New Patient Form

We have three providers in our office. We do our best to schedule you with your chosen provider each time that you need us, but on occasion may offer another provider for your acute needs. Please rest assured that we all share the same electronic medical records, so that each provider here can see your previous visits, along with your medications. We do save appointments each day, for each provider for acute needs, so please remember to call early in the day if you need to be seen. Our clinic is open Monday-Friday 8:00 am until 5:00 pm. We do close each day so that we may have lunch from 12:00 pm until 1:20 pm. We do have a provider available on call for after hour needs. If you call after hours you will receive a call back from one of our providers. Please do not leave messages with the after-hours physician to refill a medication, cancel, or reschedule an appointment. These items can be taken care of during normal business hours. Our office does request that you call in for medication refills 72 hours prior to needing those medications. If for some reason you are hospitalized while under our care, St. Peters Health Regional Medical Center uses staff doctors, known as “hospitalists “to provide your care while you are in the hospital. We will usually be contacted as you prepare to discharge from the hospital to schedule a follow-up appointment. We have enclosed items for your review and to complete prior to your appointment. This information will help you become familiar with our practice and policies. Please have these forms completed prior to your visit so that you and your physician can stay on schedule. Patient Information Form – This form gathers the necessary data for us to process your electronic medical record and process insurance claims for you. Patient Medical History Form - This provides information to the physician regarding your current health and past health history. HIPPA/Emergency Contact – (Health Insurance Portability and Accountability Act) – This form also includes an authorization to disclose medical health information to your friends, and/or family members. Billing Policy- This is the billing policy outline for all of the providers in our clinic. We will be happy to file your insurance for you, so please provide us with your current insurance card. Lab Services- We send out all labs drawn in our clinic. You have a choice about which lab provides that service for you, Labcorp or St Peter’s Health. You will be billed by us for the lab draw (venipuncture) but will receive a separate bill from the lab for those services. Please let us know your preference. We encourage you to call our office with any questions about the information or forms you have received. We believe strongly that an open line of communication is beneficial to us both. We look forward to meeting you!

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. As required by the Health Information Portability and Accountability Act of 1996 (HIPAA), The Sage Medical Clinic (Practice) may not use or disclose your personal health information without your authorization. The Practice has policies and procedures to comply with HIPAA law. Every attempt has been made to keep the process for patients and staff as efficient as possible. However, the requirements are extensive and take time, effort and cooperation to process required tasks. All patients are presented with certain notices and must sign certain forms. Depending on the course of treatment, some patients may be required to sign additional forms. The following is a summary of the most common notices and forms. Notices of Privacy Practices- This notice describes how medical information about you may be used and disclosed and how you get access to this information. Authorization for Use or Disclosure of Protected Health Information- The Practice may not use or disclose your health information for purposes other than health treatment, payment or health care operations, without your authorizations. Your signature on this form indicates that you are giving permission to the Practice for the use and disclosure of the health information listed on the form, for purpose(s) listed on the form, to the people/organization(s) listed on the form. You may revoke this authorization at any time by signing and dating the revocation section on your copy of this form and returning it to the office. Complaint-You have the right to make a complaint about the Practice’s policies, procedures or actions. The Practice will not engage in any discriminatory or other retaliatory behavior against you because of a complaint. Request to Amend Protected Health Information- You have the right to request that health information that involves you be amended if you believe that it is incorrect or incomplete. The Practice will review your request and either grant your request or explain the reason why it will not be granted. In the event that your request is not granted, you have the right to submit a statement of disagreement that will accompany the information in question for all future disclosures. Request for Inspection of protected Health Information- You have the right to request the opportunity to inspect and copy health information that pertains to you. The Practice will evaluate your request and will either grant it or explain the reason why the request will not be granted. In the event that your inspection request is not granted, you may request that someone other than the person who originally denied the request review the decision. If you request copies of your medical record, the Practice reserves the right to charge you a reasonable fee for the expenses associated with copying the requested information. Request for Accounting of Disclosures of Protected Health Information- You have a right to request an accounting of all nonroutine disclosures of health information that pertains to you. Disclosures of health information associated with treatment, payment and healthcare operations or with prior patient authorization will not be accounted for. Confidential Channel Communication Request- You have a right to request the communications concerning your personal health information be made through confidential channels. The Practice will do its best to accommodate all reasonable requests. Designation of Personal Representative- You have a right to nominate one or more persons to act on your behalf with respect to the protection of health information that pertains to you by making this request, you are informing the Practice of your wish to designate the named person as your personal representative. You may revoke this designation at any time by signing and dating the revocation of your copy of this form and returning it to this office. The goal of the HIPPA privacy act is to assure that individual’s health information is properly protected. In order to keep our patients information protected, we are asking that our patients provide us with the names of the people it will be acceptable to discuss their health information with. This release of information can include such things as: sensitive health information, billing or financial matters, medication refills, and whether you as a patient were here at our office for an appointment or not. If you are a parent of a minor child, this does not pertain to your children. If your children are 18 years of age or above, they are considered adults and we will need to have your adult children sign a release in order for us to talk to you about their health care. Even if your child is currently living at home, or currently a full time student, we are unable to give you information without a signed consent. Please list below the people it is acceptable to talk to about your health care. This could include your spouse, children, friends, or other family members. Please Note: Without a signed release, we will not give any information to anyone who calls on your behalf. 

Please review to ensure the details are correct before completion.