NEW PATIENT PAPERWORK PCP

FAMILY MEDICINE ASSOCIATES, P.C.
Name

First NameLast Name
Social Security#
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex
Home#
Work#
Cell#
Address
Apt/Lot#
City
State
Zip
Marital Status
Race
Ethnicity
Language
RESPONSIBLE PARTY: (person who carries insurance or parent of minor child) if different than above
Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security#
Relationship To Patient: Self / Spouse / Parent / Other
Address
Apt/Lot#
City
Zip
Home#
Work#
Insurance Company
Subscriber ID
PHARMACY INFORMATION: Primary Pharmacy:
Primary Pharmacy
Phone#
Format: (000) 000-0000.
Address (Major Cross Streets)
Notify in Case of Emergency
Relationship
Phone
Format: (000) 000-0000.
Authorization to Dicuss Medical matters with the Emergency Contact:
Yes or No
We want to connect with you! Did you know we have an online portal? This portal allows you to have online access to our office, ask questions, look at your lab results, get appointment reminders, and more!
We just need your email address
example@example.com
APPOINTMENT REMINDER WILL BE CALL OR TEXT WHICH WOULD YOU PREFER?
I understand that I am responsible for all charges incurred by me or my family regardless of insurance coverage and that payment is due at the time of services rendered. I also request that payment under my medical insurance program be made directly to Family Medicine Associates, P.C. on any unpaid bills for service furnished. I authorize the release of any medical information to process this claim and future claims.
Signature
Patient Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Acknowledgement of Notice of Privacy Practices

By subscribing my name below, I acknowledge that I was provided a copy of the Notice of Privacy Practices (NPP), and that I have read (or had the opportunity to read if I so chose) and understand the Notice of Privacy Practices (NPP) and agree to its terms. LOCATED ON FMAPC.COM UNDER PATIENT FORMS
Patient/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Authorization to Release Information to Family Members

Many of our patients allow other individuals such as their spouse, parents, or caregivers to call and discuss their medical care. Under the H.I.P.P.A guidelines we are unable to release information to anyone without direct patient consent. Please designate any specific individuals that you would like to allow us to discuss your care with, if necessary.

You have the right to revoke this consent, in writing at any time. Revoking consent will not apply to any information that may have been disclosed to approved individuals based off previous consents.
Name
Relation
Phone
Format: (000) 000-0000.
Name
Relation
Phone
Format: (000) 000-0000.
Patient/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Patient Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Payment Policy: Please read, initial each number and sign at the bottom

Thank you for choosing us as your primary care provider. We are committed to providing you with quality and affordable health care. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we have been advised to develop this payment policy. Please read it, ask us any questions you may have, Initial each space and sign at the bottom. A copy will be provided to you upon request.
1.Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with, but don’t have up-to date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. INITIAL
2. Co Payments and deductibles. All co payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. We may make exceptions on a case by case basis. Should we make an exception and you are billed for you co pay or deductible there will be a $5.00 billing fee. In addition, any balance over 30 days will be assest a $5.00 service charge, per month. INITIAL
3. Non covered services. Please be aware that some and perhaps all of the services you receive may be non covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit. Our office does our best to know what is and what is not covered but ultimately it is your responsibility to know what your insurance will cover. INITIAL
4. Insurance Denial. Charges denied for any reason by the Explanation of Benefits of your insurance company are due upon receipt. If you are not in agreement with your insurance company, you must pay for the services rendered and wait for reimbursement from your insurance company. We will be glad to resubmit the claim for you or help you if we can. INITIAL
5. Proof of Insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. INITIALS
6. Claims Submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract. INITIALS
7. Coverage Changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you. INITIALS
8. Nonpayment. If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice In care of default payment, I agree to pay any and all costs of collecting this account including but not limited to 1.5% per month and up to 35% collection fees, attorney fees INITIALS
9. No Shows. If you no show (do not call and cancel) or give 24 hours' notice you will be charged a $100.00 fee. In addition, if you no show (do not call and cancel) two times you and your family may be released from our office. INITIALS
Signature
Telehealth Consent Form

1.    I hereby authorize Health Care Services to use the telehealth practice platform for telecommunication for evcaluating, testing and diagnosing my medical condition.

2.    I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.

3.    I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voide communication if the technical requirements such as internet speed cannot be met.

4.    I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover.

5.    I agree that my medical records on telehealth can be kept for futher evaluation, analysis and documentation, and in all of these, my information will be kept private.
Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty: