New Patient Enrollment Form

New Patient Enrollment

Please complete this Demographic Information Form to register as a new patient at Carlden Health Family Clinic. Required fields are marked with a red asterisk (*). All parts must be completed and signed to finalize your registration. Thank you for your cooperation!
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Patient's Phone Number*
Format: (000) 000-0000.
Patient's E-mail
example@example.com
Patient's Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the Patient's GENDER?
What is the Patient's SEXUAL ORIENTATION? You may select more than one.

AsexualGayLesbianQueerIdentity Not ListedBisexualStraight / HeterosexualPansexualQuestioning / UnsurePrefer Not to Disclose
What is the Patient's MARITAL STATUS? You may only select one.
What is the Patient's ETHNICITY? *
What is the Patient's SPEAKING LANGUAGE? You may select more than one.

EnglishSpanishOther
What is the Patient's EMPLOYMENT STATUS? You may select more than one.

Employed, Part-TimeEmployed, Full-TimeStudent, Part-TimeStudent, Full-TimeDisabled, TemporaryDisabled, PermanentUnemployedRetiredOther
Patient's Emergency Contact

First NameLast Name
Patient's Emergency Contact Phone
Format: (000) 000-0000.
Patient's Relationship to Emergency Contact
eg. Parent, Brother/Sister, Friend, Spouse, etc.
Which PHARMACY would you like to use as your default pharmacy?
What is your selected PHARMACY'S PHONE NUMBER?
Format: (000) 000-0000.
Which HEALTH INSURANCE PROVIDER covers the Patient's medical services?*

Blue Cross Blue ShieldCignaUnited HealthcareMedicareAetnaOtherUninsured
What is the Patient's SUBSCRIBER ID NUMBER? *
You may skip this, if you are able to provide a photo copy of your insurance card below.
Upload a photo (.jpg, .gif, or .pdf) of the FRONT AND BACK OF THE PATIENT'S INSURANCE CARD. You will need to provide this before your appointment.

Cancelof
If completing this form for someone else, what is YOUR NAME?

First NameLast Name
What is YOUR RELATIONSHIP to the Patient?

I am the PatientMy child is the PatientMy parent is the PatientMy friend is the PatientOther
I, the undersigned, certify that the information provided on this form is accurate and truthful. If I intend to claim insurance benefits for services rendered at Carlden Health, I certify that the insurance coverage I have provided is accurate and truthful. In exchange for providing and billing these services to my insurer, I assign directly to Carlden Health Family Clinic, all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I, the Responsible Party named below, am financially responsible for all charges that have been duly processed through my insurance and still assigned to patient responsibility. I hereby authorize the doctor to release all information necessary to secure payment of my benefits. I authorize the use of this signature on all insurance submissions and claims for medical services provided by Carlden Health.
New Patient Enrollment (Part 2 of 3)

Please complete this HEALTH HISTORY FORM to register as a new patient at Carlden Health Family Clinic. Required fields are marked with a red asterisk (*). This is Part 2 of 3 in the New Patient Registration process. All parts must be completed and signed to finalize your registration. Thank you for your cooperation!
In the last two weeks, have you been bothered by feeling nervous, anxious, or on edge?*

YesNo
In the last two weeks, have you been bothered by not being able to stop or control worrying?*

YesNo
In the last two weeks have you had a loss of interest or pleasure in doing things you used to like to do?*

YesNo
In the last two weeks have you felt sad, depressed or hopeless?*

YesNo
Have you been sexually active in the last 12 months?*

YesNo
If you have been sexually active, which partners have you been with? You may choose more than one.

One Male PartnerOne Female PartnerMultiple Male PartnersMultiple Female PartnersOther
Do you have any history of Sexually Transmitted Disease (STD)?*

YesNoOther
Please list any DRUG, FOOD, & OUTDOOR ALLERGIES you may have, including your normal reactions and previous events.
Are you able to afford your medications?*

YesNo
Are you disabled?*

YesNo
Do you wear contacts or glasses?*

YesNo
Do you have a hearing impairment?*

YesNo
Do you have a Living Will and Advance Directive?
Have you had ALCOHOL in the past 12 Months?*

YesNo
If you have had alcohol, how often do you have at least one drink?
If you have had alcohol, how many drinks do you average per week?
Do you currently consume CAFFEINE more than once per month?*

YesNo
If you have had caffeine, how often do you consume it?
Do you currently use TOBACCO in any form?*

YesNo
Are you a former tobacco smoker?*

YesNo
Do you use RECREATIONAL DRUGS?*

YesNo
If you use recreational drugs, how often do you use them?
Do you use OTHER SUBSTANCES?*

YesNo
Please check off any GENERAL symptoms that you have, or had in the past year.

