Primary Care New Patient Intake Package

4400 East Highway 20, Suite #313, Niceville, FL 32578* Receptionist (850) 797-8242 * Nurse (850) 797-1344 * Fax (773) 492-8765
Name (Last)*
Name (First, MI)*
SSN*
Date of Birth*

MonthDayYear
Date
Marital Status*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Currently Employed?*

YesNo
Place of employment?
Cell Phone #*
Email Address*
example@example.com
Emergency Contact Name*
Emergency Contact Phone #*
Are you applying for any type of disability or workers compensation?*

YesNo
If any, please describe your military background:
Branch
Years of Service
Active Duty or Retired

Active DutyRetired
Highest Level of Education Completed*
Primary Insurance Carrier Or Cash?*
ID Number*
Sponsor Name (Last, First, MI)
Sponsor Date of Birth

MonthDayYear
Date
Secondary Insurance Carrier
ID Number
Sponsor Name (Last, First, MI)
Sponsor Date of Birth

MonthDayYear
Date
Reason for Visit:

Primary CareWeight LossHormone Replacement TherapyOther, Physical
List ALL medications currently prescribed to you.
Medication Dosage
Medication   Dosage
Medication   Dosage
Medication   Dosage
Medication   Dosage
Please list all past psychiatric medications taken and why you stopped taking it.
Medication Reaction
Medication Reaction
Medication Reaction
Please list substances you are using or have used in the past below.
Nicotine Intake: Do you smoke/vape?*

YesNo
If so, approximately how much per day?
How many years?
Caffeine Intake: Do you drink caffeinated beverages?*

YesNo
If Yes, How many per day?
Type of beverages typically consumed?

CoffeeTeaSodaEnergy DrinksOther
Alcohol Intake: Do you consume alcoholic beverages?*

YesNo
If so, how many per week?
Type of beverage typically consumed?
Do you, or have you, ever taken un-prescribed drugs, legal or illegal?*

YesNo
If so, what type?
Are you still using any of these?

YesNo
Which ones?
Concerning Medical History:
Past Primary Care Provider
Location (City)
Are you currently Sexually active?*

YesNo
If Yes, Are you trying to get pregnant?*

YesNoN/A
Personal Medical History Please check any condition below that applies to your personal medical history.

DiabetesHypertensionHigh CholesterolStrokeChronic PainGerd/Acid RefluxAllergic RhinitisCancerAsthmaCOPD/EmphysemaHypo/HyperthyroidismFibromyalgiaVision ProblemsArthritisIrritable Bowel DiseaseSleep ApneaCongestive Heart FailureHeart DiseaseParkinson's DiseaseSeizures/EpillepsyStrokeKidney Disease/FailureOther
Please list any past surgeries
Family Medical History Please list any family member diagnosed with any of the below medical conditions.
Diabetes
Hypertension
High Cholesterol
Asthma
Allergic Rhinitis
GERD/Acid Reflux
Sleep Apnea
Vision Problems
Arthritis
Fibromyalgia
COPD/Emphysema
Hypo/Hyperthyroidism
Vision Problems
Kidney Disease/Failure
Heart Disease
Seizures/Epilepsy
Cancer
Stroke
Parkinson's Disease
Other
Family member
Other
Family member
INFORMED CONSENT FOR MENTAL HEALTH EVALUATION/TREATMENT

I hereby voluntarily consent to medical treatment. I understand that my health information will be held private unless as described/outlined in the Privacy of Health Information Practices document I reviewed/received.
Initials*
APPOINTMENT POLICY
"Thank you for choosing Bluewater Primary Care, Inc. We are committed to your successful treatment. The following is our appointment policy which we request you read, understand, and sign prior to treatment.

It is your responsibility to schedule follow-up appointments to ensure you do not run out of medication. Appointment availability could be as long as 8 weeks out. Failure to schedule appointment before medication refill is due or missing the appointment will result in a $25 administrative fee for medication refill. Refills without an appointment are limited to 1 time, additional occurances may result in termination of treatment.

