05 SFM HCR Patient Information

SFM HCR Information Packet

SFM Patient Information
Date*

MonthDayYear
Date
Patient Name*

First NameMiddle Name or InitialLast Name
Patient Date of Birth*

MonthDayYear
Date
Responsible Party (if not the Patient)

First NameMiddle Name or InitialLast Name
If Responsible Party, Relationship to Patient
Email*
example@example.com
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Social Security Number*
ex. 123-45-6789
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Insurance Information

SFM Patient Information

{patientName}		{patientDate}		{date}
Patient Name		Patient Date of Birth		Date Completed

Please ensure that insurance information is accurate and up-to-date. Failure to provide accurate and current insurance information may result in the patient or responsible party being responsible for all charges. Please submit insurance cards and ID to SFM.
Primary Insurance*
Primary Plan Name*
Insured's Name for Primary Insurance*

First NameMiddle Name or InitialLast Name
Insured's Date of Birth for Primary Insurance*

MonthDayYear
Date
Insured's Gender for Primary Insurance*

MaleFemalePrefer not to answer
Insured's Social Security Number OR ID Number for Primary Insurance
Insured's Social Security Number OR ID Number for Primary Insurance*
Employer or Group Number for Primary Insurance
Employer or Group Number for Primary Insurance*
Primary Insurance Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Relationship to Insured of Primary Insurance:*

SelfSpouseChildOther
Identify "Other:"*
Do you have Secondary insurance that Sparks Family Medicine accepts?*

YesI do not have a Secondary Insurance that Sparks Family Medicine accepts.

Secondary Insurance Information

SFM Patient Information
Please ensure that insurance information is accurate and up-to-date. Failure to provide accurate and current insurance information may result in the patient or responsible party being responsible for all charges. Please submit insurance cards and ID to SFM.

{patientName}		{patientDate}		{date}
Patient Name		Patient Date of Birth		Date Completed

Secondary Insurance (If none, type "Back" and select "No")*
Plan Name for Secondary Insurance*
Insured's Name for Secondary Insurance*

First NameMiddle Name or InitialLast Name
Insured's Date of Birth for Secondary Insurance*

MonthDayYear
Date
Insured's Gender for Primary Insurance*

MaleFemalePrefer not to answer
Insured's Social Security Number OR ID Number for Secondary Insurance
Insured's Social Security Number OR ID Number for Secondary Insurance*
Employer or Group Number for Secondary Insurance
Employer or Group Number for Secondary Insurance*
Secondary Insurance Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Relationship to Insured of Secondary Insurance:*

SelfSpouseChildOther
Identify "Other:"*

Pharmacy Information

SFM Patient Information

{patientName}		{patientDate180}		{date57}
Patient Name		Patient Date of Birth		Date Completed

Local Pharmacy*
Please enter local pharmacy name or type "None"
Pharmacy Phone Number*
Please enter pharmacy phone number or write "None"
Pharmacy Street Address or Cross Streets*
Please enter pharmacy address or cross streets or write "None"
Mail Order Pharmacy
Please enter mail order pharmacy or write "None"
Mail Order Pharmacy Fax Number
Please enter a valid mail order pharmacy fax number
Mail Order Pharmacy Phone Number
Please enter a valid mail order pharmacy phone number
Medication Allergies and Reactions (if none, type "None"):

Patient Consent to Bill

SFM Patient Information

{patientName}		{patientDate180}		{date57}
Patient Name		Patient Date of Birth		Date Completed

I hereby authorized my insurance carrier to pay medical benefits directly to Sparks Family Medicine, Ltd. I authorize Sparks Family Medicine, Ltd. to release any medical information, including information related to psychiatric care, drug and alcohol abuse and HIV/AIDS confidential information, acquired in the course of my treatment necessary to process insurance claims or any medical information that is required for any health care related utilization review or quality assurance activities. I understand that I am financially responsible for all charges made to my account whether or not an insurance company is involved in payment. I am further responsible for all co-payment, co-insurance amounts, non-covered supplies and services, and yearly deductibles. I am also responsible for collection fees incurred by Sparks Family Medicine, Ltd. in efforts to receive payment of my financial obligations for services rendered. A photocopy of this authorization is to be considered as valid as the original, until revoked by me in writing.
HIPAA Authorization to Transmit PHI by Email*

