New patient

New Patient Application

Focus Family Medicine- Direct Primary Care
Full Name*
Date of Birth*

MonthDayYear
E-mail Address*
Phone*
Address*
Zip code*
Emergency Contact*
Contact's Phone*
Pharmacy Name*
Pharmacy Phone and Address
Employer Name/ Type of Occupation
Insurance provider -used for referrals, labs and imaging when appropriate *
Insurance Phone number
IF APPLICABLE
ID number
Group number
I acknowledge Focus Family Medicine*

will not bill or accept payment from any insurance plan, Medicare, or Medicaid.is not a health insurance plan and is not a substitution for health insurance.membership fees are not reimbursed by any insurance plan.
Where did you hear about Focus Family Medicine?

Web searchSocial mediaReferred by friendOther
Whom can we thank for the referral?
Covid-19 Status

Pfizer vaccineModerna vaccineJ&J vaccineHistory of Covid 19 infectionConsidering vaccineDecline vaccine
Are you taking any Prescription Medications or Supplements?

YesNo
If taking any Prescription Medications or Supplements- please list:*
DRUG NAME, DOSE STRENGTH, and FREQUENCY
I acknowledge Focus Family Medicine*

does not prescribe chronic controlled medications (e.g. opioids, benzodiazepines, hypnotics).requests 2 business days for prescription refills.
When would you like to schedule your first appointment? Preferred day/time.
Do you have any specific concerns you would like addressed at the first visit?
I accept the following terms:*

CONSENT TO TREAT. Patient hereby agrees to enroll as a member in the Practice’s direct primary care membership program. You acknowledge and hereby authorize Practice to use and/or disclose your health information which specifically identifies you, or which can reasonably be used to identify you, to carry out your treatment, payment, and healthcare operations.METHODS OF COMMUNICATION. You acknowledge that Practice communications may include e-mail, facsimile, video chat, messaging, and cell phone, and such communications by their nature cannot be guaranteed to be secure or confidential. You agree that by participating in the above means of communication, you expressly waive any guarantee of absolute confidentiality with respect to their use. You further understand that participation in the above means of communication is not a condition of membership in this Practice and that you have the option to decline any particular means of communication.APPROPRIATE COMMUNICATION. You understand and agree that e-mail and text messaging are not an appropriate means of communication in an emergency, for time-sensitive problems, or for disclosing sensitive information. In an emergency, or a situation that you could reasonably expect to develop into an emergency, you understand and agree to call 911 or go to the nearest Emergency room and follow the directions of emergency personnel.TECHNICAL FAILURE. Neither the Practice nor Your Physician will be liable for any loss, injury, or expense arising from a delay in responding to the Patient when that delay is caused by technical failure. Examples of technical failures: (i) failures caused by an internet or cell phone service provider; (ii) power outages; (iii) failure of electronic messaging software or email provider; (iv) failure of the Practice’s computers or computer network, or faulty telephone or cable data transmission; (iv) any interception of email communications by a third party which is unauthorized by the Practice; or (v) Patient’s failure to comply with the guidelines for the use of email or text messaging, as described in this Agreement.AVAILABILTY. This agreement is for ongoing primary care, not emergency or urgent care. The Practice will make every effort to address your medical needs in a timely manner, but we cannot guarantee availability, and we cannot guarantee that you will not need to seek treatment in an urgent care or emergency department setting under certain circumstances. After-hours communications are subject to the availability of the physician and are not guaranteed.PHYSICIAN ABSENCE. From time to time, due to vacations, illness, or personal emergency, your Physician may be temporarily unavailable. During this time you may be directed to another medical provider at your own expense.TERMINATION. Both you and the Practice have the right to terminate the agreement, without cause, with a 30-day written notification to the other party.REINSTATEMENT. If you discontinue membership and wish to re-enroll in the Practice, the Practice reserves the right to decline re-enrollment or to require a re-enrollment fee of $150.FEES. To remain financially viable, Practice reserves the right to change its fees at any time with sixty (60) days’ notice to you.NONPAYMENT. In the event that the Patient is unable to pay the monthly membership or other fees in full and on time, the Practice may, in its sole discretion, terminate this Membership Agreement. It is the Patient's responsibility to maintain a correct and up-to-date credit/debit card number on file.CONTACT INFORMATION. I understand it is my responsibility to notify Practice of changes to my address, phone number, email address and other billing or contact information. An inability to collect membership fees due to incorrect or outdated billing information may result in the termination of my membership.I hereby authorize FOCUS FAMILY MEDICINE, PLLC ("Practice") to charge payment method on file automatically every month and apply those charges to the membership fees required for participation in the direct primary care membership offered through Practice, and to any other charges I incur from services or supplies received through the participating clinics or providers that are not covered by the membership. I understand that I will remain responsible for recurring charges, additional late fees and any other applicable charges if the withdrawal to the bank account is denied for insufficient funds or otherwise becomes unavailable. In the event I have selected to have automatic payments made from a bank account, I hereby authorize Practice to initiate automatic withdrawals via electronic fund transfer entities by Practice utilized software in existence as of the date of this agreement and as amended from time to time. I acknowledge no entries may be made that violate the laws of the state of Tennessee, or party service providers involved in processing entries made hereunder against all claims, demands, losses, liability, or expense including attorney’s fees and costs that result directly or indirectly from 1) a failure to follow the rules, 2) violation of law.
I hereby authorize FOCUS FAMILY MEDICINE, PLLC ("Practice") to charge payment method on file automatically every month and apply those charges to the membership fees required for participation in the direct primary care membership offered through Practice, and to any other charges I incur from services or supplies received through the participating clinics or providers that are not covered by the membership. I understand that I will remain responsible for recurring charges, additional late fees and any other applicable charges if the withdrawal to the bank account is denied for insufficient funds or otherwise becomes unavailable.
In the event I have selected to have automatic payments made from a bank account, I hereby authorize Practice to initiate automatic withdrawals via electronic fund transfer entities by Practice utilized software in existence as of the date of this agreement and as amended from time to time. I acknowledge no entries may be made that violate the laws of the state of Tennessee, or party service providers involved in processing entries made hereunder against all claims, demands, losses, liability, or expense including attorney’s fees and costs that result directly or indirectly from 1) a failure to follow the rules, 2) violation of law.
Payment must be received prior to first visit.

Please consider using ACH/bank draft option (avoiding credit card fees).
Signature of Patient or Personal Representative*

Clear
Printed Name
Date*
*** Thank you for becoming a patient at FOCUS Family Medicine***

We look forward to serving you.
Phone: 615-819-4650 Fax: 615-622-8683 357 Riverside Dr. Ste 260 Franklin, TN 37064
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New Patient Application