Advanced Wound Care New Patient Application for Care

New Patient Application for Care

Our mission is to empower individuals to regain control of their health and lives.
Patient Name *

First Name Middle Name Last Name
Patient Date of Birth *

Month Day Year
Date
Patient Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
Patient Email Address *
example@example.com
Preferred Method of Contact *
Marital Status *

Single Married Separated Divorced Widowed
Emergency Contact Name *

First Name Last Name
Emergency Contact Number *
Please enter a valid phone number.
Medications *
Please list all prescription and non-prescription medications or upload your list below. If none are taken please write "NONE."
Medications List File Upload

Cancel of
Allergies *
Please list all allergies or upload your list below. If none are taken please write "NONE."
Allergies List File Upload

Cancel of
Surgeries *
Please list all surgeries, dates and doctor. If none have been performed write "NONE."

Insurance Information
Primary Insurance

You can upload pictures of your primary insurance card below or complete the form.
Upload Front of Insurance Card

Cancel of
Upload Back of Insurance Card

Cancel of
Insurance Company
Copay
Group #
Subscriber #
Insured Name

First Name Middle Name Last Name
Social Security Number
Subscriber Date of Birth

Month Day Year
Date
Relationship to Patient
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Secondary/Supplemental Insurance

You can upload pictures of your secondary/supplemental insurance card below or complete the form.
Upload Front of Insurance Card

Cancel of
Upload Back of Insurance Card

Cancel of
Insurance Company
Copay
Group #
Subscriber #
Insured Name

First Name Middle Name Last Name
Social Security Number
Subscriber Date of Birth

Month Day Year
Date
Relationship to Patient
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.

HIPAA Compliance Patient Consent Form
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:
- Is required by federal law to maintain the privacy of your Protected Health Information and to provide you with this Privacy Notice detailing the practice's legal duties and privacy with respect to your Protected Health Information.
- Under the Privacy Rule, may be required by State law to grant greater access or maintain greater restrictions on the use or release of your Protected Health Information than that which is provided for under federal law.
- Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
- The practice reserves the right to change the privacy policy as allowed by law.
- The patient has the right to refuse to sign or revoke this consent in writing at any time, Refusing to sign or revoking the acknowledgment does not prevent a provider from using or disclosing health information as HIPAA permits
- The practice will not retaliate against you for filing a complaint.
May we phone, email, or send a text to you to confirm appointments? *

Yes No
May we leave a message on your answering machine at home or on your cell phone? *

Yes No
May we discuss your medical condition with any member of your family? *

Yes No
If NO, please name the members ALLOWED to receive your medical information including medical conditions, medications, and test results:
Name

First Name Last Name
Relationship
Name

First Name Last Name
Relationship
Name

First Name Last Name
Relationship
This consent was signed by: (Print Name of Patient) *

First Name Last Name
Signature *

Clear
This Authorization remains valid until patient is no longer under care with Abundant Health Physical Medicine of Davenport, IA, unless effectively revoked in writing by the individual before that event.

Authorization to Release Information/Assignment of Benefits Form
Financial Responsibility

All professional services rendered are charged to the patient and are due at the time of service unless other arrangements have been made in advance with our business office. Necessary forms will be completed to file for insurance carrier payments.

Assignment of Benefits

I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carriers), including Medicare, private insurance, and any other health/medical plan, to issue payment check(s) directly to Abundant Health Physical Medicine of Davenport, IA for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.

Authorization to Release Information

I hereby authorize Abundant Health Physical Medicine of Davenport, IA to:
1. Release any information necessary to insurance carriers regarding my illness and treatments.
2. Process insurance claims generated during examination or treatment; and
3. Allow a photocopy of my signature to be used to process insurance claims for the period of lifetime.
This order will remain in effect until revoked by me in writing. I have requested medical services from Abundant Health Physical Medicine of Davenport, IA on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.
Type Name of Patient/Responsible Party *

First Name Last Name
Signature of Patient/Responsible Party *

Clear

Medical Records Release Form
By signing this form, I authorize Abundant Health Physical Medicine of Davenport, IA to release my confidential health information, by releasing a copy of my medical records, or a summary or narrative of my protected health information, to designated physician(s)/person(s)/facility/entity and/or those directly associated with the medical care I will receive at this facility.
Printed Patient Name *

First Name Last Name
Patient/Guardian Signature *

Clear
Patient Date of Birth *

Month Day Year
Date
Relationship of Guardian (If Needed)

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW TO ACCESS THIS INFORMATION. Please Review Carefully

Acknowledgement of Receipt of Notice of Privacy Practices
I acknowledge that I have reviewed the Notice of Privacy Practices of Abundant Health Physical Medicine.
(PLEASE INITIAL ONE OF THE FOLLOWING OPTIONS AND SIGN BELOW.) *

YES, I wish to receive an electronic coy of Privacy Notice NO, I do not request a copy of the Privacy Notice at this time. I acknowledge that I can request a copy at any time and the Privacy Notice is posted in the office.
If YES, Please enter the email address to where you'd like the Privacy Notice sent to.
example@example.com
Please check the button below: *

I acknowledge that if I should have a problem or question in regard to my rights, I may speak with the Front Desk about my concerns to be forwarded to the appropriate department.
Signature *

Clear
Should be Empty:

	Usually	Sometimes	Never
Walking
Climbing stairs
Descending stairs
Sitting down
Getting up from chair
Touching your feet while seated
Reaching behind your back
Reaching behind your head
Dressing yourself
Going to sleep
Staying asleep due to pain
Obtaining restful sleep
Bathing
Eating
Working

New Patient Application for Care

Past Medical History

Review Of Systems

Pharmacy & Other Physicians

Social Status/History

Insurance Information

Primary Insurance

Secondary/Supplemental Insurance

HIPAA Compliance Patient Consent Form

Authorization to Release Information/Assignment of Benefits Form

Medical Records Release Form

Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

	Physician/Home Health Agency	Specialty	Phone Number
1.
2.
3.