Demographics Form

DEMOGRAPHICS FORM
Name*

First NameLast NameSuffix
Preferred Name

First NameLast Name
Preferred Phone Number*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Email
example@example.com
By entering your email address you will have access to our patient portal. Through the portal you can send secure messages to our doctors or our staff. You can also ask for appointments, prescription refills, and view your medical history, medication list and vaccine history. You will receive an email with access to login to our portal once you are established with our practice. You are of course free to communicate with our office by portal, phone, mail or in-person.
Date of Birth*

MonthDayYear
Date
Social Security Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender
Race
Hispanic
Language
Insurance

Please bring photo ID and insurance card with you to your appointment. Thank you.
Insurance Name
Subscriber's Name

First NameLast Name
Subscriber's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscribers Date of Birth

MonthDayYear
Date
I hereby authorize Poolesville Family Practice to apply for benefits on my behalf for covered medical services rendered. I request payment be made directly to Poolesville Family Practice. I certify that the information provided is correct and further authorize release of any necessary information, including medical information for any claim by Poolesville Family Practice to the above named billing agent. I confirm that I understand and agree to the Poolesville Family Practice Patient Policy Manual, available in the office and online at www.poolesvillefamilypractice.com
Signature*

Clear

Message Permission Form and Emergency Contact
Message Permission Form

I allow Poolesville Family Practice doctors and staff to speak with the following people reguarding my health.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Emergency Contact

The following will only be contacted in case of emergency.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relation to patient.*

Programs and Agreement
HIPAA

A federal law known as HIPAA (the Health Insurance Portability and Accountability Act) requires that medical practices and other medical providers explain to you the rules governing the privacy of your medical records. We comply with HIPAA and all local/state health privacy regulations. If you would like a copy of our official HIPAA policy it is available at the front desk or our website (poolesvillefamilypractice.com ).
Poolesville Family Practice is only contracted with Medicare (and no other private insurer)

I understand that Poolesville Family Practice is not contracted with my insurance company (except Medicare). I realize that my bill would probably be lower if I were to go to a doctor contracted with my insurance. I do understand that I am ultimately responsible for the payment of my bill. I understand that the office may submit my bill to my insurance company, but I agree to be responsible for any portion of my bill which is not covered by my insurance.
Prescription History Access:

In order to better care for you, our doctors and staff may need to access your prescription medication history. By signing this document you give us permission to have access to your electronic prescription history.
Maryland Health Information Exchange:

We have chosen to participate in the Chesapeake Regional Information System for our Patients, Inc. (CRISP), a statewide health information exchange. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may “opt-out” and prevent access of your health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax or through their website at www.crisphealth.org.
Medicare patients ONLY: Maryland Primary Care Program (MDPCP):

Our practice is participating in the MDPCP, a state-wide initiative to improve primary care. Through MDPCP, the Centers for Medicare and Medicaid Services (CMS) will give our practice additional resources to help us better manage your care. We hope to provide you the highest quality patient-centered care. To help us provide you with the best care, Medicare will start sharing some of your personal health information with us and the State Designated Health Information Exchange (CRISP), to share with other health professionals providing care to you. This will provide us with a more complete picture of your health and allow us to better coordinate your care.

Your Medicare benefits ARE NOT changing. Enhanced services covered by this program will not require additional cost-sharing for you. You still have the right to use or visit any doctor or hospital that accepts Medicare, at any time. Your doctor may continue to recommend that you see particular doctors for your specific health needs, but it’s always your choice which doctors or hospital(s) you visit.

If you want Medicare to stop sharing this personal health information, please contact 1-800-MEDICARE.

A Health Information Exchange, or HIE, is a way of sharing your health information among participating doctors’ offices, hospitals, care coordinators, labs, radiology centers, and other health care providers through secure, electronic means. The purpose is so that each of your participating healthcare providers can have the benefit of the most recent information available from your other participating providers when taking care of you.

If you choose to opt out of participation in the HIE, doctors and nurses will not be able to search for your health information through the HIE to use while treating you. Your physician or other treating providers will still be able to select the HIE as a way to receive your lab results, radiology reports, and other data sent directly to them that they may have previously received by fax, mail, or other electronic communications. Additionally, in accordance with the law, Public health reporting, such as the reporting of infectious diseases to public health officials, will still occur through the HIE after you decide to opt out. Controlled Dangerous Substances (CDS) information, as part of the Maryland Prescription Drug Monitoring Program, will continue to be available through the HIE to licensed providers. If you want to opt, please visit https://crisphealth.org/for-patients-your-rights/
I agree to all of the above statements and have had all of my questions regarding the above statements answered to my satisfaction.
Signature*

Clear
Todays Date*

MonthDayYear

Request for Medical Records

19710 Fisher Ave., Ste J, Poolesville MD20837, (P) 972-7600, (F) 301-972-8006
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Name of health care provider
Provider Phone Number
Provider Fax Number
Poolesville Family Practice request the following records.
Last 2 years of medical records and all immunizations. Also any additional request as stated below. Thank you.
Purposes of Disclosure

Information listed above will be disclosed for the purpose of Continuing Medical Care.

Persons Authorized to Use of Disclose Information

Information listed above will be used or disclosed by: Poolesville Family Practice

Expiration Date of Authorization:

This authorization is effective to one year after date of signature unless revoked or terminated earlier by the patient or the patient’s personal representative.

Rights of the Individual:

You may inspect or copy information used or disclosed under this authorization

You may refuse to sign this authorization

Effect of refusing Authorization:

If you refuse to sign this authorization, we will not deny you any treatment of any kind.
Patient's Name

First NameLast Name
Patient's Signature

Clear
Date signed

MonthDayYear
Patient Representative

First NameLast Name
Relationship to patient
Signature

Clear
19710 Fisher Ave., Ste J, Poolesville MD 20837, (Phone) 972-7600, (Fax) 301-972-8006
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DEMOGRAPHICS FORM

Message Permission Form and Emergency Contact

Programs and Agreement