New Patient Paperwork EWOG

Enhanced Wellness of Oak Grove

New Patient Paperwork for B. Laurie Ryba, Nurse Practitioner
Full Name*

First NameMiddle NameLast NameSuffix
Preferred Name*
Email*

Confirmation Emailexample@example.com
Front Photo of Drivers License
Back Photo of Drivers License
Drivers License Number
Patient Mailing Address*

Street Address

If Physical address is different from mailing address please list here

CityState

Zip Code
Date of Birth*

MonthDayYear
Date
Social Security Number*
Gender*
Patient Home Phone Number*
Please enter a valid phone number.
Patient Mobile Phone Number*
Please enter a valid phone number.
Patient Marital Status*
Spouse/Partner Contact

Full NamePhone NumberDate of Birth
If under 18 y/o - Parent or Legal Guardian Name

First NameLast Name
If under 18 y/o - Parent of Legal Guardian (Address, Phone Number, Email Address)

Emergency Contact*

Full NamePhone NumberRelationship to Patient
List any other providers the patient is currently seeing (type n/a if none)*
List Names/Phone number for family members who are Enhanced Wellness patients
Who referred you to our office or how did you find out about our office

Employer

Employer NameOccupation
Employer Contact Information

Employer Phone Number

Employer Street Address

CityState

Zip Code
Pharmacy Information

Pharmacy Name

Pharmacy Phone Number

CityState

Zip Code

Insurance Information
** Tricare patients **
- The Benefits Number (DBN) is an 11-digit number on the back of the ID card
- DBN is used to file claims, not the (not DOD#).
- Tricare patients please also list the SSN of the policy holder.
Insurance or Self Pay*
Insurance Company Name (List SELF PAY if no insurance)
Ins Co Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ins Co Phone Number
Please enter a valid phone number.
Ins Co Payer ID
Guarantor Insurance (Primary)
Guarantor DOB

MonthDayYear
Date
Guarantor SSN
Guarantor Phone #
Please enter a valid phone number.
Ins Co Policy#
Member #
Benefits #
Ins Group #
Ins Co Plan #

Primary Insurance Information

	Info
Insurance Company Name
Address
City / State / Zip
Ins Co Ph#
Payer ID (5#)
Guarantor/Policy Holder Name
Ins Policy#
Member#
Benefits#
Ins Grp#
Plan#
SSN of Guarantor
DOB of Guarantor
Guarantor Ph#

Front Picture of Insurance Card-Primary
Back Picture of Insurance Card-Primary

Secondary Insurance Information

	Info
Insurance Company Name
Address
City / State / Zip
Ins Co Ph#
Payer ID (5#)
Guarantor/Policy Holder Name
Ins Policy#
Member#
Benefits#
Ins Grp#
Plan#
SSN of Guarantor
DOB of Guarantor
Guarantor Ph#

Front Picture of Insurance Card-Secondary
Back Picture of Insurance Card-Secondary

Insurance Information - Secondary
[HIDDEN] Guarantor/Policy Holder-Primary Insurance

Guarantor Full NameDate of BirthPhone Number
[HIDDEN] Relationship to patient (Guarantor/Policy Holder-Primary Insurance)
ie parent, spouse, self
[hidden] FILE UPLOAD: Previous Records or Front / back copy of drivers license and all insurance cards if you are not able to take pictures.

Cancelof
[HIDDEN] Primary Insurance

Ins Policy#, Member#, Benefits # Ins Group# / Plan# SSN of Policy Holder
[HIDDEN] Primary Insurance

Insurance Name

Street Address / City / Zip Code

Insurance Phone NumberState

Payer ID (The payer ID is generally five (5) characters)
[HIDDEN] Secondary Insurance

Insurance Name

Street Address / City / Zip Code

Insurance Phone NumberState

Payer ID (The payer ID is generally five (5) characters)
[HIDDEN] Relationship to patient (Guarantor/Policy Holder-Secondary Insurance)
ie parent, spouse, self
Secondary Insurance

Ins Policy#, Member#, Benefits # Ins Group# / Plan# SSN of Policy Holder
[ HIDDEN] Guarantor/Policy Holder-Secondary Insurance

Guarantor Full NameDate of BirthPhone Number

STATEMENT OF PATIENT FINANCIAL RESPONSIBILITY
• It is the intention of ENHANCED WELLNESS OF OAK GROVE, PLLC to provide you with a clear understanding of our financial agreements and billing procedures in the hopes of preventing any misunderstanding.
• If you have any questions regarding these agreements, please notify the front office coordinator.
• Please take the time to read, initial, and sign the patient financial responsibility form.
• If you have medical insurance, it is your responsibility to fill out the insurance details on the patient form.
• Please provide your insurance card to the front office coordinator to bill your insurance carrier completely and accurately.
• If benefits cannot be determined at the time of service, or when there is any doubt, payment in full is expected.
• Please be advised that a medical insurance card does not inform our office of active coverage.
• Your insurance policy is a contract between you and your insurance company.
• We are not a party to that contract and therefore do not know the details or specific benefits allowed by your insurer.
• As a service to you and upon your request we can bill your insurance company.
• You are responsible for payment of any unmet deductible, co-payment, and co-insurance as determined by your contract with your insurance carrier.
• We expect these payments when services are rendered.
• Many insurance companies have additional stipulations that may affect your coverage.
• You are responsible for any amount not covered by your insurance.
• If your insurance carrier denies any part of your claim, you will be responsible for your balance in full.
• There are normal and expected times that we will need to bill your insurance company.
• However, if there is a time when the costs of completing your billing are over and above the usual and customary time spent processing and follow-up on a claim, we will contact you.
• If at this time payment has not been received by your insurance carrier payment will be expected in full by you and you may pursue collecting personally.
• If payment is received from your insurance carrier you will be reimbursed.
• Once payment is received on your behalf from your insurance carrier any balances due to unmet deductible, co- payments, and co-insurance that have not already been collected will be billed to you and possible Finances charge will begin to apply on your account.
• After thirty (30) days of the first bill, a finance charge of up to $100.00 annual and/or up to $50 per month finance charge will begin to apply on your account.
• Any bill over sixty (60) days past due will be subject to collection procedures.
• If you fail to make payment arrangements or set up a payment plan, your account will be turned over to a professional collection agency.
• Upon receipt of payment from your insurance provider, you may end up with a credit balance.
• Any overpayment will remain on your account as a credit to be used towards future services or material purchases.
• If you would like to be issued a refund, please let us know and we will issue a refund check.
• There will be a $30.00 service charge for any returned check. After receiving a returned check, we will no longer accept a check on your account. Payments will have to be made using cash or credit card.
• I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered.
• I understand it is my responsibility to verify my insurance coverage prior to my appointment.
• I understand that if a REFERRAL is needed from my PCP, I am responsible for obtaining that referral.
• If a referral is required and I do not provide the referral number from insurance prior to my visit, I agree to pay the charges even if all claims are denied by insurance.
• I understand that if a PRIOR AUTHORIZATION is needed from my PCP for any services/procedures that I am responsible for alerting Enhanced Wellness of Oak Grove PLLC at least 10 days in advance in order to have approval before the date of service.
• If a PRIOR AUTHORIZATION is required and I do not have an approved PA number prior to my visit, I agree to pay the charges even if all claims are denied by insurance.
• We cannot obtain referrals or prior authorizations on the date of service.
• I agree to pay all costs of the collection, including reasonable attorney fees and court costs in the event it becomes necessary to pursue the account for collection.
• I have read and understand all of the above information and have completed this form to the best of my ability.
• I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in my status of the above information.
• I understand it’s my responsibility to ask any questions regarding cost prior to services/procedures being performed. We can provide a good faith estimate.
• I understand that some lab work/specimens are sent to outside lab facilities and therefore, that facility will bill you for those services.
• If an outside facility is billing, then you will have to contact that company directly for billing questions.
Signature of Patient or Parent/Guardian*

