New Patient Registration Form

New Patient Registration

Please complete all sections carefully.

Section 1: Patient Information

Title

Last Name *

First Name *

Middle Name

Date of Birth *

Gender *

Male Female Other

Social Security #

Marital Status

Spouse's Name

Home Address (Street) * Apt/Suite/Unit #

City *

State *

ZIP Code *

Home Phone

Cell Phone *

Work Phone

Email Address *

Preferred Method of Communication

Home Phone Cell Phone Work Phone Email Mail Decline Other

Employer Name

Employer City

Employer State

Employer ZIP

Emergency Contact Name *

Emergency Contact Phone *

Relationship to Patient

Section 2: Guarantor Information (Person Responsible for Payment)

Is the Guarantor the same as the Patient? *

Yes No

Guarantor Full Name

Relationship to Patient

Guarantor Date of Birth

Guarantor Social Security #

Guarantor Home Address (Street) Apt/Suite/Unit #

City

State

ZIP Code

Guarantor Employer

Guarantor Occupation

Guarantor Cell Phone

Guarantor Work Phone

Guarantor Email

Section 3: Insurance Information

Primary Insurance

Insurance Company Name

Policy Number

Group Name/Number

Is the Primary Insured the same as the Patient?

Yes No

Primary Insured's Details (if different from patient)

Insured's Full Name

Relationship to Patient

Insured's Date of Birth

Insured's Social Security #

Secondary Insurance

Do you have Secondary Insurance?

No Yes

Insurance Company Name

Policy Number

Group Name/Number

I hereby authorize you to release any information acquired in my examination or treatment necessary to process my insurance claims. I release you from all legal responsibility that may arise from the act I have authorized. I DO NOT authorize you to release information for insurance claims. I understand I am responsible for my medical bills.

Section 4: Patient Health History

Reason(s) for this visit *

Please list the names of all physicians you currently see:

Current Medications (List all, including dose and frequency):

Over-the-Counter Medications, Herbal Supplements, Vitamins:

Allergies (If none, write "None") *

Previous Medical History (Do you suffer from any of the following?):

High Blood Pressure Heart Disease Stroke Diabetes Asthma Malignancy/Cancer Seizures

Other conditions:

Family Medical History (Blood Relatives):

High Blood Pressure:

Yes No

Heart Disease:

Yes No

Heart Disease:

Yes No

Heart Disease:

Yes No

Heart Disease:

Yes No

Heart Disease:

Yes No

Do you smoke? How often?

Do you use alcohol? How often?

(For Female Patients Only) Date of Last Menstrual Cycle:

List any surgeries:

List other illnesses:

Retail Pharmacy Name & Phone:

Mail Order Pharmacy Name & Phone:

Section 5: Consents & Agreements

Consent for Medical Care and Treatment

I understand that my health condition may require diagnosis and treatment. I hereby voluntarily consent to such treatment, services, and procedures as ordered by my doctor, his consultants, associates and his assistants, or his designee. I also understand student nurses and others in professional training programs may be among the individuals who provide care to me.

I authorize Dr. Nwiloh and his assistants/designee to discuss my medical history, diagnosis, treatment and prognosis as provided in the notice of privacy practices. I understand this may include information regarding testing, examination and treatment for HIV, AIDS related illness, mental health and drug, alcohol or chemical abuse. I have the right to add anyone or any organization that I do not wish to have my medical information by requesting in writing at any time.

I understand there are times when the law allows Dr. Nwiloh and his assistants/designee to release information regardless of whether or not I give my consent as outlined in the notice of privacy practices. For example, Dr. Nwiloh and his assistants/designee may release information to doctors, nurses and other who provide me with health care or are prospective health care providers; to government agencies as authorized by law to insurance companies or others who are responsible for paying my medical bills; or to a court of law that issues a subpoena or court order. I understand this information may be released either orally or in document form.