If you are unable to make your scheduled appointment, we must be notified AT LEAST 24 HOURS/1 BUSINESS DAY IN ADVANCE. If staff does not receive proper notification, the time scheduled with your clinician becomes a missed opportunity and delay for another patient to be seen. If two or more sessions are missed without proper notification, you may not be able to continue services with Bluewater Behavioral Health. I also Acknowledge that I may be charged a no-show fee for missed appointments or those appointments without propper notification.

Please note: appointment reminders are a courtesy ONLY. You are responsible for your appointment date and time."
MEDICAID INSURANCE
Bluewater Primary Care is not a Medicaid participating provider. Thereby, it is illegal for Bluewater Primary Care to see patients who have Medicaid insurance benefits.
I hear-by attest that I do not qualify for any Medicaid benefits or have Medicaid insurance coverage.
Initials*
FINANCIAL POLICY
"All payments (i.e. co-pays, co-insurance, deductibles) ARE DUE AT TIME OF SERVICE. Payments are accepted in the form of cash, check, money order, and credit card (Visa, Mastercard, Discover, American Express Accounts must remain in good standing to continue receiving treatment at Bluewater Behavioral Health. In the event that your insurance denies your claim, you will be charged the cash pay rate for the appointment.
Additional charges due once remittance is received will be charged to the card on file. All unpaid balances must be paid before making additional appointments.

Cash fee rates for are as follows. Intake 30 minute appointment $175, 1 Hour 15 Minute Follow-up $100, Med refills without an appointment $25. Fee changes are at the discretion of the provider.
A $30.00 service fee will be added to your account for each returned check from your bank. Only cash payment will be accepted after two NSF
Refunds or overpayment reimbursements are only made after full insurance reimbursement and patient responsibility is paid in full for all services rendered on your account.

I understand that I may not be rescheduled or provided refills if my account balance exceeds $50.

I understand if I do not attend my scheduled follow-up appointment and fail to notify the office at least 24 hours/1 Business day in advance, I may be charged a $50 noshow/late cancellation fee per first follow-up visit missed. Additional no-show/late cancellations will be charged $75. The first missed intake appointments will be charged $100, and may result in denial of future treatment/appointments. A second missed intake appointment will be charged $150. Two or more no-shows/late cancellations may result in termination of treatment. Fee is not applicable to VA patients.

I have read, fully understand and agree to all parts of this financial policy. I understand that my account may be turned over to a collection agency if it becomes delinquent."
Initials*
PATIENT BEHAVIOR POLICY
I understand effective clinical relationships are founded on mutual respect. In the event that a patient or family member violates this principal, they will be given a warning which will be documented in the patients chart. Further violations will result in the immediate discharge for cause from the clinic.

Initial Below
Initials*
PRIVACY OF HEALTH INFORMATION PRACTICES CONSENT
You may request a paper copy, or obtain a copy from the office website: www.bluewaterbehavioralhealth.com.Bluewater Behavioral Health and staff can communicate via e-mail on matters related to your health and/or your treatment. We also invite you to participate in our online reminder system and patient portal through OnPatient. Features include:

❖ Receive text messages and auto phone call appointment reminders

❖ Confirm appointments via email

❖ Request appointments online
I want to receive text messages and auto phone reminders.*

YesNo
I want to receive and communicate through email*

YesNo
I understand that any confidential health information that I send to the practice is not secure and is sent at my own risk. I will not hold the practice, nor any of its workforce members, liable for loss of any confidentiality associated with information transmitted via email or text.

I also understand if I utilize an email provider that does not use encryption technology the information included may not be secure.I acknowledge this risk and will not hold the practice or any of its workforce members liable for any loss of confidentiality associated with such transmissions.

My signature acknowledges that I have read, fully understand and agree to all parts of this privacy policy.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

APPOINTMENT POLICY

MEDICAID INSURANCE

FINANCIAL POLICY

PATIENT BEHAVIOR POLICY

PRIVACY OF HEALTH INFORMATION PRACTICES CONSENT