Self Pay New Patient Screening Form

Thank you for your interest in establishing primary care with our practice with our self pay progam. Please complete the form in full. As part of our review process and chart creation, we require your social security number. Additionally, be prepared to provide your contact information, specific medications, and basic health history. Applications cannot be processed without this information. Lastly, this program is for patients with no insurance or out of network insurance plans only. If you are eligible for Medicare or Medicaid, you will not be permitted to participate.

Prior to completing this form, we request your acknowledgement that our physicians and nurse practitioners are committed to a proactive, prevention-focused approach to health, emphasizing cancer screenings, recommended vaccinations, annual wellness visits, and consistent follow-up visits for patients with chronic medical conditions even with the self pay program. You will be required to complete an annual wellness visit at least once yearly to remain in the self pay program. Please view the price list to ensure this program will meet your financial expectations.

I acknowledge:

This form is HIPAA compliant and secure. We need your social security number for our review and chart creation purposes. You can choose to enter it here, or our office staff will contact you to collect it after submission.

Social Security Option

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

Format: (000) 000-0000.

Date of Birth

Date

Age

Sex

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?

What type of insurance do you have if any?

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 Healthcare Marketplace plan?

You will not be permitted to participate in the self pay program if you have any form of Medicare or Medicaid or are eligible for Medicare or Medicaid. Does this currently apply to you?

Who is your current or most recent primary care provider (PCP)?

Do you see any specialists? (Including but not limited to, gastroenterology, endocrinology, rheumatology, urology, cardiology, pain management, etc.)

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?

Date

Do you take any narcotic, pain, or sleeping medications?

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.

What are your health goals for the next year? Please list 2 or 3

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.

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