New Patient Form

New Patient Form
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
SSN*
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.
Alternative Phone Number
Please enter a valid phone number.
Race
Email
example@example.com
Responsible Party (Same as Patient)Name*

First NameLast Name
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy
Pharmacy Phone Number
Please enter a valid phone number.
Place of Employment
Work Phone
Please enter a valid phone number.
Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship
Insurance Information

To file insurance claims, we must have complete information below and a scanned copy of the insurance card(s).
Member Name

First NameLast Name
Date of Birth

MonthDayYear
Date
SSN
Primary Insurance
ID#
Group#
Secondary Insurance
ID#
Group#
I hereby authorize, Family Medicine, {Warren J. Plauche, MD, Julie Ducote, FNP, Aimee Voiselle, FNP} to release and/ or receive all information: (1) Information requested by insurance company (2) Information to any hospital or physician that you may be referred to (3) Information from hospitals and physicians who have previously rendered you treatment. I understand that I am responsible for payment of all charges and if this assignment of claim is rejected, modified, or not paid within a reasonable time after it has been filed, it may be my responsibility to pay any unpaid charges in full. I hereby authorize payment of medical benefits to Family Medicine,(Warren J. Plauche, MD, Julie Ducote, FNP, Aimee Voiselle, FNP).
Patient Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGEMENT OF RECEIPT
EFFECTIVE DATE: APRIL 14, 2003
PLEASE REVIEW CAREFULLY

The Notice of Privacy Practices tells you how Family Medicine uses and discloses information about you. Not all situations will be described. We are required to give you a notice of our privacy practices for the information we collect and keep about you.
I, blanks*have been given a copy of FAMILY MEDICINE Notice of Privacy Practices.
Signature of patient or Legal Guardian *

Clear
Date*

MonthDayYear
Date
Patient's Name

First NameLast Name
Name of Legal Guardian, if applicable

First NameLast Name

Patient Consent for Use and Disclosure of Protected Health Information
I hereby give my consent for FAMILY MEDICINE to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO).

(The Notice of Privacy Practices provided by FAMILY MEDICINE describes such uses and disclosures more completely.)

I have the right to review the Notice of Privacy Practices prior to signing this consent. FAMILY MEDICINE reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to FAMILY MEDICINE, 7406 HWY 1, STE. 103, MANSURA, LA 71350.

With this consent, FAMILY MEDICINE may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.

With this consent, FAMILY MEDICINE may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”

With this consent, FAMILY MEDICINE may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that FAMILY MEDICINE restrict how it uses or discloses my PHI to carry out my TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to allow FAMILY MEDICINE to use and disclose my PHI to carry out my TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, FAMILY MEDICINE may decline to provide treatment to me.
Signature of Patient or Legal Guardian*

Clear
Patient's Name*

First NameLast Name
Date

MonthDayYear
Date
Name of patient or Legal Guardian, if applicable

First NameLast Name

NOTICE OF PRIVACY PRACTICES
Should be Empty:

New Patient Form

Insurance Information

NOTICE OF PRIVACY PRACTICES

PLEASE REVIEW CAREFULLY

Patient Consent for Use and Disclosure of Protected Health Information