Upload ID and Insurance Card(s). By uploading documents, patient or authorized representative authorizes Sparks Family Medicine and its third-party vendors to transmit uploaded documents as unsecure email attachments.I will fax ID and Insurance Card(s) to Sparks Family Medicine, Ltd at (702) 722-2201.
Upload ID and Insurance Card(s)

Cancelof
Name of Person Signing this Form*

First NameMiddle Name or InitialLast Name
Date*

MonthDayYear
Date
Electronic Signature Acknowledgement and Consent*

I understand and agree that this electronic signature is the legal equivalent of my signature in writing and I consent to be legally bound to this agreement.
Signature*

Clear

SFM Financial Policy Agreement

SFM Patient Information

{patientName}

{patientDate180}

{date57}

Sparks Family Medicine, Ltd. accepts payment in the form of cash, check and most credit cards. Sparks Family Medicine requires payment when services are rendered. Patients covered by an insurance plan with an established responsibility are responsible for payment prior to being seen. Patients with patient responsibility based on charges will be required to pay after receiving services. Sparks Family Medicine reserves the right to refuse care to patients with outstanding patient responsibility until this financial obligation is met. Sparks Family Medicine is not an urgent care or emergency care facility.

Sparks Family Medicine will submit a claim for services rendered based on the insurance company on file for the patient. If the insurance company on file does not process the claim, the claim will be resubmitted a second time. If the insurance
company requests information from the insured, please submit this information as soon as possible. After two claims have been submitted to the insurance company on file, any outstanding balance will be billed to the responsible party. After two patient statements, any outstanding balance may be turned to a collection agency.
Sparks Family Medicine charges the following fees that will be added to the patient's account balance. These fees may be amended as clearly displayed in the patient waiting room.

1. A $25 fee for all returned checks.
2. A collection fee of 35% of the outstanding balance with a $20 minimum fee.
3. Sparks Family Medicine reserves the right to charge a missed appointment fee of up to $100 for missed appointments and appointments canceled with less than two business days notice.

Summary of billing process:
1. We will file an insurance claim for services provided or collect payment at time of service.
2. The insurance company on file is required to make a prompt payment to our office.
3. You will receive an Explanation of Benefits from the insurance company showing the balance owed to our office, if any.
4. We will attempt to send the responsible party two statements showing the outstanding balance. If a statement is returned as undeliverable, the account may be turned to a collection agency with a collection fee of 35% of the outstanding balance with a $20 minimum fee.
5. Any outstanding balance will be turned to a collection agency with a collection fee of 35% of the outstanding balance with a $20 minimum fee.

{patientName}

{patientDate180}

{date57}

Financial Policy (cont.)

SFM Patient Information
The responsible party is financially responsible for all charges made to the patient's account whether or not an insurance company is involved in payment. The responsible party is responsible for all co-payments, co-insurance, non-covered supplies and services, and yearly deductibles. The responsible party is also responsible for collection fees, legal fees and other fees incurred by Sparks Family Medicine in efforts to receive payment of financial obligations for services rendered.

The responsible party is responsible for providing proof of current insurance coverage and photo identification at the time of service if Sparks Family Medicine is to submit insurance claims to an insurance company. The responsible party will be responsible for charges incurred if current insurance coverage is not correctly established at the time of service.

The responsible party is responsible for contacting their insurance to verify the participation of the providers of Sparks Family Medicine with their insurance plan using Sparks Family Medicine's Tax ID of 88-0477868 prior to providing health insurance information to Sparks Family Medicine.

