Pioneer Family Medicine & Urgent Care Intake

Intake Form

Patient Information
Date Form Completed*

MonthDayYear
Date
First Name*
Middle Initial*
Last Name*
Date of Birth*

MonthDayYear
Date
Social Security Number*
Gender*
Marital Status*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Race/Ethnicity*
Employment Status*
Emergency Contact One Name*
Emergency Contact One Phone #*
Please enter a valid phone number.
Emergency Contact One Relationship*
Emergency Contact Two Name
Emergency Contact Two Phone #
Please enter a valid phone number.
Emergency Contact Two Relationship
Are You a Recovery Plus or Recovery Plus for All Patient*

YesNo

Pharmacy Information
Pharmacy Name*
Pharmacy Phone Number*
Please enter a valid phone number.
Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Insurance Information
Name Of Insurance Company*
Insurance Company Phone Number
Please enter a valid phone number.
ID/Subscriber Number*
Group Number
Subscriber Name*

First NameLast Name
Relationship to Patient (If patient type Self) *
Subscriber DOB*

MonthDayYear
Date
Subscriber Gender*

Secondary Insurance Information (If Applicable)
Name Of Insurance Company
Insurance Company Phone Number
Please enter a valid phone number.
ID/Subscriber Number
Group Number
Subscriber Name

First NameLast Name
Relationship to Patient
Subscriber DOB

MonthDayYear
Date
Subscriber Gender

Please Answer The Following Question
Do you have a advanced directive?*

YesNo
Please Upload Your Advanced Directive

Cancelof
Would You Like To Fill Out an Advanced Directive?*

YesNo

Acknowledgement of Notice of Privacy Practices:
I have been offered a copy of the Notice of Privacy Practices. I understand that Pioneer Family Medicine, PLLC has the right to change its Notice of Privacy Practices from time to time and that I may contact Pioneer Family Medicine at any time to obtain a current copy.
Signature*

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Date*

MonthDayYear
Date

Authorization for Release of Health Information:
I hereby authorize Pioneer Family Medicine to release any medical or incidental information to my referring physician or any other physicians who have been or may become involved with my care. I also authorize the release of information that may be necessary in the processing of any insurance claims. I hereby authorize Pioneer Family Medicine and its Employees permission to discuss, send and/or receive my personal health information to/with the following individual(s):
Status *
Signature*

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Date*

MonthDayYear
Date

Authorization for Release of Prescription Information:
I hereby authorize Pioneer Family Medicine to release any prescription information to:
Name of Pharmacy*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Signature*

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Date*

MonthDayYear
Date

Acceptance of Patient Financial Agreement:
I have read, understand, and agree to the provisions of the Patient Financial Responsibility Policy.
Signature*

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Date*

MonthDayYear
Date
Acceptance of Patient Portal Authorization:*

I am declining activation of my Patient Portal Account.By signing below, I acknowledge that I would like a Patient Portal account and agree to the terms and conditions set forth in the Patient Portal Authorization Policy.
Email*
example@example.com
Signature*

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TELEPHONE CONSUMER PROTECTION ACT (TCPA) OPT IN CONSENT FORM
Our practice uses text messages to communicate with patients for a variety of purposes including appointment confirmations, appointment reminders, billing information, and request for feedback about your experience. The frequency of messages varies but is generally related to the frequency of your appointments. Mobile message and mobile data rates from your mobile carrier may apply. If you would like to receive these messages by text, you are required to “opt-in” due to recent changes to the Telephone Consumer Protection Act (TCPA). Please note that you can revoke consent to receive these messages at any time. Please take a moment to fill out this consent form indicating your desire to receive these messages in the future.I give permission to this office to contact me by my cellular device for SMS text messages. By signing, I certify that I am the owner of this cellular device and its user contract. I understand that I can revoke consent at any time or can reply “STOP” to a text message to stop receiving text messages at any time.
Name*

First NameLast Name
Signature*

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Phone Number*
Please enter a valid phone number.
Date*

MonthDayYear
Date

Patient HIPPA Acknowledgement and Consent Form
We at Pioneer Family Medicine & Urgent Care (the "Practice") are providing this Acknowledgement and Consent Form ("Consent") to You in compliance with the Health Insurance Portability and this Consent, and.by signing you acknowledge that you had the chance to review it. The terms of our Notice may change. If we change our Notice, we may notify you that a change has been made and you can obtain a revised copy by contacting our office.Restrictions and Revocation You have the right to request that we restrict how PHL about you is used or disclosed. We are not required to agree to any restrictions, but if we do, we will honor that agreement. You may revoke this Consent in a signed writing, at any time, and all disclosures from that point on will cease. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent.Protecting and Sharing Your Information Accountability Act of 1996 (HIPA), which provides guidelines to healthcare providers and other parties on safely sharing and protecting patient health information. By signing this Consent, you acknowledge that you understand its contents and you consent to our collection of your personal information, including individually identifiable health information (protected health information or ' 'PHI" such as your name, address, social security number, and insuranceUse & Disclosure Signing this Consent also represents your consent to our use and disclosure of your private personal information, including PHI, to carry out your diagnosis, treatment, payment and health care operations.You are entitled to a copy of this Consent. Notice of Privacy PracticesOur Notice of Privacy Practices ('Notice") provides information about how we may use and disclose your protected health information. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review the Notice before signingWe will do our best to protect all private and personal information that we receive, yet the sharing of such information with us is at your own risk. Information used or disclosed pursuant to this Consent may be redisclosed by the Practice and may no longer be protected by federal or state law. Conditions and ApplicationThe Practice may condition providing treatment to you upon your execution of this Consent. This Consent applies to any service the Practice provides or any interactions you have with us.In compliance with HIPAA regulations, Pioneer Family Medicine & Urgent Care is committed to protecting your private health information. We need to know the names of the people that you will allow us to discuss your medical information, if any.
Please List All Names*
I Understand & Agree to the HIPPA Acknowledgement Consent Form *

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Laboratory Freedom of Choice
(You get to choose whichever Lab you want, even if it's outside of our office)

Pioneer Family Medicine & Urgent Care uses Mako or Mako Laboratory for our Medical Labs drawn here on the premises. Mako Labs are a separate business entity from Pioneer Family Medicine. Our business has no financial arrangement with Mako nor does it profit financially in any way from the services they offer in our clinic. Because we're separate entities please keep in mind that Mako may have a separate medical In/Out of network agreement with your insurance company than the one that exists with Pioneer Family Medicine. You are responsible for knowing how these services work with your individual plan. We do not endorse Mako Labs and you as the patient are always free to use whatever Lab you most prefer. This lab is simply here as a courtesy. If you choose, a Lab order will be given to you, for you to take to the Lab of your choice.
I understand the above statement and realise I'm free to use the Lab of my choice.*

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Complete Form
Should be Empty:

Intake Form

Instructions for Completing the Kentucky LivingWill Form

Kentucky Living Will Directive and Health Care Surrogate Designation of

Health Care Surrogate

Living Will Directive

(You get to choose whichever Lab you want, even if it's outside of our office)