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Hour Minutes

CONSENT FOR ENHANCED WELLNESS TO UTILIZE THE HEALTH INFORMATION EXCHANGE (HIE)
Authorization for Access to Patient Information Through a Health Information Exchange Organization
• I request that health information regarding my care and treatment be accessed as set forth on this form. I can choose whether or not to allow ENHANCED WELLNESS OF OAK GROVE PLLC to obtain access to my medical records through a health information exchange (“HIE”). If I give consent, my medical records from the facilities and clinicians that provide me with care can be accessed using the HIE. The HIE shares health information electronically to improve the quality of health care.
• The choice I make in this form will NOT affect my ability to receive medical care. The choice I make in this form does NOT allow health insurers to have access to my information for the purpose of deciding whether to provide me with health insurance coverage or pay my medical bills.
• My questions about this form have been answered and I have been provided with a copy of this form.
Details about the information accessed through a HIE and the consent process:
1. How Your Information May be Used. Your electronic health information will be used only for the following healthcare services:
Treatment Services. Provide you with medical treatment and related services.
Insurance Eligibility Verification. Check whether you have health insurance and what it covers.
Care Management Activities. These include assisting you in obtaining appropriate medical care, improving the quality of services provided to you, coordinating the provision of multiple health care services provided to you, or supporting you in following a plan of medical care. Quality Improvement Activities. Evaluate and improve the quality of medical care provided to you and all patients.
2. What Types of Information about You Are Included.
If you give consent, ENHANCED WELLNESS OF OAK GROVE PLLC may access ALL of your electronic health information available through a HIE in which it participates. This includes information created before and after the date this form is signed. Your health records may include a history of illnesses or injuries you have had (like diabetes or a broken bone), test results (like X-rays or blood tests), and lists of medicines you have taken. This information may include sensitive health conditions, including but not limited to:
• Alcohol or drug use problems  Birth control and abortion (family planning)
• Genetic (inherited)  diseases or tests
• HIV/AIDS  Mental health conditions
• Sexually transmitted diseases  Medication and Dosages
• Diagnostic Information  Allergies
• Substance use history summaries  Clinical notes
• Discharge summary  Employment Information
• Living Situation  Social Supports
• Claims Encounter Data  Lab Tests
3. Where Health Information About You Comes From.
Information about you comes from places that have provided you with medical care or health insurance. These may include hospitals, physicians, pharmacies, clinical laboratories, health insurers, the Medicaid program, and other organizations that exchange health information electronically.
4. Who May Access Information About You, If You Give Consent.
Only health care providers permitted by law and by the HIE to access information may access your information through the HIE.
5. Public Health and Organ Procurement Organization Access. Federal, state or local public health agencies and certain organ procurement organizations are authorized by law to access health information without a patient’s consent for certain public health and organ transplant purposes.
These entities may access your information through an HIE for these purposes without regard to whether you give consent, deny consent or do not fill out a consent form.
6. Penalties for Improper Access to or Use of Your Information.
There are penalties for inappropriate access to or use or your electronic health information. If at any time you suspect that someone who should not have seen or received access to your information has done so, you may file a complaint with the Office for Civil Rights at http://www.hhs.gov/ocr/privacy/hipaa/complaints
7. Re-disclosure of Information.
Any organization(s) you have given consent to access health information about you may re-disclose your health information, but only to the extent permitted by state and federal laws and regulations. Alcohol/drug treatment-related information or confidential HIV-related information may only be accessed and may only be re-disclosed if accompanied by the required statements regarding prohibition of re-disclosure.
8. Effective Period.
This consent form will remain in effect until the day you change your consent choice, in case of a minor until he/she turns 18 years of age, or until 50 years after your death.
9. Changing Your Consent Choice.
You can change your consent choice at any time by submitting a new consent form with your new choice. Organizations that access your health information through an HIE while your consent is in are not required to return your information or remove it from their records if you later revoke this consent.
10. Copy of Form.
You are entitled to get a copy of this consent form.
Signature of Patient or Parent/Guardian*

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CONSENT TO OBTAIN MEDICATION HISTORY
Our medical practice has adopted an electronic medical record system in order to improve the quality of our services.
- This system also allows us to collect and review your “medication history.”
  A medication history is a list of prescription medicines that we or other doctors have recently prescribed for you.
- This list is collected from a variety of sources, including your pharmacy and your health insurer.
- An accurate medication history is very important to helping us treat you properly and in avoiding potentially dangerous drug interactions.
- By signing this consent form you give us permission to collect, and give your pharmacy and your health plan permission to disclose, information about your prescriptions that have been filled at any pharmacy or covered by any health insurance plan.
- This includes prescription medicines to treat AIDS/HIV and medicines used to treat mental health conditions, such as depression.
- This information will become part of your medical record.
- This medication history is a useful guide, but it may not be completely accurate.
- Some pharmacies do not make drug history available to us, and the drug history from your health plan might not include drugs that you purchased without using your health insurance.
- Your medication history might not include over the counter medicines, supplements or herbal remedies.
- It is still very important for us to take the time to discuss everything you are taking, and for you to point out to us any errors in your medication history.
- I give permission for you to obtain my medication history from my pharmacy, my health plans and my other healthcare providers.
Signature*

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ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I hereby acknowledge that I have the right to read a copy of Enhanced Wellness of Oak Grove’s(the “Practice”)Notice of Privacy Practices (the “Notice”).

