New Patient Enrollment

New Patient Enrollment
All Information Must Be Completed

Demographics: Please provide the individual's full legal name for demographic records.
Name

First NameLast Name
MI
Date of Birth

MonthDayYear
Date
Social Security
Gender

MaleFemaleOther
Facility Name
Facility Phone #
City
Patient Room #
Patient Personal Cell or Direct Phone ( if Applicable)
Marital Status

MarriedDivorcedWidowedPartneredSingle
Race/Ethnicity

American Indian/Alaska NativeAsianBlack/African-AmericanHispanic/LatinoNative Hawaiian/Other Pacific IslanderWhiteDecline to answerUnknown
Primary Language
Country of Origin
Interpreter Needed?
Drug Allergies
Medicare ID
Primary Plan
Policy ID
Group #
Secondary Plan
Policy ID #
Group #
Prescription Drug Coverage Name
Plan ID #
HCPOA Paperwork on file at Facility

YesNo
Advanced Directive Activated

YesNo
DNR Activated

YesNo
Legal Representative

I am legally authorized to act and make decisions on the patient's behalf. I will provide a copy of valid and effective documentation outlining my role as legal representative. I understand I will receive related communications, including verbally and via the Lily Connect. I understand the Lily Connect is where the team will connect about the patient's care. I release and hold harmless Lily Medical Group and its representatives from any claims or damages arising from Lily Medical Group's reliance on my attestation that I am the patient's legal representative.
Name
Relationship to Patient
Mobile Phone #
Secondary Phone #
Address

Address

Street Address Line 2

CityState

Zip
Billing Contact

Same as Healthcare Decision MakerSelfOther
Name
Relationship to Patient
Mobile Phone #
Email
example@example.com
Fax all completed form to: 262-421-5133
Consent for Services
Patients Full Name
Date of Birth

MonthDayYear
Date
Community and Room #
City/County
Consent for services and Disclosure of Information for Treatment: I give my informed consent to receive all medical evaluations, treatments, preventative care, and procedures that Lily Medical providers and their representatives consider necessary or advisable.l authorize the use of telemedicine (audio, video, or electronic communications) for diagnosis and treatment by my Lily Medical provider team.I also consent to Lily Medical's use and disclosure of my health information for treatment purposes. This includes sharing my information with healthcare providers and facilities not affiliated with Lily Medical but involved in

Health Information Exchange: Lily Medical may participate in a health information exchange to share your health information with other healthcare providers (using record locator or patient information services) and to access your information from them. If you object to this sharing and access, please check the box below: I object to the disclosure and access of my health information through a health information exchange.

Lily Medical Privacy Practices and Consent (Acknowledgement of Receipt)

I acknowledge that I have received a copy of Lily Medical's Notice of Privacy Practices. I understand that I have the right to review these practices before signing this form.I understand that Lily Medical may update its privacy practices in the future. Notice of any changes will be posted on Lily Medical's website, and I can request a copy of the revised practices at any time. understand that I may contact Lily Medical's Privacy Officer if I have any questions about the Notice of Privacy Practices In addition to the uses and disclosures outlined in the Notice of Privacy Practices, I consent to the use and disclosure of my health information for the purposes described therein, including Lily Medical's healthcare operations.

Patient Financial Responsibility: I acknowledge that understanding my insurance coverage, including applicable co-pays, co-insurance, and any outstanding balances, is my responsibility. I agree to pay these amounts as they become due. Furthermore, I confirm that I have read and agree to the terms outlined in the Lily Medical Services Patient Financial Consent policy, which can be found online at Lilyhealthcare.org

Utilization of Health Care Records for Program Evaluations and Training: Lily Medical possesses authorization to utilize and disclose treatment information, encompassing healthcare records, for the purposes of program evaluation, staff training, and comprehensive quality review. This authorization extends to the assessment of staff performance and treatment outcomes within Lily Medical.

Chronic Care Management: I authorize Lily Medical to enroll me in their chronic care management (CCM) program, when applicable. This program and CCM include practitioner/care management visits and related activities, which will be billed to my insurance and may be subject to standard deductibles and copays. I understand that only one practitioner can bill for CCM services per month. I have the right to withdraw from CCM services at any time. More information about this program is available at lilyhealthcare.org

Authorization for Electronic Communication: I, the undersigned, consent to receive communications from Lily Medical via text messages (SMS) and email. These communications may include sensitive personal information such as billing details, payment information, and appointment-related updates.

For Legal Representatives Signing: By signing as the patient's legal representative, I affirm that I am legally authorized to make decisions for them. To receive related communications, I will provide valid documentation confirming my legal representative status. By signing this form or any other Lily Medical document as the patient's legal representative, I release Lily Medical Services and its representatives from any liability resulting from their reliance on my representation of legal authority.
Objections (If Any)

I object to the disclosure and access of my health information through a health information exchange.wish to opt-out of receiving text messages.I wish to opt-out of receiving emails from Lily Medical.
Patient Signature

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Date

MonthDayYear
Date
Legal Representative if Applicable signature

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Date

MonthDayYear
Date
Legal Representative printed name
Relation to patient
Fax all completed form to: 262-421-5133
HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient's right section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with these restrictions, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:
- Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
- The Practice is authorized to disclose your healthcare information to your senior community through various communication channels, including telephone, electronic mail, Lily Connect, or alternative modalities.
- The practice reserves the right to change the privacy policy as allowed by law.
- The patient has the right to restrict the use of the information by the practice. The practice does not have to agree to those restrictions.
- The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
- The practice may condition receipt of treatment upon execution of this consent.
May we phone, email, or send texts to you to confirm appointments?

YesNo
May we leave a message on your answering machine at home or on your cell phone?

YesNo
May we discuss your medical condition with any member of your family?

YesNo
If Yes, Please name the family members allowed with their contact information (phone number, email address, and relationship to patient):
Patient Name
This consent was signed by: (Please Print Name)
Signature

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Date

MonthDayYear
Date
Patients Name (First, Middle, Last)
Patients Date of Birth (Month, Day, Year)

MonthDayYear
Date
Patient's Current Address

Patient Current Address

Street Address Line 2

CityZip codeState

Postal / Zip Code
Patient's Current Home phone
Mobile
Email Address (optional)
example@example.com
Release information from: (Previous Primary Care Provider)
Name of Healthcare system
Provider name
Doctor Office Location
Doctor Office Phone Number
Doctor Office Fax number
Release Information to: Lily Medical Group 15430 W Capitol Dr Brookfield, WI 53005 Ph. (262) 421-5133 Fax: (262) 735-0723
Purpose of Release

Treatment/Continued CarePatient UseLegalOther
Information to be released:

All RecordsHistory and PhysicalClinic NotesLab RecordsRadiology RecordsImmunizationsHospital RecordsOther
Dates Included (optional) From:

MonthDayYear
Date
To:

MonthDayYear
Date
I understand the information to be released may include records related to behavior and/or mental health care, alcohol and drug abuse treatment, HIV/AIDS, and genetics. I may be charged for copies in accordance with state law.
Signature

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Date Signed

MonthDayYear
Date
ATTENTION: This is a legal document. Please read carefully. By signing, you agree that you understand and accept the terms on this form. If the patient is 18 years of age or older, the patient must sign and date the form. If the patient is 18 years of age or older and is incapable of signing, a legally authorized substitute may sign and date the form.If the patient is 17 years of age or younger, the patient's parent or legal guardian must sign and date the form, unless an exception exists under state or federal
This authorization will expire one year from the date of signing unless I indicate an earlier date or event here

MonthDayYear
Date
Should be Empty:

New Patient Enrollment

Consent for Services