New Patient Packet **

DeLeo Family Medicine, PC
145 Sawkill Road
Kingston, NY 12401

Medical Records Release Form

The protected information that the provider will use or disclose includes my complete medical records or the patient's medical record if minor/legal guardianship involved, including but not limited to my name or patient's/minor's name, telephone number, social security number, insurers, payers, prior medical history, current medical status, diagnoses, operative procedures, course of treatment, payment information and all documentation and tests results created. Persons Authorized to make the Disclosure: Any employee or the provider is authorized to disclose the protected health information.
*Note the actual records are sent to DeLeo Family Medicine by your previous provider. You do not have to bring them to our office.
Obtain Records From: (Provider Name & Address)
Patients Name
Patient's Address
Social Security #
D.O.B.
TransferMovingNew Primary Care ProviderInsuranceSpecialistOther, Please Specify
Release Specific Information, Please Specify
Authorization: I hereby authorize the release of my medical records or medical records for patient indicated above (if minor or legal guardianship) involved, covering all my medical records regarding treatment, inpatient and outpatient care. I realize that this may specifically include information about my psychological or psychiatric conditions: drug abuse, alcoholism, Acquired Immune Deficiency Syndromes (AIDS) and/ or Human Immunodeficiency Virus (HIV (New York State law required these conditions to be specified, my signature does not imply that any of them apply to me

Patient's Right to Revoke: I understand that once the provider discloses the protected health information to a recipient, the recipient may redisclose the information which may no longer be protected by federal or state law.

Acknowledgement if Reading and Agreement: By signing below, 1 agree that I have read and understand this authorization. If a of the patient signs this authorization, i.e. guardian, (parent, if minor), the representative has the authority to act on behalf of the patient.
Patient Name (printed)
Signature of Patient

Clear
Signature of Parent/ Legal Guardian: (DeLeo Family Medicine reserves the right to obtain proof of any legal guardianship documentation pertaining to the patient)
Signature of Parent/ Legal Guardian

Clear
Date

MonthDayYear
Date
Please Complete this form in Full
Today's Date

MonthDayYear
Date
Full Legal Name (First)
(Middle)
(Last)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Phone #
Date Of Birth

MonthDayYear
Date
Age
Sex
Martial Status
Driver's License #
Ethnicity
Preferred Language
Social Security #
Employer Name
Occupation
Business Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Responsible Party Information
Full Legal Name (First)
(Middle)
(Last)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security #
Home Phone #
Format: (000) 000-0000.
Cell Phone #
Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Employer's Name
Business Phone and Ext
Format: (000) 000-0000.
Insurance Information
Primary Insurance Company
Group #
Insurance ID #
Employer
Subscriber Name
Subscriber Date of Birth

MonthDayYear
Date
Subscriber Social Security #
Secondary Insurance Company
Group #
Insurance ID #
Employer
Subscriber Name
Subscriber Date of Birth

MonthDayYear
Date
Subscriber Social Security #
Emergency and Other Information
Person to Notify In case of Emergency
Telephone #
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Other Providers You See
How did you hear about us?
Important Insurance Information
1. DeLeo Family Medicine treats all of our patients equally regardles of their insurance coverage or lack thereof. We accept most major insurance carriers, Medicare, Medicaid (exisiting patients only) and self-pay patients. For those patients that need help to obtain medical coverage informatin, please visit this website: https://www.healthcare.gov

2. All patients with contract/employer health insurance are expected to make payment, i.e., copays, co-insurance, and deductibles at the time of service. This is is accordance with your insurance plan requirements.

3. Patients with contract/employer health insurance must present their insurance card to the receptionist at the time of their first appointment. It should be noted that if the patient's health insurance changes, that patient is responsible to notify DeLeo Family Medicine as soon as this canges and must present the new insurance card to the receptionist when they come in. If this not done, the patient will responsible for charges relating to that appointment not paid by their new insurance.