The responsible party is responsible for updating any changes in personal information, including insurance coverage, in order to facilitate the timely filing and processing of all insurance claims. The responsible party is responsible for responding to requests for additional information from an insurance company in a timely manner. Failure to update personal information at the time of service or failure to provide addiction information to an insurance company will result in the responsible party being charged for services rendered. The responsible party is responsible for facilitating the processing of insurance claims by providing information requested by insurance companies, contacting insurance companies to resolve incorrectly processed claims, and monitoring the processing of insurance claims. Insurance companies are required to send and explanation of benefits for every claim submitted to them.
Acknowledgement:*

I have read the above Financial Policy Agreement. I understand and agree to abide by this agreement to facilitate payment of services to Sparks Family Medicine, Ltd.

Telemedicine Informed Consent

SFM Patient Information

{patientName}

{patientDate180}

{date57}

“Telemedicine” allows for patient evaluation and treatment by a health care provider from a distant location via electronic communication, including but not limited to video chat and telephone. It is important you understand and agree to the following about telemedicine:

• The consulting health care provider will be at a different location from me. Additional personnel may also be present in the room with the provider. HIPAA regulations still apply to telemedicine.

• I understand that my voice and image may be recorded in order to assist the medical or registration personnel and I consent to any such audio and video recording.

• I understand there are potential risks to this technology, including, but not limited to, interruptions, unauthorized access, technical difficulties, and call termination.

• I understand that my health care provider or I can discontinue the telemedicine consultation if it that the electronic communication is not adequate for my situation.

• I understand that there are limitations to this type of care. I understand it is my responsibility to communicate my conditions and symptoms and to seek care from other providers as directed.

• I understand that I am responsible for services if all or some of my consultation with provider by telemedicine is not covered by my insurance.

Authorizations

• I grant permission for Sparks Family Medicine providers to perform and administer care and treatment of the patient via telemedicine/telehealth.

• I grant permission to release to third party payor(s) (such as Medicare or private insurance companies), their representatives, and/or other physician(s) involved in the patient's care, any information needed in connection with all care rendered to patient.
Acknowledgement:*

I have read the Telemedicine Informed Consent. I understand and agree that telemedicine may be offered at Sparks Family Medicine, Ltd. with the above conditions.

Messaging Policy Consent Form

SFM Patient Information

{patientName}

{patientDate180}

{date57}

Sparks Family Medicine (SFM) utilizes different modalities to communicate with patients, including phone, SMS text messaging, email, and patient portal messaging. Patient acknowledges the following regarding the use of these messaging modalities:

• Patient portal messaging is the most secure modality of messaging.
• Patients may request for Protected Health Information (PHI) to be shared by phone, SMS text messaging, and email, but these modalities are not as secure as patient portal messaging.
• SFM may share the least amount needed for operations when utilizing phone, SMS text messaging, and email.
• SFM does not engage in SMS text marketing. Should SFM engage in SMS text marketing in the future, you will receive an SMS text message to opt-in to receive marketing texts. SMS will not sell or provide your personal information to third parties.
• Customer data is not shared with 3rd parties for promotional or marketing purposes.
• By providing your phone number and agreeing to receive texts, you consent to receive text messages from Sparks Family Medicine, Ltd from 702-722-2200, 702-665-2492, or 725-222-1121 regarding appointments and other operational issues. Consent is not required.
• Message frequency varies. Message and data rates may apply.
• You can reply STOP to unsubscribe at any time or HELP for assistance. You can also contact us at 702-722-2200 or contact@sparksfamilymedicine.com for assistance.
Acknowledgement*

I have read the Messaging Policy Consent Form. I understand and consent to SFM's Message Policy to communicate with patients. I understand I my rights to amend how SFM communicates with me.

Long-Term Controlled Substances Agreement

SFM Patient Information

{patientName}

{patientDate180}

{date57}

This agreement protects your access to controlled substances and to protect our ability to prescribe for you. The long-term use of such substances as opioids (narcotic analgesics), benzodiazepine, tranquilizers, and barbiturate sedatives is controversial because of uncertainty regarding the extent to which they provide long-term benefit. There is also the risk of an addictive disorder developing or of relapse occurring in a person with a prior addiction. Because these drugs have potential for abuse or diversion, strict accountability is necessary when use is prolonged. For this reason the following policies are agreed to by you, the patient, as consideration for, and a condition of, the willingness of the physician to consider the initial and/or continued prescription of controlled substances to treat your chronic pain.

