AALFA New Patient Form

Date printed for data entry into OPS? *

Month Day Year
Date
Name of AALFA staff member who printed form for data entry into OPS system *
New Patient Registration Form

This form is fully HIPAA compliant.
Form Name
As a new patient we would like to welcome you to AALFA Family Clinic.

Please review and complete this form to register with our clinic. Additionally, we have a Patient Information Packet available as a resource to provide our patients current information about our clinic policies and helpful visit information.

Click on the link above to go to our web site and download important information regarding your care at AALFA Family Clinic. If you have any questions, feel free to contact our Office Manager at 651-653-0062.

The Patient Information Packet includes:
- Patient Welcome Letter
- Patient Bill of Rights and Responsibilities
- HIPAA Privacy Notice
- Insurance Letter
- Protection Against Medical Identity Theft
- Patient Medication and Prescription Refill Policy
Patient Information Packet *
HIPAA Notice of Privacy
Patient Financial Responsibility Agreement
In the event that one of the staff is exposed to blood or other potentially infectious materials, I give consent to draw the appropriate blood-work. *
Authorization for Data Sharing Arrangement *
AALFA Family Clinic is a Certified Health Care Home-HCH (Medical Home) Facility. A Health Care Home is your primary site for care. This initiative is a way of delivering healthcare through a team approach that gives you access to all services and support you need. This team design facilitates your medical care between your Primary Provider, other Health Care Providers, staff, and may also include trusted family or friends involved in your healthcare. Select the "yes" button below if you would like AALFA Family Clinic to be your primary clinic. *

Yes No
Page 1 of 6

Patient Information
Legal Name *

Patient_First Name Patient_Middle Patient_Last Name
Preferred Name
Date of Birth *

Month Day Year
Date
Patient_Date of Birth
Gender *
Patient_Gender
SSN: *
Patient_SSN
Marital Status *
Patient_Marital Status
Preferred Phone *
Patient_Phone
Alternate Phone
Patient_Alternate Phone
Email (required if you want receipt of submitted form)
example@example.com
Patient_Email

Address *

Patient_Street Address
Patient_Street Address 2
Patient_City	Patient_State
Patient_Zip Code	Country

Emergency Contact: First Name *
Contact_First Name
Emergency Contact: Last Name *
Contact_Last Name
Emergency Contact Phone *
Contact_Phone *
Page 2 of 6

*We are required to ask for this information for state reporting. If you prefer not to provide this information please indicate in your answers.
Race *

White Black or African American Asian American Indian or Alaskan Native Native Hawaiian/ Other Pacific Islander Refuse
Patient_Race
Ethnicity *

Hispanic or Latino Non-Hispanic or Non-Latino Refuse
Patient_Ethnicity
Preferred Language *
Patient_Language
Country in which you were born *
Page 3 of 6

Patient is Guarantor (the person responsible for paying medical bills)? *

Yes No
Guarantor Legal Name *

Guarantor_First Name Guarantor_Middle Guarantor_Last Name
Guarantor_First Name
Guarantor_Middle
Middle Initial
Guarantor_Last Name
Middle Initial
Guarantor Date of Birth *

Month Day Year
Date
Guarantor_Date of Birth
Guarantor Gender *
Guarantor_Gender
Relationship to the Patient *
Guarantor_Relationship
Is Guarantor Address same as Patient Address? *

Yes No

Primary Phone *
Guarantor_Phone
Alternate Phone
Guarantor_Alternate Phone
Page 4 of 6

Primary Insurance
Primary Insurance Company *
Primary_Insurance
Insurance ID *
This could also be referred to as Policy Member ID
Primary_Policy
Policy Group Number *
Type "NA" if this does not apply
Primary_Group Number
Primary_Relationship
Do you have secondary insurance? *

Yes No
Secondary Insurance
Secondary Insurance Company *
Secondary_Insurance
Insurance ID *
Secondary_Policy
Policy Group Number *
Type "NA" if this does not apply
Secondary_Group Number
Secondary_Relationship
Page 5 of 6

Authorization and Assignment

Authorization to Release Information to Pay Benefits to Physician: I hereby authorize AALFA FAMILY PRACTICE to release any pertinent medical information acquired in the course of my exam and ongoing care to the above listed insurance carrier(s) and/or the physicians to whom I am referred. In addition, I also hereby authorize payment to be made directly to AALFA FAMILY PRACTICE, P.A.
Do you have Medicare? *

Yes No
Medicare Authorization

I request that payment of authorized Medicare benefits be made to me or on my behalf to AALFA FAMILY PRACTICE, P.A. for any services furnished me by that physician/clinic/supervisor. I authorize any holder of medical information about me to release to the Health are Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I permit a copy of this authorization to be used in place of the original.
We will contact you within one business day to schedule your appointment.
Thank you.
DATE_SIGNED

Month Day Year
Date
If after clicking the blue "Submit Form" button above, your screen does not clear and show a Thank You screen, then there is one or more required fields that need to be completed. Use the bubbles at the top of the form to navigate quickly between pages 1 through 6.
Page 6 of 6
Should be Empty:

Guarantor_Street Address
Guarantor_Street Address 2
Guarantor_City	Guarantor_State
Guarantor_Zip Code	Country

New Patient Registration Form

Patient Information

Primary Insurance

Secondary Insurance

Authorization and Assignment

Medicare Authorization