Patient Registration Form

Getting Started with Compassion Care Family Practice
PATIENT PACKET

Please fill out the new patient packet completely. Incomplete packets will delay the process. This includes reading the controlled substance policy and reading and signing the financial policy.
Permission to Release Medical Records

This is where you list your previous provider so we can request your records. Please list as much information as you can. If you do not list a previous provider, we cannot request any medical records.
Authorization to Share Medical Information

This is where you list a spouse, family member, caregivers, etc., that we are allowed to share information about you with.
Get to know each other

Once your packet is processed, our office will call to set up an appointment to establish care. Please note that the initial establish care visit is a “get to know each other” visit. In addition, we can discuss your most important medical issue. Future appointments will be scheduled to handle additional issues.
Contact information
Compassion Care Family Practice
2525 12th Street SE Suite 260
Salem, Oregon 97302
PH. 503.559.3312
FAX. 1.855.868.6823
Email: office@compassioncarefamilypractice.com
After Hours Access: A Provider is on-call after hours (503.559.3312)

Office Hours:
Monday-Thursday 8:00 am – 4:30pm
Friday-Saturday-Sunday Closed
Initials

Guarantor Information:
(Person who is financially responsible)
First NameMiddle NameLast Name
Sex
Date of Birth
SSN#
Relationship to Patient
Preferred Phone (check one)
Marital Status
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Pharmacy Information:
Do you you have a preferred pharmacy?
Pharmacy Name
General Location (city and/or street name)

Emergency Contact Information:
Name

First NameLast Name
Relationship to Patient
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Contact Number
Please enter a valid phone number.Format: (000) 000-0000.

Primary Insurance Information:
Name of Insurance Company
ID/Policy Number
Group Number
Address of Insurance Company
Do you have a co-pay?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Policy Holder
Person carrying insurance
Policy Holder's Date of Birth
Policy Holder's SSN#
Relationship to Patient

Secondary Insurance Information:
Name of Insurance Company
ID/Policy Number
Group Number
Address of Insurance Company
Do you have a co-pay?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Policy Holder
Person carrying insurance
Policy Holder's Date of Birth
Policy Holder's SSN#
Relationship to Patient

Surgeries and Procedures
Have you had any Surgeries/Procedures?
List all Surgeries/Procedures
Are you taking any Medication/Supplements
Medication/Supplements
Any Known Medication Allergies
Medication Allergies

Social History:
Do you smoke?
(smoke) when?
(smoke) how much/how often?
Do you use smokeless tobacco?
(tobacco) when?
(tobacco) how much/how often?
Do you drink alcohol?
(alcohol) when?
(alcohol) how much/how often?
Do you use illegal drugs?
(drugs) when?
(drugs) how much/how often?
Do you use caffeine?
(caffeine) how much/how often?
How often do you exercise?
Do you have a living will or advance directive?
Are you adopted?

Family Medical History

Please list any family history of the following conditions. For each, specify the condition, the affected family member, and the age at which it started. Use the 'Add another family history item' button as needed.
Do you have any family medical history?
List each condition, the family member affected, and the age at diagnosis.

New Patient Controlled Substance Policy

Our goal is to safely improve function and quality of life. We practice evidence-based medicine and follow the set forth guidelines for controlled substances. These include narcotics, benzodiazepines, and stimulants. Unfortunately, there is a high potential for tolerance, dependence, and side effects with these medications. Therefore, prescribing such medications is tightly regulated and must be carefully monitored.
- We do not prescribe continuous narcotics.
- No patient will be given a prescription for a controlled substance on the first visit.
- Pain control will first be attempted with non-controlled medication/methods.
- For patients who are currently on narcotics (excluding cancer patients/ palliative care / post-surgical patients currently in facilities on controlled substances) the Provider will slowly taper doses each month at a safe rate until the medication can be discontinued.
- We will refer to pain management if needed, but these clinics are limited in the area. We care about the health, function and quality of life for each patient. Practicing safe medicine is our highest priority.
Medication Refills

Our goal is to fill all medication refill requests within 48 business hours. This can be requested through your patient portal or by calling your pharmacy. Please do not call the office for refills as your pharmacy will contact us after you notify them of your refill request or notify them that you have a new PCP.