DepressionDizziness / FaintingFever / ChillsForgetfulnessHeadacheLoss of SleepLoss of WeightNervousnessNumbnessSweats
Please check off any CARDIOVASCULAR symptoms that you have, or had in the past year.

Chest PainHigh Blood PressureIrregular Heart BeatLow Blood PressurePoor CirculationRapid Heart BeatSwelling of AnklesVaricose VeinsOther
Please check off any EYE, EAR, NOSE, & THROAT symptoms that you have, or had in the past year.

Bleeding GumsBlurred VisionCrossed EyesDifficulty SwallowingDouble VisionEarache / DischargeHay FeverHoarsenessLoss of HearingNosebleedsPersistent CoughRinging in EarsSinus ProblemsSnoringVision Flashes / HalosOther
Please check off any GASTRO symptoms that you have, or had in the past year.

Poor AppetiteBloatingBowel ChangesConstipationDiarrheaExcessive HungerExcessive ThirstGasHemorrhoidsIndigestionNauseaRectal BleedingStomach PainVomitingVomiting BloodOther
Please check off any GENITO-URINARY symptoms that you have, or had in the past year.

Blood in UrineFrequent UrinationLack of Bladder ControlPainful UrinationOther
Please check off any REPRODUCTIVE HEALTH symptoms that you have, or had in the past year.

Abnormal Pap SmearBleeding Between PeriodsBreast LumpErection DifficultiesExtreme Menstrual PainHot FlashesLump in TesticlesNipple DischargePainful IntercoursePenis DischargeSore of PenisVaginal DischargeOther
Please check off any SKIN symptoms that you have, or had in the past year.

Bruise EasilyHivesRash / ItchingChange in MolesScarsSores That Won't HealAcneOther
Please check off the location of any MUSCLE & JOINT PAIN or NUMBNESS that you have, or had in the past year.

Arms / HandsHipsBackLegs / FeetNeckAcneOther
When was the last time you saw a CARDIOLOGIST?
When was the last time you saw a DEMATOLOGIST?
When was the last time you saw a ENDOCRINOLOGIST?
When was the last time you saw an ENT?
When was the last time you saw a GASTROENTEROLOGIST?
When was the last time you saw a HEMATOLOGIST?
When was the last time you saw a NEPHROLOGIST?
When was the last time you saw a OBGYN?
When was the last time you saw a ONCOLOGIST?
When was the last time you saw a ORTHOPEDIST?
When was the last time you saw a PHYSICAL THERAPIST?
When was the last time you saw a PSYCHIATRIST?
When was the last time you saw a PULMONOLOGIST?
When was the last time you saw a RHEUMATOLOGIST?
When was the last time you saw a SLEEP SPECIALIST?
When was the last time you saw a UROLOGIST?
Have you had a DENTAL exam in the last year?*

YesNo
Have you had a VISION screening in the last year?*

YesNo
Have you had a MAMMOGRAM in the last year?*

YesNo
Describe your FATHER's Health Problems, if any.
Describe your MOTHER's Health Problems, if any.
Describe your SIBLING's Health Problems, if any.
Describe ANOTHER FAMILY MEMBER's Health Problems that may be relevant to you, if any.
Please check off every CONDITION you have had in your lifetime.

AidsAlcoholismAnemiaAnorexiaAppendicitisArthritisAsthmaBleeding DisorderBreast LumpBronchitisBulimiaCancerCataractsChemical DependencyChicken PoxDiabetesEmphysemaEpilepsyGlaucomaGoiterGonorrheaGoutHeart DiseaseHepatitisHerniaHerpesHigh CholesterolHIV PositiveKidney DiseaseLiver DiseaseMeaslesMigraine HeadachesMiscarriageMononucleosisMultiple SclerosisMumpsPacemakerPneumoniaPolioProstate ProblemsPsychiatric CareRheumatic FeverScarlet FeverStrokeSuicide AttemptThyroid ProblemsTonsillitisTuberculosisTyphoid FeverUlcersVaginal InfectionsVenereal DiseaseOther
Please describe dates and circumstances of any SERIOUS ILLNESS OR INJURY.
Please describe dates and circumstances of any HOSPITALIZATIONS.
Please describe dates, complications, and outcomes of any PREGNANCIES.
I, the undersigned, certify that the information provided on this form is accurate and truthful. If I intend to claim insurance benefits for services rendered at Carlden Health, I certify that the insurance coverage I have provided is accurate and truthful. In exchange for providing and billing these services to my insurer, I assign directly to Carlden Health Family Clinic, all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I, the Responsible Party named below, am financially responsible for all charges that have been duly processed through my insurance and still assigned to patient responsibility. I hereby authorize the doctor to release all information necessary to secure payment of my benefits. I authorize the use of this signature on all insurance submissions and claims for medical services provided by Carlden Health.
New Patient Enrollment (Part 3 of 3)

Please review and sign our Practice Policies to complete your registration as a new patient at Carlden Health Family Clinic. All questions must be answered.We kindly ask that you read our Patient Policies carefully to ensure a clear understanding and to help us provide the highest quality care to all our patients.This is Part 3 of 3 in the New Patient Registration process. Once you have signed your name and clicked Submit, your registration will be complete.Thank you for your cooperation!
Insurance Claim Policies

These policies relate to your health insurance, filing claims, and coverage.
Please read the following scenarios and select which one you expect to apply based on your current insurance coverage. We will attempt to confirm your benefits prior to your visit and notify you if we have different expectations. If we cannot confirm your benefit details prior to your visit, we will follow your expectation and notify you 2-3 weeks after your visit if your benefits process differently. (Note: New Patient appointments are not considered preventive.)

I do not have insurance. I will be paying for the visit.My insurance is out-of-network. I will be paying for this visit.My insurance is in-network. I have a $X co-payment for all PCP services.My insurance is in-network. I have a deductible that HAS NOT been met.My insurance is in-network. I have a deductible that HAS been met, but I HAVE NOT met my out-of-pocket maximum..My insurance is in-network. I have a deductible that HAS been met and I HAVE met my out-of-pocket maximum.Other
INSURANCE COVERAGE DETERMINATION: Please bring a current insurance card with you to every appointment. Full payment for your service must be paid at the time of visit if you cannot provide the information needed to file your insurance claim. The patient and/or bearer of the insurance policy are ultimately responsible for payment for services not covered by their insurance plan.*

I AGREE. I will provide my current insurance information at every visit.
PRIMARY INSURANCE CLAIMS: Carlden Health Family Clinic is not responsible for knowing the coverage and limitations of your insurance plan. It is your responsibility to understand whether or not preventive care or other services are covered by your plan; whether or not Carlden Health Family Clinic is a part of your insurance provider network; and the total and remaining amounts of your co-pay and your deductible. If Carlden Health has successfully filed your claim and received a final determination from your insurance company within 90 days, the remaining balance is the patient’s responsibility.*

I AGREE. I am responsible for understanding my health insurancebenefits.
SECONDARY INSURANCE CLAIMS: We do not file secondary insurance claims. If requested, you will be provided with the information and paperwork you will need to file a secondary claim through your insurance.*

IAGREE. I am responsible for filing my secondary insurance claims.N/A. I do not use a secondary insurance.
MEDICARE CLAIMS. Carlden Health does not Accept Assignment of Medicare benefits. We will still file Medicare claims; however, payment must be made in full at the time of service for Medicare patients. Payment from Medicare will be sent to the patient directly as part of your Quarterly Benefit Summary from Medicare.*

I AGREE. I will pay up front as a Medicare patient.N/A. I do not have Medicare.
OUT-OF-NETWORK CLAIMS: If we are not contracted with your insurance company, we require full payment at the time of service. Patients without-of-network insurance will be responsible for their bill in full at the time of checkout. It is the patient’s responsibility to find out if we are in-network before being seen.*

I AGREE. If my insurance is Out-of-Network, I will pay at the time ofservice.
WORKER’S COMPENSATION / MOTOR VEHICLE ACCIDENTS: We do not process Worker’s Compensation, or handle car accident cases where your benefits are not handled by your health insurance. These are treated like Out-of-Network claims ,so you must pay up front for all services related to a workplace injury or car accident.*

I AGREE. I will pay up front for Worker's Compensation or Car Insuranceclaims.
Medical Services Policies

These policies relate to medical services provided at Carlden Health.
LABORATORY CHARGES: Charges for blood collections will be filed with your insurance company and you may owe a balance to Quest Diagnostics for the charges. For services rendered by Carlden Health employees, you are required to pay $10 at the time of your blood draw at our office to cover specimen handling fees. Quest will bill your insurance for the individual tests as a separate claim from any visit to a Family Care provider.*

IAGREE. I understand that lab services are billed separately by Quest Diagnostics.
PRESCRIPTION REFILL REQUESTS: Please allow 2-3 days from the time of receipt for prescription refill requests. Refill requests are primarily handled during an office visit. We do not fill controlled drugs over the phone or after office hours. It is the patient’s responsibility to have a list of the current medications that will need to be refilled prior to your follow up appointment. Failure to request a refill on a medication during an appointment may require the patient to return for another appointment.*

I AGREE. I will allow 2-3 days for all prescription refill requests.
CONTROLLED SUBSTANCE POLICY: Requests for controlled substance refills will not be given until prior records of usage has been obtained. Controlled substances will not be filled at your first appointment to our office. Controlled substances will only be refilled by the ordering provider and will not be filled after hours or on weekends. Patients requesting controlled prescriptions may be required to pick up a paper prescription in the office; prescriptions will not be mailed to patient. Patients requesting such medication agree to random drug screening at the provider’s request. Patients receiving controlled substances must arrive in-person for follow-up appointments a minimum of every three months.*

I AGREE. I will not abuse controlled substances.
VACCINATIONS: Adult and child vaccines are offered through our office. Most vaccines are covered by insurance, but some are not. Payment for some vaccines is expected at the time of service. Patients are required to sign a waiver prior to receiving the vaccine.*

I AGREE. I will pay for vaccines I receive that are not covered by myinsurance.
VACCINE NON-COMPLIANCE: While we recognize and respect the individual’s role as the ultimate decision maker for themselves and their child’s healthcare, we believe strongly that we are obligated to deliver the best and safest healthcare possible for our patients and our community. Refusal of recommended vaccinations indicates a significant difference of philosophy of care and we feel professionally uncomfortable caring for patients who will not receive recommended vaccinations. We will not admit any individual who is more than six months behind the CDC’s recommended schedule(http://bit.ly/CDCChildVax).*

I AGREE. I will stay up to date on all recommended vaccines.
Appointment Policies

These policies relate to scheduling and appointments.
PHONE CONSULTATIONS: All patient phone conversations with a medical provider may be billed as phone consultations. If the patient has medical questions, concerns, or treatment options that are discussed and covered during the phone call by their provider, this appointment would be billed similarly to a regular office visit and any co-payments or deductibles owed by the patient may apply.*

I AGREE. I understand that phone conversations with my provider may be billable.
MISSED APPOINTMENTS: A $25 Missed Appointment charge will be added to your account if you do not show or arrive more than 10 minutes late for your appointment or if you cancel any scheduled appointment within 6 hours of your appointment. Cancellations by email or through voice mail before 8:00am on the day of your appointment are acceptable. Carlden Health reserves the right to dismiss from the practice any patient who frequently misses scheduled appointments without prior notice. Patients who miss 3 consecutive scheduled appointments, or more than half of their appointments in a year, may be discharged at the discretion of Carlden Health.*

I AGREE. I will owe $25 if I miss an appointment or cancel too late.
Administrative & Payment Policies

These policies relate to administrative functions and payments owed.
PATIENT UNDER AGE 18: The parents, guardian or adult accompanying the minor is responsible for payment. For unaccompanied minors, non-emergency treatment will be denied unless consent for treatment and charges have been pre-authorized by a parent or guardian.*

I AGREE. I will be financially responsible for my child until they are 18 years old.N/A. I am not completing this form for a child who is under the age of 18 years old.
FORMS: There is a $10 charge for any forms that are brought in to be filled out outside of a scheduled appointment. Forms completed during an appointment are not subject to an additional charge.*

I AGREE. I will pay $10 for any forms that need to be completed outsideof a visit.
CO-PAYMENTS / DEDUCTIBLES: Co-Pays and estimated Responsible Amounts must be paid at the time of service. In the event you do not pay the proper amount at the time of checkout and owe a balance, the following billing process will apply for any amounts owed over $25 that were not paid at the time of service. If you owe for services rendered, your first billing statement will be sent via email. You will receive an explanation and a link to pay online.*

I AGREE. I will pay my bills on time and may be assessed a late fee if Idon't.
OVER-PAYMENTS: If you overpay for services, your account will be credited to use towards any expected expenses during your next appointment. You may also request a refund by mail at any time.*

I AGREE. If I overpay, I will receive credit on my account or a refund by check.
Privacy Policies

We have a legal duty to protect health information about you. The Patient hereby consents to the use or disclosure or his/her individually identifiable health information (“protected health information”) by Carlden Health in order to carry out treatment, payment, or health care operations
We may use and disclose Protected Health Information (PHI) about you without your authorization in the following circumstances: (1) We may use and disclose PHI about you to provide health care treatment to you. (2) We may use and disclose PHI about you to obtain payment for services. (3) We may use and disclose PHI about you for health care operations. (4) We may use and disclose PHI when required to do so because of the law. (5) You can object to certain uses and disclosures. (6) We may contact you to provide appointment reminders.(7) We may contact you with information about treatment or services

I AGREE. I allow Carlden Health to use my PHI to facilitate my care.
We participate in an Organized Health Care Arrangement (OHCA) with providers in the UNC Health Alliance. We may use your PHI for our own health care operations and for those of the OHCA in which we participate. Effective April 1, 2017.

I AGREE. I allow Family Care to share information with my other UNCproviders.
You have several rights regarding PHI about you. (1) You have the right to request restrictions on uses and disclosures of PHI. (2) You have the right to request different ways to communicate with you. (3) You have the right to see and copy PHI about you. (4)You have the right to request amendment of PHI about you. (5) You have the right to a listing of disclosures we have made. (6) You have a right to a copy of this Notice.

I AGREE. I understand how to view and restrict access to my PHI.
You may file a complaint in writing about our privacy practices to 198 Thomas Johnson Dr. STE 103, Frederick MD, 21702. Effective date of this notice is April 14, 2022.

I AGREE. I understand how to file a complaint.
The Patient should review the Facility’s Notice of Privacy Practices for Protected Health Information (this form) for a more complete description of the potential use sand disclosures of such information, and the Patient has the right to review such Notice prior to signing this consent form. Facility reserves for itself the right to change the terms of its Notice of Privacy Practices for Protected Health Information at any time. If the Facility does change the terms of its Notice of Privacy Practices, Patient may obtain a copy of the revised Notice by writing to 198 Thomas Johnson Dr. STE 103, Frederick MD, 21702.

I AGREE. I have read these questions and understand how to obtain a copy of them.
The Patient retains the right to request that the Facility further restrict how his/her protected health information is used or disclosed to carry out treatment, payment, or healthcare operations. The Facility is not required to agree to such requested restrictions however, if the Facility does agree to Patient’s requested restriction(s), such restrictions are then binding to the Facility.

I AGREE. I understand I may request further restrictions on my PHI.
Patient retains the right to revoke this Consent. Such revocation must be submitted to the Facility in writing. The revocation shall be effective except to the extent that the Facility has already taken action in reliance on the Consent. Consent may be revoked upon written request to 198 Thomas Johnson Dr. STE 103, Frederick MD, 21702

I AGREE. I understand I may revoke this Consent.
The Facility may refuse to treat Patient if he/she (or an authorized representative) does not sign this Consent Form, except to the extent that the Facility is required by law to treat individuals. If Patient (or authorized representative) signs this Consent Form and then revokes Consent, the Facility has the right to refuse to provide further treatment to Patient as of the time of revocation Form (except to the extent that the Facility is required by law to treat individuals).

I AGREE. I understand Carlden Health is not required to treat me if I do not sign this form.
Please provide the NAME & DATE OF BIRTH of any other person you would like to have access to your account at Carlden Health. (eg. Parent, Sibling, Spouse, etc.)
Please write the individual's name, DOB, and relationship to patient.
I authorize the above named person to have the following access to my account at Family Care. You may choose more than one option.

This person can schedule appointments for me.This person can request prescription refills and pick up paper prescriptions.This person can view all office visit notes.This person can view all lab notes.This person can manage my billing and payments.Other
I have read and understand this information. I have the right to a copy of this form and I am the patient or am authorized to act on behalf of the patient to sign this document verifying consent to the above stated terms.
Please verify that you are human*
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New Patient Enrollment

New Patient Enrollment (Part 2 of 3)

New Patient Enrollment (Part 3 of 3)

Insurance Claim Policies

Medical Services Policies

Appointment Policies

Administrative & Payment Policies

Privacy Policies