New Patient Enrollment Form

New Patient Enrollment

Evergreen Adult Medicine
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number
Sex*
Primary Contact Number:*
undefined
Email*
example@example.com
Communication Preference for results, reminder calls etc. (May choose more than one.) :*

EmailText - Reminder calls onlyPrimary phone/ voicemail
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status*
Employment Status*
Race*
Ethnicity*
Language*
Do you need an interpreter

YesNo
In case of emergency. Please note this person may receive medical information about you in an emergency.
Emergency Contact:*

First NameLast Name
Relationship*
Contact Number*
Permission to Communicate

Please list here, names and contact information of those we are allowed to communicate with regarding your healthcare. If this is not completed, we will not share your information with anyone.
Name

First NameLast Name
DOB

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Relationship
Name

First NameLast Name
DOB

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Relationship
*We have chosen to participate in the Chesapeake Regional Information System for our Patients (CRISP), a regional health information exchange serving Maryland and D.C. 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 disable access to your health information available through CRISP by calling 877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax or through their website at www.crisphealth.org. Public health reporting and Controlled Dangerous Substances information, as part of the Marylan Prescription Drug Monitoring Program (PDMP), will still be available providers.

With my signature below, I acknowledge and understand that this Authorization will be kept as part of my medical record and that the communication instructions listed above will remain in effect until revoked by me in writing. It is my responsibility to notify Evergreen Adult Medicine in writing should I wish to change any of the information noted above and notify Evergreen Adult Medicine if my contact information changes.
Signature*

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Date signed*

MonthDayYear
Date

Insurance information

Please complete fields. Please check with insurance company or office to make sure we are a participating provider.
Do you have insurance or are you self pay? If you have insurance, complete the following.*

Self PayInsurance
Insurance Company Name*
Insurance ID number*
Insurance Group Number*
Insurance phone number for Providers*
Please enter a valid phone number.
Name of the Subscriber

First NameLast Name
Date of birth

MonthDayYear
Date
Relationship to Subscriber

SelfSpouseParentOther
Phone Number of the Subscriber if not the patient
Please enter a valid phone number.
Address of Subscriber if not the patient

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Secondary Insurance

If you do not have a secondary insurance, please proceed to the next section.
Secondary Insurance Name
Insurance ID number
Insurance Group Number
Insurance phone number for Providers
Please enter a valid phone number.
Name of Subscriber

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to the Subscriber

SelfSpouseParentOther
Phone Number of the Subscriber if not the patient
Please enter a valid phone number.
Address of the subscriber if not the patient

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Medical Record Release Form

Please complete the following release form. This is a mandatory form.
Name of patient*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I hereby authorize Evergreen Adult Medicine, 20 Frederick Road, Thurmont, MD 21788 to request and receive my records from:*
Name of Physician and Facility
Address of Facility*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Facility*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Please forward records on patient from two years ago to present. Please include labs, imaging and immunization list. You may fax records to 717-338-9070 or mail them to 20 Frederick Road, Thurmont, MD 21788.
Please include the following in my medical record transfer:

IncludeDrug and Alcohol Treatment Records (protected by the Pennsylvania Drug &Alcohol Abuse Control Act, 71 P.S. § 1690.108)IncludeMental Health Records (protected by the Mental Health Procedures Act, 50 P.S. §7111)IncludeAIDS/HIV - Related Records (protected by Confidentiality of HIV-RelatedInformation Act, 35 P.S. § 7607)AllAIDS/HIV-Related RecordInclude Sexual Abuse/Assault andDomestic Violence Counseling Records (protected by 42 Pa.C.S.A. § 5945.1 and 23Pa.C.S.A. § 6116, respectively)
This authorization will expire 1 year after the date of this request.

I understand that I may revoke this authorization at any time by notifying my provider or by notifying the provider or entity that is authorized to receive these records. I understand that revocation will not have any effect on actions taken prior to any revocation and will not apply to information that has already been released in response to this authorization. This authorization is voluntary. I can refuse to sign this authorization. I understand that if the organization authorized to receive the information is not a health plan or a health care provider, the information may no longer be protected by federal privacy regulations. I understand that this information may be re-released by the recipient and no longer protected. By signing below, I certify that I understand the nature of this Release. I understand that the provider named above may not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization. If mental health records are being released as permitted by the Mental Health Procedures Act, I understand that I have a right, subject to 55 Pa. Code § 5100.33, to inspect the material to be released. If AIDS or HIV-related information is being released, this information has been disclosed to you from records protected by Pennsylvania law. Pennsylvania law prohibits you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or is authorized by the Confidentiality of HIV-Related Information Act. A general authorization for the release of medical or other information is not sufficient for this purpose.By signing below, I authorize the release of the medical information requested and specifically waive the confidentiality protection afforded by Pennsylvania statutory law for the Special Records indicated above.This waiver is applicable only to this request and is not meant to be a general waiver.
Signature of patient*

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Date of Signature*

MonthDayYear
Date

Appointment Preference

We will take this in consideration while scheduling. Please note your preferred time may not be available until a later date.
Our office hours are Monday through Friday 8:00 AM to 4:30 PM. Do you have a time preference when our staff calls to schedule you? *If already scheduled, please skip to Enroll.*

MorningAfternoonNo preference
Day of the week preference?

MondayTuesdayWednesdayThursdayFriday
Is there anything you would like us to know regarding your appointment?
Please verify that you are human*
Should be Empty:

New Patient Enrollment

Permission to Communicate

Patient Health Survey

Insurance information

Secondary Insurance

Medical Record Release Form

Appointment Preference