4. Some contract health plans require you to notify them of your Primary Care Provider selection, such as any HMO plan. It is the responsibility of the patient and/or plan guarantor to notify their insurance prior to coming in for their appointment. If this is not done, the patient and/or plan guarantor will be responsible for charges relating to that appointment not paid by their insurance.

5. We submit your claim to your primary insurance and most secondary and tertiary insurances, if applicable.

6. We offer access to a secure DeLeo Family Medicine patient portal so that you may have access to your medical information online. Please see the attached Patient Portal Packet.

7. Should the need arise, upson advance notification from you, we can arrange Language Interpretation, through SpectraCorp Language Interpreter Services at 1(866) 895-7374 to assist with your communication needs.

8. For those patients requiring Sign Language Interpretation, upon advance notification form you or your scheduled appointmet, we can arrange these services through Georgia Interpreting Services Network 1(800) 228-4992 or NexTalk (Remote Interpretative software program). You can watch a short video about their services at https://www.youtube.com/watch?v=aYJU2E7Idck

9. If you have any questions about the form, please call us at (845) 853-7003 and we will be happy to assist you.
Patient Name (Printed)
Signature of Patient

Clear
Date

MonthDayYear
Date
If minor or patient unable to sign or understand this form, signature of legal guardian or legal primary responsible
Signature

Clear
Date

MonthDayYear
Date
(DeLeo Family Medicine reserves the rights to obtain proof of any legal guardianship documentation pertaining to the patient)
Patient Payment and Insurance Authorization
Patient Name (Printed)
Disclosure of Billing Information: I authorize the following persons to obtain any/all of my billing information.
Name
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Name
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
I understand this authorization will be in effect until I provide a signed and dated revocation.
Signature of Patient

Clear
Date

MonthDayYear
Date
Signature of parent/legal guardian if minor

Clear
Date

MonthDayYear
Date
Insurance Benefits and Information Release: I hereby authorize DeLeo Family Medicine to release any and all information necessary concerning diagnosis and treatment for the purpose of securing payment from my insurance company and also authorize payment of the insurance benefits directly to DeLeo Family Medicine rendered that are not paid for directly by me.
Signature of Patient

Clear
Date

MonthDayYear
Date
Signature of parent/legal guardian if minor

Clear
Date

MonthDayYear
Date
Payment of Services: I understand that I am responsible for payment of all medical services rendered to me and/or the patient (listed above) regardless of the decision regarding reimbursement made by my insurance carrier.
Signature of Patient

Clear
Date

MonthDayYear
Date
Signature of parent/legal guardian if minor

Clear
Date

MonthDayYear
Date
Medicare Authorization-Medicare Health Insurance #
I request that payment of authorized Medicare Benefits be made to DeLeo Family Medicine on my behalf for any services furnished by any of their providers. I also authorize any Medicare agent or agency to release any information needed to determine benefits or benefits payable for the services relating to my care at DeLeo Family Medicine, PC.
Signature of Patient

Clear
Date

MonthDayYear
Date
Signature of parent/legal guardian if minor

Clear
Date

MonthDayYear
Date
Authorization to Treat a Minor - Patient's Name:
As the parent/legal guardian of the above-named child/minor, I hereby give my permission to DeLeo Family Medicine, PC to treat the child/minor in the event of that a medical emergency arises and I am unable to personally consent to the treatment. I also agree to be responsible to DeLeo Family Medicine, PC for charges relating to these medical services rendered.
Signature of parent/legal guardian if minor

Clear
Date

MonthDayYear
Date
Authorization to Disclose My Protected Health Information
Patient Name
Date of Birth

