New Patient Forms

New Patient Forms

Please fill out all required fields and sign on each page where indicated.
Your information is safe on our secure HIPPA compliant website and forms.
Western Reserve Medical Group Referral
Name of Community
Please Select Your Current Residence Type:

Private Residence Assisted Living Independent Living Group Home
Patient Name

First Name Last Name
DOB
Street Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax
Please enter a valid phone number.
Power of Attorney

The primary person with Power of Attorney for the patient
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Insurance
Medicare ID
Primary Insurance Policy #
Secondary Insurance Policy #
Pharmacy
Pharmacy Name
Pharmacy Phone Number
Please enter a valid phone number.
Billable Party

(if other than patient)
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Contact

(if other than patiient)
Name

First Name Last Name
Phone Number
Please enter a valid phone number.
Relationship to Patient
Primary Contact has POA?

Yes No

CONSENT TO WESTERN RESERVE MEDICAL GROUP (M/LLS MED/CAL PRACT/CES)AND CORPORATE AFF/L/ATES FOR SERVICES
I request and authorize medical care as my physician, his assistant or designees (collectively called “the physicians”) may deem necessary or advisable. This care may include, but is not limited to, routine diagnostics, radiology and laboratory procedures, administration of routine drugs, biological and other therapeutics, and routine medical and nursing care. I authorize my physician(s) to perform other additional or extended services in emergency situations if it may be necessary or advisable in order to preserve my life or health. I understand that my (the patient) care is directed by my physician(s) and that other personnel render care and services to me (the patient) according to the physicians(s) instructions.

• I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made with respect to results of such
diagnostic procedure or treatment.

• I understand that samples of body fluids and/or tissues may be withdrawn from me (the patient) during routine diagnostic procedures. I authorize WESTERN RESERVE MEDICAL GROUP (MILLS MEDICAL PRACTICES) to dispose of those bodily fluids.

• I have been informed and understand that an HIV (human immunodeficiency virus-AIDS) test may be performed on me without my consent if a health professional or Western Reserve Medical Group employee or First Responder sustains exposure to my blood or other body fluid.

By signing this, I agree to receive services provided by Western Reserve Medical Group/ Mills Medical Practices.

I also acknowledge that I have received a copy of the Western Reserve Medical Group Notice of Privacy Practices.
Name of Beneficiary

First Name Last Name
Patient Name

First Name Last Name
Name of Beneficiary's Representative (If patient unable to sign)

First Name Last Name
Signature of Beneficiary's Representative (If patient unable to sign)

Clear
Date

Month Day Year
Date

GENERAL CONSENT FOR TREATMENT
We are a Medicare Participating Provider
My signature and date below affirms and authorizes each of the following:

1. Medical care deemed necessary or advisable by Western Reserve
Medical Group (Mills Medical Practices) Physicians, Nurse Practitioners,
and Physician Assistants.

2. Direct billing to Medicare, Medicare Supplement or other insurance on my
behalf.

3. Release of my medical information to my insurance provider and their agents

4. Western Reserve Medical Group and/or any of their corporate affiliates
to obtain medical or other information necessary in order to process claim(s), including determining eligibility and seeking reimbursement for medical supplies and/or medications provided.

5. I acknowledge that I have received a copy of Western Reserve Medical Groups Notice of Privacy Practices.

Please sign date and return this form as soon as possible in order for us to provide medical care and bill Medicare and/or other insurance for your medical care, medical supplies and/or medications
Name of Beneficiary

First Name Last Name
Beneficiary Signature

Clear
Name of Beneficiary's Representative (If patient unable to sign)

First Name Last Name
Beneficiary Representative Signature (If patient unable to sign)

Clear
Date

Month Day Year
Date

Consent for Chronic Care Management Services

As a patient with two or more chronic conditions, you may benefit from a new Medicare benefit called Chronic Care Management (CCM) and Behavioral Health Integration that (BHI) we are now offering. CCM/BHI Services are available to you
because you have: 1) been diagnosed with two or more chronic conditions expected to last at least 12 months, and which place you at significant risk of decline and or 2) been diagnosed with one or more behavioral health conditions. Our goal is to ensure
you get the best care possible, to keep you out of the hospital, and to minimize costs and inconvenience to you due to unnecessary visits to doctors, emergency room visits, laboratory testing, or hospital admissions.

By signing this Agreement, you consent to, providing chronic care management and/or behavioral health services (referred to as “CCM / BHI Services”) to you as more fully described below.