Missed/Late Appointments

Due to the high demand for appointments, we require all patients to arrive on time and provide adequate notice if an appointment must be canceled or rescheduled. Tardiness and missed appointments significantly impact our ability to care for other patients.
- All patients must arrive within 10 minutes of their scheduled appointment time.
- New patients: One (1) no-show appointment will result in dismissal from the practice.
- Established patients: Two (2) no-show appointments will result in dismissal from the practice.
Patients who exceed these limits will be asked to find another healthcare provider. We appreciate your understanding and cooperation in helping us provide timely care to all patients.
Initials

Authorization to Share Medical Information

Compassion Care Family Practice, LLC
Share Medical Information
Patient Name:

First NameMiddle NameLast Name
Date of Birth:
Social Security Number:
I authorize sharing medical information with the following:
I authorize sharing of the following information (please check all that apply)
Other (please specify)
** This authorization will remain in effect (please check only one)
From the date this is signed until (future date)

MonthDayYear
Date
Until the following occurs (please specify)
By signing this I authorize the disclosure of all information checked above. I acknowledge I have reviewed and understand this authorization form.
Date

MonthDayYear
Date

Patient Grievance Policy:

To provide patients and/or their families, other health care providers, or any other entity involved, an opportunity to express concerns regarding services rendered at compassion Care Family Practice. These concerns will then be reviewed, addressed, and resolved. The aim is to increase patient satisfaction, improve quality of care, and better identify areas that need improvement with a timely response to complaints. You may inquire with any staff member regarding this process.
Initials

Financial Policy

Compassion Care Family Practice, LLC
Thank you for choosing us as your primary care provider. We are committed to providing you with quality and affordable health care. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we have been advised to develop this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.

1. Insurance. We participate in most insurance plans, including Medicare. If you are insured by a plan we are not contracted with, we will attempt to submit a claim on your behalf, but often times these claims will be paid at an ‘out of network’ rate. You may be billed for the remaining balance. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

2. Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit.

3. Non-covered services. Please be aware that some – and perhaps all – of the services you receive may be non-covered or not considered reasonable or necessary by Medicare or other insurers. You may be billed for these services or required to pay for these services in full at the time of visit.

4. Proof of insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver’s license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.

5. Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

6. Coverage changes. If your insurance changes, please notify us at or before your next visit so we can make the appropriate changes to help you receive your maximum benefits.

7. Payment at Time of Visit. Our office offers a 20% discount to patients without insurance who pay for services received on the date of their visit. We are able to offer this discount because of the costs we save in billing you. If you have received a bill for these services, we will not be able to give you the discount.

8. Payment Plans. Our office is happy to work with our patients to arrange payment plans. We are willing to find a payment that works for your budget. We will not charge interest, we simply ask that a payment be made every month. In the event that you do not make a payment for 3 consecutive months, your account will be referred to our collection agency.

9. Nonpayment. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. We will consider seeing you as a patient once your entire balance has been paid to the collection agency.

10. Bankruptcy. In the event that you file bankruptcy, and our office must write off your balance, you and your immediate family members will be discharged from our practice. We will not be able to consider seeing you in the future.

11. Missed appointments. Our policy is to charge for missed appointments. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment. Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns. I have read and understand the payment policy and agree to abide by its guidelines:
Signature
Date

MonthDayYear
Date

Permission to Release Medical Records
Should be Empty:

Getting Started with Compassion Care Family Practice

PATIENT PACKET

Permission to Release Medical Records

Authorization to Share Medical Information

Get to know each other

Patient Information:

Guarantor Information:

Preferred Pharmacy Information:

Emergency Contact Information:

Primary Insurance Information:

Secondary Insurance Information:

Personal Health History

Surgeries and Procedures

Social History:

Family Medical History

Women Only:

Authorization to Share Medical Information

Financial Policy