hurtheel.com - New Patient Form

Name

First NameM.I.Last Name

DOB:

Date

Address:

Street Address

Street Address Line 2

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Postal / Zip Code

Primary Contact #:

Please enter a valid phone number.

Secondary Contact#:

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SSN:

Gender:

FemaleMaleNon Binary

Marital Status:

SMDW

Emergency Contact Name:

Relation:

Phone #:

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Referring Provider (First & Last Name):

First NameLast Name

If you were not referred by another provider, how did you hear about our office?

Subscriber (if not self):

Subscriber DOB:

Date

Relation to Subscriber:

Subscriber ID:

Group #:

Subscriber (if not self):

Subscriber DOB:

Date

Relation to Subscriber:

Subscriber ID:

Group #:

E-RX Consent: Sovereign Medical Group implements the process of ePrescribing in the office. ePrescribing is a federally mandated initiative that requires all physicians prescribe in this manner. ePrescribing software sends prescriptions over the internet to your pharmacy in a safe, secure way, through the same technology used by credit card companies. This helps protect the privacy of your personal information. ePrescribing software also lets your doctor see important information, like drug interactions and prescription history. The benefits to you are reduced possibility of medical errors, less chance of adverse drug reactions, fewer trips to drop off at the pharmacy and a safer, faster, easier way to get your prescription filled. I agree that Sovereign Medical Group may request and use my prescription medication history from other healthcare providers or third party pharmacy benefit payers for treatment purposes.

Patient Signature

Date

Notice of Privacy Practices: The Notice of Privacy Practices describes how Protected Health Information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Sovereign Medical Group is required by law to protect the privacy of health information that may reveal your identity, and to provide you with a copy of this notice, which describes the health information privacy practices of our practice, its medical staff, and affiliated health care providers that jointly perform payment activities and business operations with our Practice. “Protected Health Information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. PLEASE FEEL FREE TO REQUEST A COPY.

Signature of Patient/Health Care Agent/Guardian/Relative(This signature indicates you were offered /received a copy of the Notice of Privacy Practices.)

Date

Patient is unable to sign due to medical reasonPatient refuses to sign

Ethnicity:

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Language:

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Race:

Email Address:

example@example.com

Pharmacy:

City/State:

Please list anyone you authorize us to speak with regarding your medical information (results, refills, appts, etc.):

Financial Policy- General Consent & Release:

FINANCIAL RESPONSIBILITY: You are responsible to supply our staff with your insurance ID cards. It will automatically file the claim for you; however, you are responsible for any deductible or co-pay due at the time of service as described by your insurance policy. If any of the procedures performed here are not covered under your plan, you will be financially responsible for full payment. You hereby guarantee payment in full to Highland Park Medical Associates, P.A. for all charges for serves rendered and/or charges exceeding third party payments (except when prohibited by law or under contract). You also authorize Highland Park Medical Associates, P.A. to release to government agencies insurance carriers and other who may be financially liable for the services, all information necessary to pre-authorize services, determine medical necessity and/or the extent or amount of liability and challenge denials of medical necessity. You hereby assign all amounts payable for services rendered to Highland Park Medical Associates, P.A.. You understand that this constitutes a waiver of confidentiality under 42 C > F.R. part 2 (drug and alcohol records) and N.J.S.A. 26: 5c-1 et seq. (FTW and AIDS records) and that this authorization is revocable, except to the extent that action has been taken in reliance thereon and will otherwise remain in force indefinitely in order to effectuate the purpose for which it is given. It is your responsibility to understand which insurance plans SMG participates with. The bill is your responsibility. Your insurance policy is a contract between you and your insurance company. Our office is not a part of the contract. We are happy to file your claim for you directly with you insurance company; however, the ultimate responsibility for payment is yours. You certify that the information given to you in applying for payment under the Title XVIII of the Social Security Act is correct. You authorize any holder of medical or other information to release to the Social Security Administration or its intermediaries or carries the information necessary for this or related to the Medicare claim. You request that payment of authorize benefits be made on your behalf. You hereby request and consent to, examination and treatment (including lab procedures, diagnostic and medical/surgical) rendered by Highland Park Medical Associates, P.A. and their associates. You also consent to the removal of specimens taken by lab or pathology examination. It is your responsibility to understand which lab your insurance company affiliates with. Our office will not be held liable for services rendered to you by a non-participating lab. We accept cash, check, money order, and credit cards. There is a $25.00 fee for any returned check. Please be aware in the event your bill remains unpaid, we are forced to use a collection agency and you will be responsible for all costs associated with the process. Do not hesitate to call our office with any billing questions or concerns. Phone: (201) 703-5500. PLEASE NOTE: IF YOU DO NOT SHOW FOR YOUR SCHEDULED APPOINTMENT(S) WITHOUT CALLING THE OFFICE TO CANCEL/RESCHEDULE, YOU WILL BE CHARGED $25. I certify that I have read this form and understand its contents. I also acknowledge no guarantees have been made to me as to the results of exams or treatment.

Patient Signature

Date

NEW PATIENT FORM

Insurance Information:

Primary Insurance:

Secondary Insurance:

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Additional Information:

Medical History:

Family History:

Please select any of the following issues you’ve had or currently have

Advance Beneficiary Notice of Non-Coverage (ABN)

(H) Additional Information: