New Patient Form- Primary Care

PLEASE NOTE THIS FORM MAY NOT LET YOU SIGN IN MOBILE VERSION ON A CELL PHONE- YOU MAY NEED TO VIEW IN DESKTOP VERSION ON YOUR PHONE OR USE LAPTOP TABLET OR PC

Thank you for choosing HorizonView Health for your care. We look forward to learning more about you and your needs. Please complete this paperwork at least 3 days before your appointment to give your provider time to review it. 

Please arrive 15 minutes prior to your first appointment and bring your insurance card, your ID card, and copayment (if you have one). We accept debit card, credit card, FSA or HSA and CareCredit. 

We have multiple locations. Please make note of which location your provider is located when scheduling your appointment.

Main Location (Near Good Sam)

1408 3rd St SE Suite 200

Puyallup, WA 98372

West Location (Next to Puyallup Motel)

201 15th Ave SW Unit B

Puyallup, WA 98372

If you are unable to keep your appointment, please call us within 24 hours of appointment to cancel. We can be reached at 253-268-3345.

Thank you,

HorizonView Health staff

We, at HorizonView Health, understand that sometimes you need to cancel or reschedule your appointment and that there are emergencies. If you are unable to keep your appointment, please call us as soon as possible. We require at least 24-hour notice when canceling your scheduled appointment. You can cancel appointments by calling us at 253-268-3345.

To ensure that each patient is given the proper amount of time allotted for their visit and to provide the highest quality care, it is very important for each scheduled patient to attend their visit on time. As a courtesy, an appointment reminder call is attempted two (2) business days prior to your scheduled appointment. However, it is the responsibility of the patient to arrive for their appointment on time.

Please review the following policy:

1. Please cancel your appointment with at least 24 hours' notice so your appointment time can be
offered to other patients.
2. If less than 24-hour notice is given, this will be documented as a late cancellation.
3. If you do not show up to your scheduled appointment, this will be documented as a no show.
4. Behavioral Health patients will be charged a $75 fee per no show/late cancellation.

5. All other patients will be charged a $40 fee per no show/late cancellation.
6. If you have three (3) or more no shows/late cancellations, a warning letter will be sent.

7. Patients with continuous no shows/late cancellations will be discharged from HorizonView Health at our discretion.

I have read and understand HorizonView Health's no show/late cancellation policy and understand my responsibility to plan appointments accordingly and notify HorizonView Health appropriately if I have difficulty keeping my scheduled appointments.

 

CONSENT: I consent to medical services discussed and ordered by a physician and given by HorizonView Health. HorizonView Health may share health information about me, my guardian(s) or parent(s) to physicians and providers who treat me.

FINANCIAL AGREEMENT: I, the patient or guarantor, certify that the information provided is true to the best of my knowledge. I accept responsibility for the medical charges incurred by the patient and agree to pay all bills at the time of service unless arrangements are made. I authorize HorizonView Health, to release any information to process insurance claims. I also authorize my insurance claim to be paid directly to HorizonView Health.

RELEASE OF INFORMATION: I permit HorizonView Health to release information needed for eligibility and benefits, and to process claims for payments. I agree that all insurance payments be paid directly to HorizonView Health for services rendered.

By my signature below, I agree to the Consent of Treatment & have received the Notice of Privacy Practices of HorizonView Health.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) in accordance with all applicable law. It also describes your rights regarding how you may gain access to and control your PHI. We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and Privacy Practices with respect to PHI. We are required to abide by the terms of the Notice of Privacy Practices. We reserve the right to change the terms of the Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will make available a revised Notice of Privacy Practices upon request.

A Telehealth service means that my visit with a practitioner at the distant site will happen by using special audiovisual equipment (Zoom). This consent is valid for all follow-up Telehealth services with HorizonView Health.

I understand that:

• I can decline the Telehealth service at any time without affecting my right to future care or treatment.
• If I decline the Telehealth services, the alternative option would be in-person services.
• The same confidentiality protections that apply to my other medical care also apply to the Telehealth services.
• I will have access to all medical information resulting from the Telehealth service as provided by law.
• The information from the Telehealth service (images that can be identified as mine or other medical information from the Telehealth service) cannot be released to researchers or anyone else without my additional written consent. I understand that my insurance will be billed for the telehealth services, and that I will be billed for what my insurance does not cover.
• By signing this consent, I am giving permission to release information to my insurance company or third-party payor for billing purposes.
• I have read this document carefully, and my questions have been answered to my satisfaction.
• I understand this consent is valid for all telehealth follow-ups at HorizonView Health.