Adult New Patient Form Step 1 of 13 7% Patient Last Name*MIPatient First Name*Prefix Mr. Mrs. Miss Ms. Marital Status Single Married Divorced Separated Widow Race* American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Hispanic, Latino or Spanish Yes Gender* Male Female Date of Birth* MM slash DD slash YYYY Social Security Number* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Primary Phone* Cell Phone Home Phone Primary Number*Secondary Phone Cell Phone Home Phone Secondary NumberEmail Address Is this visit/injury work related? Yes No OccupationEmployerEmployer Phone Preferred PharmacyPharmacy PhonePharmacy Fax Referred byWho referred the patient to us?Insurance NamePolicy #Subscriber/Policy Holder's NameSubscriber DOBThe policy is under: Patient Spouse Parent Select the relationship of the policy holder.Secondary InsurancePolicy # Emergency Contact*Phone #*Relationship to Patient*The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understandthat I am responsible for any copays and/or balance. I also authorize Family Health Care Center or insurance company to release any information required to process my claims.Patient / Guardian Signature*Relationship to Patient* FHCC Insurance Disclaimer Please be aware that you as the patient are responsible for any charges that are not covered by your insurance. It is the patient’s responsibility to make sure that our office is in network and is participating with your insurance plan . It is also the patient’s responsibility to know if the insurance requires you to have a designated Primary Care Provider (PCP). If you are not sure if our office is participating with your plan or if your insurance requires you to have a dedicated PCP, please call the customer service number conveniently located on the back of the insurance card to verify participation make any necessary changes. With insurance constantly changing and the implementation of the AFFORDABLE Care Act (Obamacare), Our office can NOT accommodate the phone calls required to make sure we are in network with every patient’s insurance plan and/or call to verify if they will deny your medical claim due to missed premium payments. We will file your insurance; this does not mean in any way that our office is a participating provider for your health plan, or that your insurance will pay for your visit. Therefore, you may receive an additional bill for any balances that we re unpaid by your insurance. Please note that if your insurance premiums are not paid, any medical claims during that period will be denied or possibly pend. For patients with PCPs different than the providers in our office - it is the patient’s responsibility to change their PCP to the appropriate provider or to provide written documentation that a PCP is not required for the patient’s specific plan. If you are currently in a grace period at the time of your visit, you will be treated as a SELF - PAY patient. For patients that have managed health care plans - You MUST provide proof of FULL premium payment at the time of visit. If payments are not made by the end of your premium grace period, you will be held responsible for any and all charges for t reatment from your visit. Therefore, any patient that is currently in a grace period will be treated as a SELF PAY patient.Patient / Guardian Signature* PLEASE REMEMBER Photo ID Insurance Card Copays All Medications Currently Prescribed Patient Insurances Preferred Services Many insurance companies are now specifying which commercial laboratories, hospitals, radiology services and other services you may use for studies. It is YOUR responsibility as the patient to be a ware of this information. For instance, if your lab work is sent to a non - preferred lab you will be responsible for payment. Our in - office lab can perform only limited testing and when appropriate, we will perform what we can in - house. All other specimens m ust be sent to a reference lab such as labcorp. Please indicate your insurance carrier’s preferred lab and/or radiology services. Inaccurate or erroneous information will re sults in you being held responsible for all lab charges. If you are unsure, please contact yo ur insurance carrier by calling the customer service number listed on the back of your insurance card.Laboratory Lab Corp Quest Diagnostics Radiology Services: East Georgia Regional Medical Center Patient / Guardian Signature* Patient Acknowledgement Review or Receipt of Notice I understand FHCC has a legal responsibility to protect patient privacy. To do this, the practice strives to keep patient inf ormation confidential and to safeguard the privacy of all patient information. I understand the FHCC has the authority to use and disclose my private health information to carry out treatment, payment, an d healthcare operations, and that my private health information will not be released to ot her activities unless I sign a release authorizing this disclosure. By signing this form, I acknowledge that I have been provided with FHCC’s Notice of Privacy Practices to review, and have bee n informed that I may obtain a copy upon request. I understan d that Family Health Care Center has the right to change its Notice of Privacy Practices. If so, FHCC will issue a revised Acknowledgement of Review/Receipt of Privacy Practices. Patient / Guardian Signature* HIPAA FORM Please list any family member or other persons / physicians to whom Family Health Care Center may release information concerning your medical records:NamePhoneRelationshipNamePhoneRelationshipNamePhoneRelationshipPlease Note: Our automated computer system will automatically call all patients with appointments 2 days prior to t he scheduled appointment date. Please confirm YES with the system by pressing #1 or can cel the appointment by pressing #2. Please list the best number for all appointment reminder callsAppointment Reminder CallsMay Family Health Care Center leave messages on your home answering machine or voicemail?