• CCM/BHI Services include 24-hours-a-day, 7-days-a-week access to a health care provider in Provider’s practice to address acute needs; a systematic assessment of your health and behavioral health care needs; processes to assure that you timely
receive preventative care services; medication reviews and oversight; a plan of care covering your health issues; and management of care transitions among health care providers and settings. The Provider will discuss with you the specific
services that will be available to you and how to access those services.

Provider’s Obligations. When providing CCM/BHI Services, the Provider must:

• Explain to you (and your caregiver, if applicable), and offer to you, all the Services that are applicable to your conditions.

• Provide a copy of the CCM/BHI care plan to you according to your preference specified below.

Beneficiary Acknowledgement and Authorization. By signing this agreement, you agree to the following:

• You consent to the Provider providing CCM/BHI Services to you.

• You authorize electronic communication of your medical information with other treating providers as part of the coordination of your care.

• You opt in to receiving occasional (estimated frequency is one per month) text messages and/or email messages to help identify care needs you may have and to help your provider align resources.

• You acknowledge that only one practitioner can furnish CCM/BHI Services to you during a calendar month.

• You understand that cost sharing will apply to these Services, so you may be billed for a portion of the Services even though Services will not involve a face-to-face meeting with the provider.

Beneficiary Rights. You have the following rights with respect to CCM Services:
My preference is that I would like to receive / review my CCM care plan using the following method:

I would like to receive a copy of my CCM care plan electronically by email or text message. Written copy provided during a provider visit
Email Address
example@example.com
Mobile Phone Number (Used for text messages)
Please enter a valid phone number.
You have the right to stop CCM Services by revoking this Agreement at the end of a calendar month. You may revoke this agreement verbally or in writing by notifying Provider or care team member.

We believe that this new Medicare benefit can provide significant value to our patients and we appreciate your consideration.
Name of Patient/Beneficiary Providing Consent

First Name Last Name
Signature of Patient/Beneficiary Providing Consent

Clear
Today's Date

Month Day Year
Date
Date of Birth

Month Day Year
Date
Medical Record Number
Name of Beneficiary's Representative Providing Consent (if Applicable)

First Name Last Name
Signature of Beneficiary's Representative Providing Consent (if Applicable)

Clear
Today's Date

Month Day Year
Date

Authorization to Release Protected Health Information
Patient Name

First Name Last Name
Address
City/State/Zip
Date of Birth

Month Day Year
Date
Phone Number
Please enter a valid phone number.
I hereby authorize the following provider to disclose the above-named individual’s health information. I understand that the information in my health record may include information relating to communicable disease, Acquired Immunodeficiency Syndrome
(AIDS), or Human Immunodeficiency Virus (HIV), genetic testing or screening, behavioral or mental health, alcohol/drug (substance) abuse or any such related information.
Name of Facility Releasing Information
Provider to whom this information will be released:

Western Reserve Medical Group
26110 Emery Road, Suite 300
Warrensville Heights, Ohio 44128

Purpose of Disclosure:

TREATMENT
Information to be used/disclosed: Progress Notes

Consultations Most recent history and physical Immunization record Other
Information to be used/disclosed: Laboratory Reports

Radiology/Imaging reports Entire medical record
Start Date of Information Disclosed:

Month Day Year
Date
End Date of Information Disclosed:

Month Day Year
Date
By signing this authorization, I agree to the following

> I understand if I authorize my information to be released to persons or organizations not subject to federal privacy laws, the information may be re-disclosed by the recipient and the information will no longer be protected.

> I understand that authorizing the use and disclosure of this health information is voluntary and that I can refuse to sign this authorization. I do not need to sign this form in order to receive treatment.

> I understand that I may inspect a copy of the information to be used or disclosed.

> I understand that I can revoke this authorization at any time by contacting my provider, but any revocation will not apply to the extent that my provider has acted in reliance of this authorization.

> I authorize the use and disclosure of my health information as described above. This authorization expires one year from the date on which it was signed, unless otherwise specified.
Otherwise specified date, event, or condition:
Signature of Patient or Personal Representative

Clear
If not signed by patient, list personal representative’s authority to act for the patient

First Name Last Name
Date

Month Day Year
Date
Should be Empty:

New Patient Forms

Your information is safe on our secure HIPPA compliant website and forms.

Western Reserve Medical Group Referral

Power of Attorney

Insurance

Pharmacy

Billable Party

Primary Contact

CONSENT TO WESTERN RESERVE MEDICAL GROUP (M/LLS MED/CAL PRACT/CES)AND CORPORATE AFF/L/ATES FOR SERVICES

GENERAL CONSENT FOR TREATMENT

Authorization to Release Protected Health Information