MonthDayYear
Date
Social Security #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone #
Format: (000) 000-0000.
Cell Phone #
Format: (000) 000-0000.
The following individual(s) are authorized to communicate with and/or obtain any of my medical information from DeLeo Family Medicine, PC:
Name
Home Phone #
Format: (000) 000-0000.
Cell Phone #
Format: (000) 000-0000.
Name
Home Phone #
Format: (000) 000-0000.
Cell Phone #
Format: (000) 000-0000.
Name
Home Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone #
Format: (000) 000-0000.
Name
Home Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone #
Format: (000) 000-0000.
Please specify any medical information "Exceptions" that we are not to discuss with the above listed individuals:
I authorize DeLeo Family Medicine, PC to do the following regarding leaving appointment messages and other medical information: (Please check the appropriate items listed below)
Cell PhoneHome PhoneOffice VoicemailWith Another Person*Send Through MailPatient Portal
Cell PhoneHome PhoneOffice VoicemailWith Another Person*Send Through MailPatient Portal
*Name(s) of Individuals that we can leave your appointment and medical information on:
Sensitive Information: I understand that the information in my record may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or infection with the Human Immunodeficiency Virus (HIV). It may also include information about behavioral or mental health services or treatment for alcohol and drug abuse.

Right to Revoke: I understand that I have the right to revoke this authorization at any time. I understand that my revocation must be in writing and signed by me and dated. (If I do not specify an expiration date, this authorization will remain in effect until otherwise revokes or amended by me.)
Signature of Patient or Legal Guardian

Clear
Date

MonthDayYear
Date
If signed by legal guardian, indicate relationship to the patient

Clear
(Deleo Family Medicine reserves the right to obtain proof of any legal guardianship documentation pertaining to the patient)
Patient Payment Policy REVISED Effective April 1, 2016
1) Payment is expected at the time of service. Non-payment of service(s) rendered will result in a $15 service charge to your account. A finance charge of 1 1/2% will be added for any outstanding balances over 30 days. This includes copays, coinsurance, deductibles, charges incurred for patients with no insurance and insurances that we do not participate with. For your convenience we accept cash, checks, Visa, Discover, and MasterCard Returned checks will result in an overdraft fee of $35 being charged to your account.

2) If you are a current member of a PPO or HMP in which we participate: Copays are expected at the time of service in accordance with our contractual agreement with that plan. A service charge or $15 will be incurred for those copays not paid at the time of service and for each month these

3) Your coverage will be verified prior to treatment. If for any reason there is an issue with eligibility, you will be requested to sign an agreement accepting responsibility for payment in full if your charges are denied by your insurance company. In order to successfully bill your insurance company, you will need to provide us with updated and correct insurance information and a copy of your current insurance card prior to your appointment. If you have any changes in your insurance, you must notify us at the time the change occurs by calling us at (845) 853-7003. If this is not done and your insurance denies your medical services, you will be responsible for payment in full.

4) Difficulty Paying Payment Balance: If you anticipate difficulty in paying for services or your outstanding balance, please let us know in advance so our Billing Department may assist you in a

5) No Show Policy- If you need to cancel your appointment, please give us at least 24 hours notice prior to your scheduled appointment. If you fail to cancel your appointment, your account willbe charged a $50 service fee. Please note we do try to call 48 hours in advance to confirm your appointment, however this is a courtesy, you are responsible to keep track of your scheduled
Patient Printed Name
Patient Signature (if minor, parent or legal guardian): (Deleo Family Medicine reserves the right to obtain proof of any legal guardianship documentation pertaining to the patient)

Clear
Date

MonthDayYear
Date
Patient Signature (if minor, parent or legal guardian):

(Deleo Family Medicine reserves the right to obtain proof of any legal guardianship documentation
Social History