I also understand and acknowledge that Texas law provides if any health care worker is exposed to my blood or other bodily fluid, Dr. Nwiloh and his assistants/designee may perform tests, with or without my consent, on my blood or other bodily fluid to determine the presence of any communicable disease, including but not limited to, Hepatitis, HIV/AIDS and Syphilis. I understand that such testing is necessary to protect those who will be caring for me while I am a patient of Dr. Nwiloh. I understand that the results of tests taken under these circumstances are confidential and do not become a part of my medical record.

I acknowledge that it may be difficult for the physician(s), his/her assistants, or his/her designee to personally communicate with the patient regarding laboratory/diagnostic test results, etc.It is the policy of Dr. Nwiloh's Office to leave this information on the patient's telephone answering machine.

NO GUARANTEE: I acknowledge that the practice of medicine is not an exact science and that Dr. Nwiloh has made no guarantees or warranties to me as to the result of treatments or examination.

It is the policy of Dr. Nwiloh's Office not to release confidential medical information to patient's family members. We cannot discuss your medical condition, or release diagnostic test results to anyone without your consent. I hereby give consent that information regarding my medical condition, including laboratory and diagnostic test results can be given to:

I have read, understood, and consent to the Medical Care and Treatment terms. *

Authorize release of information to specific individuals?

No Yes

Notice of Privacy Practices (HIPAA)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This notice is being provided to you in accordance with the requirements of the Standards for Privacy of Individually Identifiable Health Information of the Health Insurance Portability and Accountability Act (HIPAA) and by the amendments to the HIPAA Privacy Rules made by the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH Act).

I acknowledge that I have been provided with Heritage Healthcare Clinic (HHC) Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the Notice of Privacy Practices prior to signing this content. I understand that HHC reserves the right to change its Notice of Privacy Practices and prior to implementation will mail a copy of any revised notice to the address I have provided.

By signing this form, I consent to HHC use and disclosure of my health information for treatment, payment, and health care operations.

I acknowledge I have been provided with the Notice of Privacy Practices and consent to the use and disclosure of my health information. *

Patient Informed Consent for Electronic Medical Services

HHC has implemented an electronic health record in part to meet the U.S. Department Health and Human Services initiative to improve health information technology, toward the goal of improving quality of health care. Our electronic health record integrates your clinical record with appointments, registration, and billing and makes this information available to the clinicians who are involved in your health care.

In connection with its electronic communication systems, HHC has also implemented and has in place privacy and security policies and procedures to minimize risk of inadvertent or unauthorized disclosure, corruption and/or loss or distortion of data, but as with all record keeping systems, whether paper or digital, some risks remain of loss, inadvertent disclosure or errors in the recorded data.

I have read and understand the information provided regarding Electronic Medical Services, have discussed it with my physician, his/her assistants, or his/her designee, and all of my questions have been answered to my satisfaction.

I hereby give my informed consent for the use of Electronic Medical Services in the course of my diagnosis and treatment and consent to the electronic communication of my personal health care information to other entities for treatment, payment or health care operations, including electronic transfer of medical data to other medical practitioners participating in my medical care.

I have read, understood, and give my informed consent for the use of Electronic Medical Services. *

Informed Consent for Prescriptions

HHC continues its position as the network exchange for the flow of vital patient information to physicians and other health care providers. It is essential to improve patient safety and the continuity of care with electronic connectivity between payers, physicians and pharmacists. HHC electronic health record (EHR) provides secure access for patients with commercial prescription coverage in the United States.

Prescription eligibility, benefit, formulary and medication history information is provided for consenting patients to authorized physicians at the point of care. Electronic prescriptions are delivered in real-time to pharmacists in the retail and mail order settings.

I consent to electronic prescriptions and acknowledge that HHC will use electronic connectivity between payers, physicians and pharmacists.

I consent to electronic prescriptions and acknowledge the electronic connectivity. *

Insurance & Financial Responsibility Agreement

Welcome to Heritage Healthcare Clinic. We believe that you deserve the best care. That's why we always provide you with the best medical care possible to treat your personal situation...

Please initial key points (optional, or use main checkbox below):

Your medical benefits are a contract between you/your employer and an insurance company. [...]

We will bill your insurance as a courtesy. If insurance does not pay within 45 days, you are responsible. [...]

It is your responsibility to know if Dr. Nwiloh is in-network. Estimates are not guarantees. [...]