I can view it in the clinic by request. I understand that I may address any questions or concerns I may have about the Notice.
Signature*

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PRESCRIPTION REFILL POLICY
• I understand that prescription refills and follow up care are my responsibility, and that I should call ENHANCED WELLNESS OF OAK GROVE, PLLC at least 1 week before I need a prescription refill.
• Refills are provided only at the provider’s discretion and can take up to 3 business days to review/approve.
• We DO NOT do same day prescription refills.
Signature*

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NO SHOW / LATE / MISSED APPOINTMENTS POLICY
• We understand that circumstances may arise that do not allow you to keep your appointment or that you may forget occasionally.
• Please remember to be courteous to us and the other patients by calling at least 24 hours prior to the time of your appointment to cancel if you cannot make it.
• This will allow us to serve our patients better.
• Patients arriving more than 15 minutes late for their appointments will be counted as a ‘no-show visit’, and they will need to reschedule their appointments.
• We enforce a 3- strike policy for missed/late/no show appointments.
• After your 3rd strike, we will no longer be able to serve you as your health care provider.
• Missed appointments cost us all time, effort, and money. If you have any questions, please ask any of the staff or your provider.
• No-show appointments may be subject to a $25.00 fee
Signature*

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INTEGRATIVE MEDICINE CONSENT
• I understand that Enhanced Wellness of Oak Grove, PLLC is an integrative medicine practice focusing on whole body health and wellness by using naturally healing methods/treatment.
• Integrative medicine includes recommendations for nutrition, supplements/vitamins, and bio identical hormone evaluations (estradiol, progesterone, testosterone, thyroid).
• I understand that some services may be considered non-traditional, non-conventional, or alternative medicine.
Signature*

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GENERAL CONSENT FOR CARE AND TREATMENT
• This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment.
• By signing below, you are indicating that
1.) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and
2.) you consent to treatment at this office or any other satellite office under common ownership. You have the right to discuss the treatment plan with your provider about the purpose, potential risks and benefits of any test ordered for you.
• I understand I will be responsible for the cost of any treatment, procedures, or diagnostics testing (IE-lab work) if it is denied or not paid by my insurance.
• I understand I have the right to verify any cost before the testing is done as we cannot revoke any charges once services/treatment is completed.
• If you have any concerns regarding any test or treatment recommended by your health care provider, we encourage you to ask questions.
• I voluntarily request any health care providers, or the designee I as deem necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice.
• The consent will remain fully effective until it is revoked in writing.
• You have the right to discontinue services at any time.
• I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.
Signature*

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Assignment of Benefits
• I have read the policies regarding my financial responsibility to ENHANCED WELLNESS OF OAK GROVE, PLLC for services performed to myself or the patient.
• I authorize my insurer to pay any benefits directly to ENHANCED WELLNESS OF OAK GROVE, PLLC.
• I agree to pay the full and entire amount of all bills incurred by the patient, as well as any amount due after my insurance carrier has made a payment.
Signature*

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Enhanced Wellness of Oak Grove (EWOG) has implemented a new credit card policy. Like many other Private Medical
practices/offices, we have adopted a similar policy. We kindly request a credit card for each patient, which may be
used later to pay any balance that may be due on your bill.

Co-Pays are still due at the time of service. At registration and/or check-in, your credit card information will be
obtained and kept securely until your insurance(s) have paid their portion and notifies us of the balance due, if any.
The information will be held securely until your insurance has paid their portion of the claim and notified us of any
additional amount owed by the patient. At that time, we will notify you that your outstanding balance will be charged
to your credit card five (5) days from the date of the notice.

You may call our office if you have a question about your balance. We will send you a receipt for the charge. This
“Card-on-File” program simplifies payment for you and eases the administrative burden on your provider’s office. It
reduces paperwork and ultimately helps lower the cost of healthcare.

Your statements will be available via your patient portal and our Customer Support line is available to answer any
questions about the balance due. If you have any questions about the card-on-file payment method, please do not
hesitate to let us know.
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By signing below, I authorize EWOG to keep my signature and my credit card information securely on-file in my
account. I authorize EWOG to charge my credit card for any outstanding balances when due.
Signature*

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PATIENT AUTHORIZATION FORM
Authorization to Release Information to Family Members Many of our patients allow family members such as their spouse, significant other, parents or children to call and request the result of tests, procedures, and financial information. Under the requirements for HIPAA. We are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical information, any diagnostic test results and/or financial information released to any family members you must sign this form. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent. I authorize ENHANCED WELLNESS OF OAK GROVE PLLC to release my records and any information requested to the following individuals. If none leave blank
Name - Release of Information 1