1. All controlled substances must come from the patient's primary physician or, during his or her absence, by the covering physician, unless specific authorization is obtained for an exception. (Multiple sources can lead to untoward drug interactions or poor coordination of treatment).

2. You are expected to inform our office of any new medications or medical conditions, and of any adverse effects you experience from any of the medications that you take.

3. The prescribing physician has permission to discuss all diagnostic and treatment details with dispensing pharmacists or other professionals who provide your health care for purposes of maintaining accountability.

4. You may not share, sell, or otherwise permit others to have access to these medications.

5. Unannounced, random urine or serum toxicology screens may be requested, this will be at the patient's expense and your cooperation is required. Presence of unauthorized substances may be subject to discontinuation of medication and/or termination from care effective immediately.

6. Prescriptions and bottles of these medications may be sought by other individuals with chemical dependency and should be closely safeguarded. It is expected that you will take the highest possible degree of care with your medication and prescription. They should not be left where others might see or otherwise have access to them.

7. Since the drugs may be hazardous or lethal to a person who is not tolerant to their effects, especially a child, you must keep them out of reach of such people.

8. Medications may not be replaced if they are lost, get wet, are destroyed, left on an airplane etc. If your medication has been stolen and you complete a police report regarding the theft, an exception may be made.

9. Early refills will generally not be given.

10. If the responsible legal authorities have questions concerning your treatment, as might occur, for example, if you were obtaining medications at several pharmacies, all confidentiality is waived and these authorities may be given full access to our records of controlled substances administration.

11. It is understood that failure to adhere to these policies may result in cessation of therapy with controlled substance prescribing by this office and referral for further specialty assessment.

12. Precription renewals are contingent on keeping scheduled appointments and completing the required controlled substance paperwork. Please do not phone for prescriptions after hours or on weekends.

13. The risks and potential benefits of these therapies will be discussed between you and your provider.
Acknowledgement:*

I have read the Long-Term Controlled Substance form. I understand and agree to abide by this agreement and other required documents for controlled substance providing at Sparks Family Medicine, Ltd.

Patient Rights and Responsibilities

SFM Patient Information

{patientName}

{patientDate180}

{date57}

Sparks Family Medicine, Ltd. providers try to address patient concerns at office visits. Patients should be prepared for office visits, including providing the names and dosage of current medications and supplements.

Sparks Family Medicine providers may refer patients to specialists, laboratory and imaging services, and other services. Patients have the right to collaborate with their provider on the vendors providing the referral services. Patients should verify that ALL vendors participate with their insurance, if applicable. Patients may decline to receive these services.

Sparks Family Medicine providers may prescribe medication. Patients have the right to understand the risks and benefits of the medication prescribed and to discuss their concerns with their provider. Sparks Family Medicine providers may recommend speciality laboratory testing, nutritional and herbal supplements, complementary and alternative medical services (CAMs) and/or adjunct therapy. Patients have the right to decline these services.

1. I understand that I have the right to decline referrals, services, medication and products.

2. I understand that I have the right to discuss my objective and concerns with my provider.

3. I understand that I am responsible for verifying the participation of vendors—labs, imaging centers, specialits, etc.—with my insurance, if applicable.

4. I understand that I am urged to schedule a follow-up appointment for all ordered tests.

5. I understand that my SFM provider and I are in a collaborative relationship focused on my health, including preventive, Integrative and Funcitonal Medicine options.

6. I understand that I have the right to be treated with respect and courtesy by the SFM staff and providers. I understand that I am expected to treat the SFM staff and providers with respect and courtesy.
Acknowledgement:*

I have read the above Patient Rights and Responsibilities. I understand and agree to abide by this agreement to receive services at Sparks Family Medicine, Ltd.