Diet and Exercise:
RegularVegetarianVeganGluten FreeSpecificCarbohydrateCardiacDiabetic
NoneOccasionalModerateHeavy
What types of sporting activities do you participate in?
Activities of Daily Living
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Marriage and Sexuality
UnknownSingleMarriedDivorcedSeparatedWidowedDomestic PartnerOther
YesNo
How many children do you have?
Education and Occupation
Never attended/kindergarten only1st Grade2nd Grade3rd Grade4th Grade5th grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade No DiplomaGED or EquivalentHigh School GraduateSome college, no degreeAssociates Degree: occupational, technical, or vocational programAssociates Degree: academic programBachelor's Degree (e.g. BA, AB, BS)Master's Degree (e.g. MA, MS, Med, MSW, MBA)Professional School Degree (e.g. MD, DDS,DVM, JD)Doctoral Degree (example: PhD, EdD)Don't KnowRefused
YesNo
What is your occupation?
Home and Environment
NoneRelativePrivate SitterDaycare/Preschool
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Substance Use
Never SmokerFormer SmokerCurrent every day smokerCurrent some day smokerSmoker-current status unknownUnknown if ever smokedNot ToleratedPatient RefusesNot Indicated
YesNo
NoneOccasionalModerateHeavy
YesNo
NoneOccasionalModerateHeavy
Lifestyle
Not at allOnly a littleTo some extentRather muchVery Much
YesNo
YesNo
Public Health and Travel
YesNo
YesNo
YesNo
Advanced Directive
YesNo
Gender Identity and LQBTQ Identity
Identifies as maleIdentifies as femaleGender non-conforming (neither exclusively male or female)Transgender male/female to male (FTW)Transgender female/male to female (MTF)Additional gender category/other, please specifyChoose not to disclose
MaleFemaleChoose not to discloseUnknown
he/himshe/herthey/them
Lesbian, gay, or homosexualStraight or HeterosexualBisexualSomething else, please describeDon't KnowChoose not to disclose
Surgical History: (Including your Colonoscopy)
Patient Name
Procedure
Surgery Date

MonthDayYear
Date
Surgeon
Procedure:
Surgery Date

MonthDayYear
Date
Surgeon
Procedure
Surgery Date

MonthDayYear
Date
Surgeon
Procedure
Surgery Date

MonthDayYear
Date
Surgeon
Medications: Please list all medications, vitamins and herbs (include dose and frequency)
Preferred Pharmacy Local/ Mail Away Pharmacy Information
Other Doctors/Providers You See

Allergies/Adverse Reaction:

Rows	Drug/Allergen	Reaction	Onset Date
1.
2.
3.
4,

Family History: Not Applicable if adopted or unknown
Mother's Date Of Birth

MonthDayYear
Date
YesNo
Age at Death:
Medical Problems:
Father Date of Birth

MonthDayYear
Date
YesNo
Age at Death:
Medical Problems:
Brothers Date of Birth

MonthDayYear
Date
YesNo
Age at Death:
Medical Problems:
Sisters Date of Birth

MonthDayYear
Date
YesNo
Age at Death
Medical Problems:
Son Date of Birth

MonthDayYear
Date
YesNo
Age at Death
Medical Problems
Daughter Date of Birth

MonthDayYear
Date
YesNo
Age at Death
Medical Problems
GYN History
Duration of Flow (days)
LMP
Frequency of Cycle
YesNo
LightModerateHeavy
Age at first Child
Age at First Period
Current Birth Control Method
YesNo
If Post Menopausal, Age at Menopause
Date of last mammography

