OCF Healing New Patient Form

Neil Spiegel, DO and Jennifer Gularson, PA-C
3200 Tower Oaks Blvd, #430
Rockville, MD 20852
Phone (301) 231-5050
Fax (877)781-0056
Date

MonthDayYear
Date
Name of Patient

First NameLast Name
Date of Birth

MonthDayYear
Date
Sex
Marital Status
Race
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
TextEmailPhone
Name of Employer/School
Yes
Emergency Contact: Name, Phone and Relationship to patient
Pharmacy Name
Pharmacy Phone
Please enter a valid phone number.Format: (000) 000-0000.
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who referred you?
Reason for today's visit:
Responsible Party’s Signature

Powered by Jotform SignClear

Height
Weight
Smoking History
YesNo
YesNo
If yes, how long did you smoke? How many packs per day?
If you quit, how long ago? What method did you use to quit?
Medication History
Please list all medications and supplements. Include name, dosage, frequency and prescriber.
Please list any allergies and your reaction (If None, Please type NO KNOWN DRUG ALLERGIES)
Upload Medication List

Financial Agreement
Patient Name

First NameLast Name
Financial Responsible Party

First NameLast Name
Signature of Financially Responsible Party

Powered by Jotform SignClear

Patient Acknowledgement and Consent Form

Use and Disclosure of Protected Health Information
Our notice of Privacy Practice states that we reserve the right to change the terms described. Should this happen, you will receive a revised copy. You have the right to request restrictions on how your protected health information may be used or disclosed for treatment, payment, or health care operations. Please acknowledge receipt or reading of our Notice of Private Practices by initialing in the space below.
Patient Initials:

Powered by Jotform SignClear
Date

MonthDayYear
Date

Medicare Patient Only

Patient Financial Responsibility Agreement (If not applicable, go to next page)
This Agreement ("Agreement") is entered into by and between
blanks ,hereinafter referred to as "Patient," and Osteopathic Center for Healing, hereinafter referred to as the "Provider," on
blank
1. Fee-for-Service Acknowledgment

The Patient acknowledges that the Provider operates as a fee-for-service healthcare provider, and Medicare does not cover services rendered by non-participating providers.

2. Non-Participation in Medicare

The Patient understands and agrees that the Provider is not a participating provider with Medicare. As a result, Medicare will not reimburse the Patient for any services provided by the Provider.

3. Patient Financial Responsibility

The Patient acknowledges and accepts full responsibility for all fees associated with the services provided by the Provider. This includes, but is not limited to, consultation fees, diagnostic tests, and any other services rendered by the Provider.

4. Payment at the Time of Service

The Patient agrees to make full payment for all services at the time of each visit. The Provider does not submit claims to Medicare on behalf of the Patient, and the Patient is responsible for settling all fees directly with the Provider.

5. Documentation of Non-Coverage

The Patient acknowledges receipt of information regarding the non-participation of the Provider in Medicare and understands the implications of Medicare non-coverage for the services provided.

6. Medicare Waiver

The Patient agrees to waive any right to submit claims to Medicare for reimbursement for services received from the Provider.

7. Governing Law

This Agreement shall be governed by and construed in accordance with the laws of Maryland, without regard to its conflict of laws principles.

IN WITNESS WHEREOF, the Patient and Provider have executed this Agreement as of the date first above written.
Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date

No-Show/Cancellation Policy
Appointment and Cancellation Policy

We understand the importance of timely access to healthcare and are committed to providing you with the best possible care. To ensure appointment availability for all patients, we have implemented the following policy:

Payment Information

Effective immediately, we may request a payment method on file. Please be assured that no charges will be incurred unless you miss an appointment, cancel within 48 hours of your scheduled appointment, or have completed services.

Appointment Scheduling and Cancellations

• Arriving on Time: Please arrive on time for your scheduled appointment with new patient forms completed.

• Cancellations: If you are unable to keep your appointment, please provide at least 48 hours’ notice.

• Late Arrivals: Depending on the provider’s schedule, you may be asked to reschedule if you arrive more than 10 minutes late. Please note that if you come in late, the remaining time of your appointment will remain as scheduled and no extra time will be given. Please call our office as soon as possible if you are running late.

Missed Appointment Fees

• First missed appointment:

o New patient: $250
o Established patient: Half of the visit fee

• Second missed appointment: Full visit fee

• Patients who miss more than two appointments may be required to prepay for future appointments. Alternatively, they may call the day of the desired appointment to check for available openings. Patients with a card on file will be subject to the fees outlined above and scheduling restrictions will not apply.

We appreciate your understanding and cooperation in adhering to this policy.
Patient Initials

Powered by Jotform SignClear
Date

MonthDayYear
Date

Authorization for Release of Information

I hereby give my informed consent to: Neil Spiegel D.O. or Jennifer Gularson, PA-C
Name to disclose information to: Name
Name to obtain information for: Name
Name to exchange information with: Name
Doctor Name

First NameLast Name
Doctor Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Doctor Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Initial assessmentPhysician’s Progress NotesPhysical Therapy Progress NotesLaboratory ReportsOther (specify)
Client Name

First NameLast Name
Date of Birth

MonthDayYear
Date
The consent will automatically expire one year from the date signed by the client or legal representative and may be revoked, in writing by the undersigned at any time.
Signature of Individual or Legal Representative

Powered by Jotform SignClear
Date

MonthDayYear
Date
Signature of Witness

Powered by Jotform SignClear
Date

MonthDayYear
Date
Signature of the staff member

Powered by Jotform SignClear
Date

MonthDayYear
Date
TO AGENCIES RECEIVING THE MEDICAL REPORT: PROHIBITION OF REDISCLOSURE: THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM A MEDICAL RECORD WHOSE CONFIDENTIALITY IS PROTECTED. ANY FURTHER REDISCLOSURE IS PROHIBITED.
I agree
Should be Empty:

Smoking History

Medication History

Financial Agreement

Patient Acknowledgement and Consent Form

Medicare Patient Only

No-Show/Cancellation Policy

Authorization for Release of Information