physicians Group PLLC and Dr. Leung will make all attempts to protect patient’s medical information.
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Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Medical Physicians Group PLLC

Cancellation Policy and Payment Policy

I understand that there is a $100 for any cancellation or change in scheduling/rescheduling less than 24 hours prior to the actual appointment. I understand if insurance does not pay for your benefits and/or if your benefits have expired, then it is the patient’s responsibility to pay for the office visit and/or the procedure, vaccination, and/or any medical services rendered.
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Sign
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Medical Physicians Group PLLC New Patient Information
Patient's Legal Name:
FIRST NAME & LAST NAME
Patient's Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate05/30/1978
Sex
Ethnicity
Races
Gender Identity
Sexual Orientation
Patient Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Phone Number:
Phone operating system iPhone OR Android
We are requesting this information to provide patient centric care ------------------------TELEMEDICINE Visit if requested------------------------
Patient's Email:
example@example.com
Guardian/Responsible Party (if any):
This field is necessary for the patient under age of 18

Emergency Contact Name:
Relation to Patient:
Emergency Contact's Phone Number:
Emergency Contact's Email:
example@example.com
Date of Last Physician Visit (Known or Approximate):

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Last Physician Seen:
Last Physician's Phone Number:
Reason for Last Office Visit:
Primary Care Physician's Name (if different from above):
Primary Care Physician's Phone Number:
Date Last Seen by Primary Care Physician:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Pharmacy Name / Preferred Pharmacy :
Eg. Walmart Pharmacy,
Primary Pharmacy Telephone:
Patient's Primary Pharmacy Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Insurance Information
Primary Insurance Company's Name
Group Number:
Policy Number:
Policy Holder's Name
Relation to Patient:
Phon Number:
Policyholder's Email:
example@example.com
Policyholder's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Holder's Place of Employment:
Secondary Insurance Company Name:
Group Number:
Policy Number:
Policyholder's Name:
I hereby attest that all insurance information is truthful and current. If insurance information is unable to be verified at time of appointment, or a company rejects any claim, it is up to the patient or patient’ representative to pay via cash and perform a self-claim filed with their own insurance company for self-reimbursement.
Patient or Patient's Representative Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Reason for Today's Visit:
Please CLARIFY if You Have Seen a Physician or Have Been Diagnosed with Any of the Following:
Arthritis (which joints?)
Blurry Vision
Cancer (which cancer?)
Chest Pain
Circulation Issues (which issues?)
Diabetes
Digestive Issues (which issues?)
Dizziness
Fatigue
Female Health/Gynecological (routine care or specific concerns?)
Heart Conditions (which conditions?)
High Cholesterol
High Blood Pressure
Hormonal Issues (which issues?)
Incontinence (bowel or urinary?)
Insomnia
Low Blood Pressure
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Male Health (routine care or specific concerns?)
Mental Health Conditions (which conditions?)
Migraines
Pain (which locations?)
Paralysis (which locations?)
Respiratory Conditions (which conditions?)
Substance Abuse/Chemical Dependency (which substance?)
Do you currently use any medical devices? This includes assistive devices used as needed or prescribed regular use equipment. Some examples can include a nebulizer, CPAP machine, walker/cane, oxygen system, etc. If so, please list below:
I hereby attest to the best of my knowledge, all above statements regarding my previous known health conditions have been disclosed and answered truthfully.
Patient's Signature
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

For females, if you are 21 years old or above, when was the last time you had a pap smear done?
For females, if you are 50 years old or above, when was the last time you had a mammogram done?
Please list all medications taken. Include name of medication including strength and how often you take this medication. This includes prescription medication, medical supplements (both physician and non-prescription prescribed), and any recreational drugs.
By completing the above information, you acknowledge the following: All

prescribed and non-prescribed medications taken, including their current dosages and

strengths, have been truthfully stated on this form. Should our physician prescribe

medication which could cause a reaction with any unknown substances at the time of prescription, the patient agrees to hold harmless said physician.

If there is any change in medication taken from another provider, or another provider issues a new or change of prescription, it is up to the patient to notify us to update this change in his/her medical records and advise patient regarding any possible drug
Signature of Patient or Patient's Representative:
Date Signed: