New Patient Registration

(statements will be addressed to responsible party)

if different from above

(Please list someone who does not live with you)

I understand that by signing this agreement, I indicate my wish to establish medical care with Outreach Medical Group.

I understand that I am under the medical supervision of a healthcare provider. I understand that my healthcare provider is responsible for diagnosing and prescribing drugs, therapy, and for supervising my medical care.

The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the Outreach Medical Group. I understand that I am financially responsible for any balance. I also authorize Outreach Medical Group or insurance company to release any information required to process my claims. In addition, I acknowledge that I have been informed of the OUTREACH MEDICALGROUP’s Notice of Privacy Practices. I understand OUTREACH MEDICAL GROUP is a HIPAA compliantoffice. As a patient, I have the right to obtain a copy of theNotice of Privacy Practices at any time.

Our mission at Outreach Medical Group is to provide patient-centered team-based care with excellence in quality services, and access to all despite any barriers, stigma, socioeconomic or health disparity. Our payment policy was created to reduce administrative costs in order to keep our fees as low as possible for our patients. Payment is required at the time of service. Any applicable co-payments, co-insurance, negotiated payment plans and/or deductibles are due at the time of service. For patients with medical insurance benefits, we will bill your insurance. All charges incurred at Outreach Medical Group ultimately the responsibility of the patient, regardless of insurance benefits. We accept payment in the form of cash, check or credit card. A fee of $25 will be charged for returned checks. At Outreach Medical Group, we want to manage our time efficiently, so we can deliver excellent personal care to our patients. We request a 24 hour notice for all cancellations/reschedules. If you no-show for your appointment you will be charged $25 on the second occurrence. This fee is not covered by insurance and is the sole responsibility of the patient. Please understand this policy is to ensure efficient time management, so all patient’s get the time they need with our medical providers.

Patient Choice in Pharmacy: The Patient has been notified and informed by Outreach Medical Clinic Downtown, LLC (“Clinic”)staff that the Patient is free to select a health care provider of their choice, including a pharmacy to fill prescriptions written by the Clinic’s health care providers. The Patient’s choice shall not impact the Clinic’s willingness to begin or continue consultation, diagnosis, or treatment of the Patient. Clinic’s Disclosure of Financial Interest: Pursuant to Section 431:10C-308.7 of the Hawaii Revised Statutes, a referring health care provider is prohibited from referring a patient to an entity in which it has a financial interest without first disclosing that financial interest to the patient. The Clinic shares common ownership with several pharmacies in Hawaii, including all 5 Minute Pharmacy storefronts. If the Patient objects to this shared ownership financial interest, they are free to choose a different health care provider. By signing this Consent Form, Patient understands and acknowledges the shared ownership financial interest of the owner(s) of the Clinic. Further, if the Patient selects a 5 Minute Pharmacy storefront to fill their prescriptions written by a Clinic health care provider, Patient consents to the shared ownership financial interest. I have read the consents, policies, release of Information and payment policy above. I understand and agree to all its provisions.