Patient Acknowledgement of Notice of Privacy Practices

SFM Patient Information

{patientName}

{patientDate180}

{date57}

As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

I acknowledge that online access to the Notice of Privacy Practices from Sparks Family Medicine, Ltd. has been provided to me. I understand that I may request a copy of the Notice of Privacy Practices. I also understand that any concerns about protected health information should be directed in writing to:

Sparks Family Medicine, Ltd.

Attn: Office Manager

410 South Rampart, Suite 390

Las Vegas, NV 89145

Contact@sparksfamilymedicine.com
Acknowledgement:*

I have read the Patient Acknowledgement of Notice of Privacy Practices. I understand how to access and/or receive Sparks Family Medicine's Notice of Privacy Practices and who to contact with concerns about protected health information.

Confirmation of Agreements and Consents

SFM Patient Information
By signing below, patient or patient's representative acknowledges that they have reviewed the above SFM Patient Information forms, (Protected Health Information Consent, Financial Policy Agreement, Patient Rights and Responsibilities Agreement, Adjust Therapy Informed Consent, Telemedicine Informed Consent, Messaging Policy Consent Form, Long-Term Controlled Substances Agreement and Patient Acknowledgement of Privacy Practices), and that they both understand and agree to their content.
Patient Name*

First NameMiddle Name or InitialLast Name
Patient Date of Birth*

MonthDayYear
Date of Birth
Email*
example@example.com
Responsible Party (if not the Patient)

First NameMiddle Name or InitialLast Name
Relationship to Patient
E.g. Parent, Spouse, Partner, Guardian, Sibling
Name of Person Signing this Form*

First NameMiddle Name or InitialLast Name
Electronic Signature Acknowledgement and Consent*

I understand and agree that this electronic signature is the legal equivalent of my signature in writing and I consent to be legally bound to this agreement.
Authorization to Receive Password Protected Attachment*

I understand I will receive an email response at the provided email from Sparks Family Medicine, Ltd upon submission of this document with a PDF of the completed agreements attachment. I must use the password Patient#1 to open and save this attachment.
I understand that this is the first of two required forms.*

Upon submission of these Agreements and Consents, I will complete directed to https://sparks.fmenergycenter.com/fm-program-agreement-2025/ to complete the FM Program Agreement. I must use the password Patient#1 to access this page.
Signature*

Clear
Should be Empty:

Rows	1st Choice	2nd Choice	3rd Choice	Do Not Use
Phone
Text
Email

SFM HCR Information Packet

{patientName}

{patientDate}

{date}

Primary Insurance Information

{patientName}

{patientDate}

{date}

Please ensure that insurance information is accurate and up-to-date. Failure to provide accurate and current insurance information may result in the patient or responsible party being responsible for all charges. Please submit insurance cards and ID to SFM.

Secondary Insurance Information

Please ensure that insurance information is accurate and up-to-date. Failure to provide accurate and current insurance information may result in the patient or responsible party being responsible for all charges. Please submit insurance cards and ID to SFM.

{patientName}

{patientDate}

{date}

Pharmacy Information

{patientName}

{patientDate180}

{date57}

Patient Consent to Bill

{patientName}

{patientDate180}

{date57}

Protected Health Information Consent

{patientName}

{patientDate180}

{date57}

SFM Financial Policy Agreement

{patientName}

{patientDate180}

{date57}

{patientName}

{patientDate180}

{date57}

Financial Policy (cont.)

Telemedicine Informed Consent

{patientName}

{patientDate180}

{date57}

Messaging Policy Consent Form

{patientName}

{patientDate180}

{date57}

Long-Term Controlled Substances Agreement

{patientName}

{patientDate180}

{date57}

Patient Rights and Responsibilities

{patientName}

{patientDate180}

{date57}

Patient Acknowledgement of Notice of Privacy Practices

{patientName}

{patientDate180}

{date57}

Confirmation of Agreements and Consents