* Yes No Please indicate if you would like to create a patient portal account. With this account, you will be able to review your lab results, ask non - urgent medical questions, request medication, and schedule appointments. Yes No Patient / Guardian Signature*Parent/Guardian of Minors under age 18 has access to medical records, with the exception of any State Law protecting the privacy of information of minors. This will remain in effect until I give written notification to discontinue. Administrative Policy Family Health Care Center (FHCC) is striving to do everything possible to hold down the cost of medical care to all by ensuring proper payment to our office. You, the patient, can help us by adhering to the following administrative policy. By signing at the bottom of the Administrative Policy , you are indicating that you understand our policies and agree to adhere to them. If you have questions prior to signing , please ask at the front desk. Appointments It is a patient’s responsibility to provide FHCC with complete and correct information. You must bring your current insurance cards to each visit. If you fail to do so and your new insurance requires a preauthorization or we find that our services will not be reimbursed, or we are unable to properly bill y our insurance, any balances will become the patient’s responsibility. It is the new patient’s responsibility to complete all patient and medical history forms at the time of their visit. All appointments must be cancelled at least 24 hours in advance . If you fail to cancel the appointment and do not show up, a $25 No Show fee will be assessed to your account. If you continue to neglect to show up for appointments, we may have no other option except to dismiss you from our practice. Please understand that this patient practice is costly to our office. All patients are required to provide their Social Security Number upon their initial visit. Under no circumstances will a patient be allowed to be seen without providing it. FHCC respects your privacy and will not share your personal information with anyone other than your insurance carrier, Collection Agency, or whomever you have ag reed in writing to allow access to your account or health information. Insurance FHCC will bill all participating insurance carriers as a courtesy to our patients. If your insurance fails to pay your claim within 60 days from the date it is billed, the balance will become the patient’s responsibility . Assignment of Benefits: By signing this policy the patient or guarantor authorizes payment of medical benefits to FHCC for all in - network insurance carriers. Appeals: By signing this policy, the patient or guarantor agrees to allow FHCC to submit and follow up on medical appeals on behalf of the patient. Cooperation: The patient or guarantor agrees to cooperate with the insurance company and with FHCC to provide any information necessary to properly process the medical claim. Payments All copays, co-insurances, and deductibles are due at the time of service. All payments may be made via cash, check, or credit card (Visa, MasterCard, Discover, American Express, Debit Card). Any payment made by check will be processed electronically and w ill be automatically debited from your account within 24 hours. Credit Card Payments: Your signature at the bottom of this policy will stand as a signature on file for any payment you authorize by credit card via the telephone, fax or Internet. Returned checks: All accounts will be assessed a $40 processing fee for returned checks. If you fail to reimburse FHCC within 10 days of notification from your bank, you will not be allowed to use a check for any future payments. Out of Network Patients: If FHCC i s not a participant in your insurance network, you will be required to pay the portion of your balance not paid by your insurance company. Uninsured Patients: You will be considered a Self Pay Patient (see paragraph vi below). Self Pay Patients: You must bring a minimum of $150 to each visit. This does not mean your visit will be less than $150. It will depend on the type of visit and /or any tests or procedures that may be provided. If you pay your balance at the time of service we will provide a 30% discount at Check Out. If you have insurance of which we do not participate with, our staff will provide you with an encounter receipt which will include all information necessary for you to be reimbursed by your insurance carrier. All balances to FHCC will be due at the time of service. Collections Patient Balances: Balances including copays, co - insurances, and deductibles that are not paid in full at the time of service creates costs to FHCC. Balances are due at your office visit. If you have a balance after your insurance has paid, you will receive a statement to be paid within 2 weeks of receipt. If after 2 statements have been sent and FHCC has not received your payment due at 60 days, we may attempt a courtesy phone call requesting that you return our call. If no payment is received, at 90 days your balance will be turned over to a collection agency. FHCC will add a 30% collection fee to your total balance to cover collection costs incurred by FHCC. Hospital Admissions Dr. Riley believes that you are entitled to make informed decisions regarding your medical care. To assist you in making an informed decision, Dr. Riley hereby notifies