MonthDayYear
Date
Date of last pap smear

MonthDayYear
Date
Most Recent Bone Density

MonthDayYear
Date
YesNo
Past Medical History
ADD/ADHDAIDS/HIVAbuse/Domestic ViolenceAcid Reflux (GERD)AcneAllergiesAllergies (food, seasonal, environmental)Allergies/HayfeverAnemiaAnesthesia ComplicationsAnxiety DisorderArt (IVF or FET)ArthritisAsthmaAutism Spectrum Disorder (ASD)Autoimmune DiseaseBedwettingBirth Defects or Inherited DiseaseBladder or Kidney ProblemsBlood DiseaseBlood TransfusionBreast CancerBreast ProblemCOPDCancerChicken PoxChronic Ear InfectionsCongenital AnomaliesCongestive Heart Failure (CHF)Coronary Artery DiseaseDepressionDepression/Postpartum DepressionDermatological DisordersDevelopmental or Behavioral DisordersDiabetesDifficulty SwallowingDiverticulitisDrug/Latex Allergies/ReactionsEar of Hearing ProblemsEating DisorderEczemaEndometriosisFibromyalgiaGERD/ RefluxGI ProblemsGestational DiabetesGoutHead Injury/ConcussionHeadachesHeart DiseaseHematologic DisordersHepatitisHepatitis/Liver DiseaseHigh CholesterolHistory of STIHistory of Abnormal PapHospitalizationsHypertensionHyperthyroidismInfertilityKidney DiseaseKidney or Bladder ProblemsLiver DiseaseLung DiseaseMRSA ExposureMeniere's DiseaseMental DisorderMental IllnessMuscle, Joint, or Bone ProblemsNeurologic/EpilepsyObesityObstructive Sleep ApneaOsteoporosisOvarian CancerPolycystic Ovary SyndromePolypsPre-EclampsiaPsychiatric IllnessPulmonary (TB, Asthma)Pulmonary EmbolismSeizure/EpilepsySerious Illness or InjurySkin ProblemsStrokeThrombophiliaTrauma/ViolenceVaricositiesVision or Eye ProblemsAny Mental Health Issues
Notes
Patient Portal Consent Form
I, blanks agree to hold DeLeo Family Medicine, PC harmless for any breath of confidentiality of my medical information if I allow and person(s) access to my DeLeo Family Medicine, PC patient portal website and/or give my sign in and/or password to any person(s) to this site.
Print Patient Name
Patient Signature

Clear
Patient Email Address
example@example.com
Home Phone Number
Format: (000) 000-0000.
Cell Phone Number
Format: (000) 000-0000.
Date

MonthDayYear
Date
HealtheConnections

Authorization for Access to Patient Information through a Health Information Exchange Organization
Patient Name
Date of Birth

MonthDayYear
Date
Other Names used (e.g., Maiden Name)
I request that health information regarding my care and treatment be accessed as set forth on this form. I can choose whether or not to allow the Organization named above to obtain access to my medical records through the health information exchange organization called HealtheConnections. If I give my consent, my medical records from different places where I get health care can be accessed using a statewide computer network.

HealtheConnections is a not-for-profit organization that shares information about people's health electronically and meet the privacy and security standards for HIPAA and New York State Law. To learn more visit HealtheConnections website at http://healtheconnections.org/

The choice I make on this form will NOT affect my ability to get medical care. The choice I make on this form does NOT allow health insurers to have access to my information for the purpose of deciding whether to provide me with health insurance coverage or pay my medical bills.
I GIVE CONSENT for the Organization named about to access ALL of my electronic health information through HealtheConnections to provide health care services (including emergency care)I DENT CONSET for the Organization name above to access my electronic health information through HealtheConnections for any purpose, even in a medical emergency.
If I want to deny consent for all Provider Organizations and Health Plans participating in HealtheConnections to access my electronic health information through HealtheConnections, I may do so by visiting HealtheConnections at http://healtheconnections.org/ or by calling HealtheConnections at 315.671.2241 x5.

My questions about this form have been answered and I have been provided a copy of this form. Signature of Patient or Patient's Legal Representative
Signature of Patient or Patient's Legal Representative

Clear
Date

MonthDayYear
Date
Print Name of Legal Representative (if applicable)
Relationship of Legal Representative to Patient (if applicable)
Should be Empty:

Please Complete this form in Full

Responsible Party Information

Insurance Information

Emergency and Other Information

Important Insurance Information

Patient Payment and Insurance Authorization

Authorization to Disclose My Protected Health Information

Patient Payment Policy REVISED Effective April 1, 2016

Social History

Activities of Daily Living

Marriage and Sexuality

Education and Occupation

Home and Environment

Substance Use

Lifestyle

Public Health and Travel

Advanced Directive

Gender Identity and LQBTQ Identity

Surgical History: (Including your Colonoscopy)

Family History: Not Applicable if adopted or unknown

GYN History

Past Medical History

Patient Portal Consent Form

HealtheConnections