PFM New Patient Packet

PATIENT INFORMATION
First Name*
Middle Name
Last Name*
Sex*
Date of Birth*

MonthDayYear
Date
Age*
Address*

Street Address

Street Address Line 2

CityState

Zip
Home Phone
Cell Phone*
E Mail*
example@example.com
Social Security #*
Employer
Next of Kin / Emergency Contact Name*
Relationship*
Phone #*

INDIVIDUAL RESPONSIBLE FOR PAYMENT
First*
Middle
Last*
Date of Birth*

MonthDayYear
Date
Social Security #*
Address*

Street Address

Street Address Line 2

CityState

Zip
Home Phone*
Work Phone
Employer
Employer Address

PRIMARY INSURANCE COMPANY
Insurance Company Name*
Policy ID No.*
Group #*
Address

Street Address

Street Address Line 2

CityState

Zip
Name of Policy Holder*
Relationship to Insured*
Subscriber Name
Date of Birth*

MonthDayYear
Date
Social Security #

SECONDARY INSURANCE COMPANY

Leave Blank If Not Applicable and Select Next
Insurance Company Name
Policy ID No.
Group #
Address

Street Address

Street Address Line 2

CityState

Zip
Name of Policy Holder
Relationship to Insured

PREFERRED PHARMACY
Pharmacy Name
Location
ASSIGNMENT OF BENEFITS
I understand that I am responsible for payment in full of all charges. I authorize payment of benefits from my insurance be paid directly to Pioneer Family Medicine, PLLC. I also authorize Pioneer Family Medicine, PLLC, to release to my insurance company any and all information neccesary for the processing of insurance claims.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

A Copy of this notice can be downloaded in PDF format from this page.
On April 14, 2003 the Pioneer Family Medicine joined every health care provider in the country in initiating implementation of the Federal Health Insurance Portability and Accountability Act of 1996 --- known as HIPPA.

Our practice has always respected the privacy of those who come to us seeking care and healing.

While HIPPA may be mandatory, it really is an extension of something we have been doing throughout our entire history. We continually make efforts to “Respect Privacy.”

In order to make sure that our patients are aware of their rights under HIPPA and how the practice may use and disclose their protected health information, we are making a concerted effort to make sure that each of our patients receives a copy of our Notice of Privacy Practices.

To help us keep track of who has and how has not received a copy of our Notice of Privacy Practices, please take a moment to complete the information below.
Select One:*

I have received a copy of the practices Notice of Privacy PracticesI respectfully decline the receipt of a copy of the practices Notice of Privacy Practices

CREDIT POLICY
Disclosure:

Pioneer Family Medicine, PLLC, is committed to providing quality medical services at a reasonable cost. It is our policy to collect all accounts receivable within 90 days from the date of service. This policy is written to assist our clinic in serving patients at the most affordable cost.

For those patients with insurance coverage, we will bill insurance regularly and in a timely manner. However, the patient is ultimately responsible to understand the specifics of their individual insurance coverage. The insurance contract is between the covered individual and the insurance company. The patient retains ultimate responsibility for financial charges incurred as a result of treatment. Our staff is available for assistance with insurance billing questions during operating hours.

For those patients who do not have insurance coverage, we are very sensitive to your individual financial constraints. If necessary, we encourage patients to contact our office manager or billing department to arrange an acceptable payment schedule.

We request payment of dedictibles or co-payments at the time of service. If this is not possible, please discuss this with our office manager or billing department to arrange an acceptable payment schedule.

In the event that an account has not closed in 90 days from the date of service, and no financial agreement has been arranged, the individual will receive final notification by letter that payment is due. If no response is received indicating a willingness to pay, the patient’s account will be referred to a professional credit agency and the patient released from medical care at our facility.

We are disclosing this policy to you now so that we may avoid a misunderstanding in the future.
I have read and understand this policy and my questions have been answered to my satisfaction.

Consent To Treat

I consent to, and authorize the physicians at the Pioneer Family Medicine to furnish me and my dependents with necessary medical care. This medical care may include radiology examinations, laboratory testing and other diagnostic procedures as may be required.
Yes
Release of Medical Information

I consent to, and authorize the Pioneer Family Medician physicians/provider to disclose all or part of my, or my dependent’s record to any mutually agreed upon referring physician.
Yes
Insurance Authorization and Assignment of Benefits

I consent to, and authorize the Pioneer Family Medicine to furnish medical information to any third party that may be responsible for payment of all or part of any charges incurred at the Pioneer Family Medicine. I authorize my insurance company, or any responsible third party to pay benefits directly to the Pioneer Family Medicine.
Yes
Financial Responsibility

I understand that I am financially responsible for the payment of medical charges incurred on my behalf at the Pioneer Family Medicine, regardless of third party coverage.
Yes
Patient Printed Name
Select Any That Apply

Patient is under 18 years of age and there considered a minorPatient is physically or mentally incompetentNot Applicable
Relationship to Patient
Guardian Email Address
example@example.com

AUTHORIZATION TO RELEASE HEALTH INFORMATION
Please list any family member names that health information may be released to:
Type of health information to be included:

Any information concerning the patient's health or health care
Select One:

Authorization Expires on Specific DateAuthorization Does Not Expire
This authorization will expire on the following date

MonthDayYear
Date

COMPLETE PHYSICAL EXAM

Why you might get more than one bill when you see a medical provider:
If you are here today for your annual wellness exam (i.e. well-child check, preventative exam, yearly physical), the claim submitted to your insurance company will reflect this. Depending on your health plan, this visit may or may not be covered. Not all insurance plans cover wellness visits.

If other significant ailments are discussed and evaluated during your wellness appointment (ex: hypertension, depression, diabetes, pain, acne, sore throat, joint pain, etc), you may receive a second charge for an office visit on top of the charge for a wellness visit. This additional service may not be considered part of your wellness benefit and your insurance may require you to pay a co-pay or they may apply the second charge towards your deductible or co-insurance.

You may also receive a second bill from our lab, Interpath Laboratory, as some insurance companies do not let us bill them directly for some or all lab services. (i.e. bloot tests, urine culture, pap smear, STD testing)

Each service your provider performs has a billing code. Your provider codes your services according to the guidelines and must use the correct codes for the service actually done. Providers use these codes when they submit claims to the insurance companies. If you insurance company does not cover some or all of the charges, you will be billed for any outstanding balance. It is fraudulent for your provider to manipulate the coding system to satisfy payer or patient coverage rules. If there is a billing error, that can be corrected.

Please contact your insurance company with any questions about what is covered under your policy.

Thank you.
Patient or Guardian Signature*

Clear
Today's Date and Time*

MonthDayYear
Date
Should be Empty:

PATIENT INFORMATION

INDIVIDUAL RESPONSIBLE FOR PAYMENT

PRIMARY INSURANCE COMPANY

SECONDARY INSURANCE COMPANY

PREFERRED PHARMACY

ASSIGNMENT OF BENEFITS

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

CREDIT POLICY

PATIENT HEALTH HISTORY

Surgeries/Hospitalizations (Type and Year)

Long Standing Medical Problems:

Current Medications (Include dose and frequency, if known)

Allergies: (Include medications, food and environmental)

Social History:

AUTHORIZATION TO RELEASE HEALTH INFORMATION

COMPLETE PHYSICAL EXAM