Full NamePhone# and Relationship to Patient
Type of Information - Release of Information 1
Name - Release of Information 2

Full NamePhone# and Relationship to Patient
Type of Information - Release of Information 2
Name - Release of Information 3

Full NamePhone# and Relationship to Patient
Type of Information - Release of Information 3
Name - Release of Information 4

Full NamePhone# and Relationship to Patient
Type of Information - Release of Information 4
Date*

MonthDayYear
Date
Signature*

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Authorization Regarding Messages

- Please check all that apply. ** Authorization to Release Information
Preferred Phone Number for messages (VM or SMS)*
Please enter a valid phone number.
Preferred Phone Number2 for messages (VM or SMS)
Please enter a valid phone number.
I authorize you to leave a detailed message, SMS, and/or voicemail:*

on my preferred numbers regarding appointments.on my preferred numbers regarding medical and/or financial information.No messages - Speak directly to patient only
I authorize you to leave a detailed message, SMS, and/or voicemail:*

Messages can be left with anyone who answers the phone on preferred numbers.Messages may only be left with Release Person #1 (per selection above)Messages may only be left with Release Person #2 (per selection above)Messages may only be left with Release Person #3 (per selection above)Messages may only be left with Release Person #4 (per selection aboveNo messages - Speak directly to patient only

Medical History Form
Height
Weight
Race
Reason for visit:

Tobacco Use*

Never SmokedFormer/Past SmokerCurrent User
Tobacco Type Used (Smoker, Dip, Vape, e-Cig, Other)
Year Started/Stopped using tobacco:
If smoker: How many times per day? (ie: 1 in morning, 1-9 per day)

	Date/Age symptoms started/# of days
Date of Last Period
Age when period started
AVG # of days period last and # of days between periods

Ears, Nose, and Throat*

Bleeding from noseBothersome nasal allergiesProblems with taste/smellRecurring sinus infectionsRinging in the earsTrouble breathing via noseNoneOther
Other

Endocrine*

Type 1 DiabetesType 2 DiabetesCushing's DiseaseHyperthyroidism (overactive)Hyperthyroidism (underactive)OsteoporosisGoiterNoneOther
Other

General*

Any new lumps/bumps on the bodyDifficulty with sleepFatigue, tirednessFever or chillsIncreased thirst or urinationNight SweatsUnexplained weight loss/gainNoneOther
Other

Hematologic*

Abnormal bleeding/bruisingPernicious anemiaRecurrent blood clotsNoneOther
Other

	Date/Location	Never
Date of last Bone Density (1x lifetime)
-
Date of last Colorectal Cancer screening
-
Fecal/Stool Occult Blood test
-
Colonoscopy (~ 10 years)
-
Comp tomography/Flex sigmoidoscopy (~ 5yrs)
-
Date of your last eye exam
-
MALE ONLY- Prostate Rectal Exam (DRE):
-
MALE ONLY- PSA Lab
-
FEMALE ONLY- Pap Smear/Pelvic exam:
-
FEMALE ONLY- Breast Exam
-
FEMALE ONLY- Mammogram
-

	# of times	Never
Times Pregnant
Premature Births/Miscarriages
Abortions
Live Births

	Name of Medication	Dose (amount) taken (ie - mg)	Times per day	Approximate date started medication
1
2
3
4
5
6
7
8

	Father	Mother	Brother	Sister	Pat Grand father	Pat Grand mother	Mat Grand father	Mat Grand mother
Alive
Deceased
High Cholesterol
Hypertension
Aneurysm
Ulcers
Kidney Stones
Stroke
Alzheimer's
Diabetes
Thyroid
Early Menopause
Cancer

	Allergic to	Reaction to
1
2
3
4

	Name of surgery/procedure	Date occurred	Side (left vs right)
1
2
3
4
5
6

Enhanced Wellness of Oak Grove

Insurance Information

Insurance Information - Secondary

STATEMENT OF PATIENT FINANCIAL RESPONSIBILITY

CONSENT FOR ENHANCED WELLNESS TO UTILIZE THE HEALTH INFORMATION EXCHANGE (HIE)

CONSENT TO OBTAIN MEDICATION HISTORY

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

PRESCRIPTION REFILL POLICY

NO SHOW / LATE / MISSED APPOINTMENTS POLICY

INTEGRATIVE MEDICINE CONSENT

GENERAL CONSENT FOR CARE AND TREATMENT

Assignment of Benefits

PATIENT AUTHORIZATION FORM

Authorization Regarding Messages

Medical History Form

Medical Review of Systems