It is your responsibility to know your deductibles, co-payments, agelimits, exclusions, waiting periods, clauses or any other type of benefit limitation for the services received. Many times these exclusions are provided to employees only & are not made available to our staff when confirming benefits. [...]

Payment for your estimated portion is due at time of service. NSF check fee is \$25. [...]

A \$25 cancellation fee for office visits and \$35 for Physical/Wellness visits with less than 24 hours' notice. [...]

I have read, understood, and agree to the Insurance & Financial Responsibility Agreement. *

Office Policies Agreement

Check In Process:

Insurance card and valid ID required for every visit.
Notify office of changes in address, phone, or insurance.
Past due balances must be paid.
Responsible for charges if benefits cannot be verified.
Payment due at time of service (Cash, Check, Visa, MC, AmEx, Discover).
Co-pay/contracted percentage collected at every visit. Deductible payments required if not met.

Appointments:

Arrive 10-15 minutes prior to appointment.
Rescheduling may be necessary if late.
Office visits are 15 mins, Physical/Wellness 20-25 mins, unless extended by Dr. Nwiloh.
Walk-ins are for one medical complaint only.
Wellness/Physical exams cannot be scheduled same-day.
If scheduled for physical/wellness with other issues, co-pay for other issues due.
Cancellation fees: \$25.00 fee for a cancelled office visit and \$35 fee for a cancelled physical/wellness appointment with <24hrs notice.

Financial Responsibilities:

All due balances must be paid prior to being seen (except emergencies).
No exception for deductibles and co-pays at time of service.
Private pay patients pay estimated fee upfront.
\$25.00 fee for returned checks.

Medication Refills:

ADD/ADHD medication checks every 3 months. Refills require kept appointments. Allow 48hrs for pickup. \$15 rewrite fee if not picked up/filled in 7 days.
Refills for stable chronic conditions by phone (e.g., asthma, hypertension). Allow 72hrs. No refills after hours/weekends. Follow-up may be needed.
Antibiotics not prescribed over phone.
Narcotics & controlled substances will not be called in. Patient MUST see the Doctor for an appointment to discuss these medications.

Others:

Medical records faxed to another physician free of charge for continuum of care. Fee for entire record for PCP change or personal use.
Medical records copy fee. Provided on USB or paper (additional fee may apply).
Excused absence note only if seen for illness, obtained at time of visit.
\$25.00 fee for paperwork requiring physician's signature.
Due to HIPAA laws patients must check in with the receptionist and are not allowed in the back office without consent.

I have read, understood, and agree to the Office Policies. *

Section 6: Authorization for Release of Patient's PHI

(This section is typically for specific requests to release your records. Complete if applicable.)

Information to be released FROM: Person/Facility: Address: City/State/Zip: Phone: Fax:

Information to be released TO: Person/Facility: Address: City/State/Zip: Phone: Fax:

Purpose of this disclosure:

Continuance of Medical care Attorney Insurance

Other

Specific records to be disclosed:

Copy of all health records Laboratory Tests Progress Notes Billing Records X-Ray Reports

Other

Records to be faxed or electronically transmitted?

Yes No

Acknowledgement

I understand that the information released as a result of this Authorization may be subject to re-disclosure and no longer protected by federal or state laws applying to medical information release.

I understand that there may be a fee for copying of my medical records if it is to be used for other than continuance of healthcare with another provider.

I understand that this Authorization may be revoked in writing at any time. I understand that revocation will apply only to releases of information made after the date of my revocation.

Unless otherwise indicated, this authorization will expire twelve (12) months from the date of signature. A photocopy of this authorization will be considered as valid as the original. I understand that I will be provided a copy of this Authorization upon request.

I understand and agree that my medical record will be maintained in an electronic medical record (EMR) format and that records may be transmitted electronically via fax, E-mail, Internet, or data transfer system.

I have read, understood, and agree to this Authorization for Release of PHI.

Section 7: Signature & Submission

Patient/Legally Authorized Representative Signature *

Date *

By signing and submitting this form, I certify that the information provided is true and accurate to the best of my knowledge.