New Patient Screening Form

New Patient Screening Form

Formerly known as Internists Associated. Same great practice, same great care, new name. Please fill out the form in its entirety. Please know that part of our review is verifying your insurance using your social security number. Your application will not be processed without this information.
Please be prepared to provide your contact information, insurance details, and basic health history for our initial screening.
This form is HIPAA compliant and secure. We need your social security number for insurance verification purposes. You can choose to enter it here, or our office staff will contact you to collect it after submission.
For Insurance Verification*
Number
Email*
example@example.com
Which doctor or nurse practitioner do you request to see?*
Name*

First NameMiddle NameLast Name
Preferred Name
Best Contact Number*
Date of Birth*

MonthDayYear
Date
Age*
Sex*

MaleFemale
Preferred Pronouns (optional)
Address (Please include the street, city, and zip code)*
Street, City, Zip Code
How did you hear about us?*
Have you been seen at this practice before?*

NoYes
What type of insurance do you have?*
Please list as it appears on your insurance card
Insurance member ID number*
As it appears on the front of your insurance card
Is this a Heathcare Marketplace plan?*

NoYes
We are currently not accepting new Medicaid patients at this time. Do you have any form of Medicaid?*

NoYes
Who is your current or most recent physician or nurse practitioner?*
What was the date of your last full wellness exam or physical?
If you do not know the exact date, please give you best approximation.
What was the date of your last full wellness exam or physical?*

MonthDayYear
Date
Do you take any narcotic, pain, or sleeping medications?*

NoYes
Please list all current PRESCRIPTION medications. We cannot process your form without this information.*
In order for us to allow adequate time for your initial new patient visit, please check all of the following conditions for which you have been previously treated for or are currently being treated for.*

ADHD/ADDAnemiaAnxiety or depressionArthritisAutoimmune disorder including Lupus, Rheumatoid Arthritis, Ulcerative colitis, PsoriasisBack PainCancerChronic PainDementiaDiabetesDizzinessFrequent fallsGoutHeadachesHeart diseaseHeart failureHigh blood pressureHigh cholesterolIrregular heart beatKidney diseaseLiver DiseaseLung disease including asthma, copd, fibrosis, frequent bronchitisNeurological conditions including Parkinsons, Multiple Sclerosis, paralysisSeasonal allergiesSeizuresSinus troubleSleep ApneaStomach/intestinal problemsStrokeThyroid diseaseWeight loss or gainNo concerns at this timeOther
Is there anything else you would like us to know that will help us care for you?*
Thank you!

The office will contact you upon review to collect your social security number for insurance verification purposes. Your application will not be processed until we have received this information.
Thank you!

Your application will be processed, and we will reach out to you with a determination as soon as possible.
Should be Empty:

New Patient Screening Form

Please be prepared to provide your contact information, insurance details, and basic health history for our initial screening.

Thank you!

Thank you!