you that he has an ownership interest in East Georgia Regional Medical Center, which is a physician - owned hospital, pursuant to 42 C.F.R § 4.89.3. Please address any questions to the front office staff or to our billing/insurance staff at (912) 489 - 4090, ext 127, 128 or 129. Anyone who fails to comply with any part of our policy may be asked to reschedule so you will have time to comply with the policy. Those who repeatedly miss appointments, are noncompliant with a plan of care, or are abusive to our staff may be rescheduled or dismissed from our practice. If you have any additional questions or concerns you may contact the Practice Administrator at (912) 489 - 4090, ext 123. This policy remains in effect until superseded. You will be provided a copy of this policy upon request. Patient / Guardian Signature*Guarantor Dear Patient, Thank you for choosing us to provide healthcare for you and your family. We at Family Health Care Center constantly strive to provide you with the ultimate patient experience and customer service. We are excited to offer an online patient portal for o ur pa tients so that you can have faster, reliable communication that is accessible to you at all times. Our internet - based patient portal, Next MD, simplifies communication with your physician or provider and eliminated time - consuming phone calls to the practi ce. Whether you want to schedule an appointment or review your test results , the patient portal delivers the information you need through a convenient, easy - to - use patient portal. NextMD is a secure, confidential, and easy - to - use website that gives patien ts 24 - hour access to their medical information. It uses the latest encryption technology to deliver secure communication between patient and our office. By signing up and enrolling in N extMD, you will be able to: Correspond online with Family Health Care C enter, that is channeled to proper personnel for quicker response times Request appointments and receive appointment reminders Access important health information from your medical record including: medications, immunizations, and test results View medicat ion lists and request prescription refills directly through your provider/provider nurse Obtain educational information Maintain account information including username, password, access privileges, and email address How do you sign up?? Patients and their legal guardians can sign up for NextMD. All you have to do is provide your name and e mail address to us below. We will the n provide you with and instruction sheet with a temporary password or enrollment token. The en rollment token will allow you to log in to the system and create your own private username and password. After you sign up and begin u sing the patient portal, Next MD will generate a notice that will be emailed to your personal email account to notify you that you have important information waiting in you NextMD account. We look forward to providing this service to you and hope that you will take advantage of its many benefits.I have an email and would like to sign up for NextMD , your online patient portal.* Yes No, I do not have an email address Not interested Email Date MM slash DD slash YYYY AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION (THIS FORM MUST BE COMPLETED IN FULL TO RECEIVE RECORDS.) Name of Patient*Date of Birth* MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code I authorize the use and/or release of my protected health information as described below. I understand that the information u sed or released as a result of this Authorization may no longer be protected by federal privacy laws and may be further used or released by persons or organizations receiving it without obtaining my authorization. I may refuse to sign this Authorization, which will not aff ect my ability to o btain treatment or payment of claims. I have the right to revoke this authorization by providing written notice to Family Hea lth Care Center. Revocation of this Authorization will not affect any action taken before receipt of the written revocation. I AUTHORIZE:Name of Physician / Health Care Facility / OtherAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country TO RELEASE PROTECTED HEALTH INFORMATION TO:Name of Physician / Health Care Facility / OtherAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code HEALTH INFORMATION TO BE RELEASED: All Medical Records Immunization Records Lab Reports X-Ray Reports Billing Reports Other Describe OtherOR THE FOLLOWING DATE(S) OR TIME FRAMEFrom MM slash DD slash YYYY To MM slash DD slash YYYY Federal and state laws require special per mission to release certain information. Please check if these records SHOULD BE released Mental Health Alcohol and/or Drug Abuse HIV/AIDS test results Development Disabilities PURPOSE OR NEED FOR DISCLOSURE: (Check Applicable Categories) Further Medical Care Patient's Request Insurance/Eligibility Benefits Disability Determination Legal Investigation Other Describe OtherEXPIRATION: MM slash DD slash YYYY Set the date this authorization will expire. If I do not indicate a date, this will expire one (1) year from the date on my signature below. A photocopy of this authorization is as valid as the original.SIGNATURE: I understand that this author ization is voluntary. I am confirming my authorization that the health care provider may use and/or disclose to persons and/or organizations named in this form the protected health information described in this form.SIGNATURE*Date MM slash DD slash YYYY If this authorization is signed by a representative on behalf of the patient, complete the following:Representative's Name:Relationship to patient:
