Patient Health Survey- Initial Visit

New Patient Registration Form

Apple Ridge Family Medicine
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Place of Birth:
Social Security Number
Name of Parents/Guardian if a minor, or disabled:
Gender:*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email- We do have patient portal capability. This is a secure way to communicate, schedule and ask questions directly with the office.
example@example.com
Phone Number- Daytime*

Area CodePhone Number
Phone Number- Mobile

Area CodePhone Number
Name of Emergency Contact *
Relationship of Emergency contact*
Phone Number for Emergency Contact*
Employer:
Occupation:

Insurance Information

Apple Ridge Family Medicine
Name of Patient*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Do you have Insurance?*

YesNo, I would be self pay
If you marked yes to insurance, you must complete the Primary Insurance information fields. If you have a secondary, you must complete the information fields. These fields are required. If you are truly self pay, type 'self pay' into the required fields. If proper insurance information is not provided, you agree to be personally responsible for charges. Please note, we do not accept medicaid. We do accept accept a wide variety of PPO commercial plans and limited HMO plans. Contact the office directly for further information regarding accepted insurance plans. Insurance will be verified prior to the appointment.
Name of Primary Insurance*
Enter the Full Name of the Insurance as listed on your insurance card.
Member ID Number*
Group Number*
Full Name of the Person with the Insurance*

First NameLast Name
Date of Birth of Subscriber*
Phone Number of the Subsciber*

Area CodePhone Number
Are you the Subscriber to the Insurance*
Are you the Dependent?*
Type your relationship to the subscriber*
Date Insurance Started

MonthDayYear
Date
800 number on card for Provider Services*

Area CodePhone Number
Name of the Responsible party for billing. (Note, if you are 18 or older, you would be responsible party, regardless of Subscriber to the Insurance. )

First NameLast Name
Do you have a secondary insurance?*

YesNo
If yes, enter the name of the secondary plan
Member ID Number
This could include letters
Group Number
Full Name of the person with insurance

First NameLast Name
Date of Birth of Subscriber
Phone Number of Subscriber

Area CodePhone Number
Are you the subscriber?
Are you the dependent?
Type your relationship to the subscriber
Date the insurance started

MonthDayYear
Date
800 Number for provider servies

Area CodePhone Number
Today's date*

MonthDayYear
Date
I agree that everything above is true to the best of my knowlege and will inform Apple Ridge Family Medicine if anything changes. *

HIPAA Privacy Standards form

Apple Ridge Family Medicine
Name of Patient*

First NameLast Name
Date of Birth*

MonthDayYear
Date
From time to time it may be necessary for a representative of Apple Ridge Family Medicine to contact patients for various notification purposes that could include disclosure of Protected Health Information such as:

·       Appointment reminders/confirmation/rescheduling

·       Prescription renewal/reminder information

·       Lab/Imaging test results

·       Requests to call the doctor for other issues

We would like to know how we can contact you and with whom we can leave a message or share other information about your Protected Health Information.
I authorize Apple Ridge Family Medicine physicians and/or staff to contact me and leave messages that could include Protected Health Information pertaining to my care by the methods I have selected below. I authorize Apple Ridge Family Medicine to leave detailed, personal health information by the following means. (Choose all that apply)*

Daytime/Home Number/voice messageMobile phone/voice messageWork Telephone/voice messageEmail
*If I have authorized contact via email, I understand that the message may not be encrypted and therefore security from an unauthorized access cannot be guaranteed. I further understand that Apple Ridge Family Medicine cannot guarantee receipt of message.
Authorization to share Personal Health Information with Certain Individuals
1. Name of authorized individual and realtionship
Phone Number of Individual

Area CodePhone Number
2. Name of authorized individual and relationship
Phone Number of Individual

Area CodePhone Number
3. Name of authorized individual and relationship
Phone Number of Individual

Area CodePhone Number
I do not approve of anyone receiving protected information

Agree
Today's date*

MonthDayYear
Date
With my Signature Below, I acknowledge and understand that this Authorization will be kept as part of my medical record and that the communication instructions listed above will remain in effect until revoked by me in writing. It is my responsibility to notify Apple Ridge Family Medicine in writing should I wish to change any of information noted above and to notify Apple Ridge Family Medicine if my contact information changes.*

Clear

Statement of Patient Financial Responsibility

Apple Ridge Family Medicine
Name of Patient*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Name of person completing form is patient requires power of attorney, or is a minor

First NameLast Name
Apple Ridge Family Medicine appreciates the confidence you show in choosing us to provide for your health care needs. The services you have elected to participate in, implies a financial responsibility on your part. The responsibility obligates you to ensure payment in full of your fees. As a courtesy, we will bill your insurance carrier/s on your behalf. However, you are ultimately responsible for payment in full of your bill.

Many insurance companies have additional stipulations that may affect your coverage. It is ultimately the patients/guarantor’s responsibility to know your coverage benefits. I authorize Apple Ridge Family Medicine to furnish information to insurance carriers concerning my care. You are responsible for any amounts not covered by your insurance. If your insurance carrier denies any part of your claim, or if you elect to continue services past your coverage/policy period, you will be responsible for your balance in full.

You are responsible for the payment of any deductible, co-payments/coinsurance as determined by your contract with your insurance carrier. Some health insurance carriers require the patient to pay a co-pay for services rendered. This is a contract between you and your insurance carrier. Payment of all co-pays is expected at the time of service is rendered for the patient. If you do not have the co-pay, you may be asked to reschedule.
Coinsurance, deductible and non covered items are due 30 days from receipt of first statement. I understand that the return check fee is $25.00*

I understand.
I understand that I am responsible for co-payments and deductible/coinsurance as dictated by my insurance carrier.*

I understand.
I fully understand that I am ultimately responsible for all changes associated with my account and that if I fail to pay any amount due, I will also be responsible for all collection fees, court cost, attorney fees and any other charges incurred in the collection of any balance due. I further understand that a fee of, as much as 25%, will be added to my total account balance in accordance with this facility's contract with it's collection agency. I understand that I will be discharge from the practive for financial non compliance.*

I understand.
Today's Date*

MonthDayYear
Date
I have read the above policy regarding my financial responsibility to Apple Ridge Family Medicine, for providing medical services to me or the above-named patient. I certify that the information is, to the best of my knowledge, true and accurate. I authorize my insurer to pay any benefits directly to Apple Ridge Family Medicine. I understand that any amount remaining after such payment has been made by my insurance carrier becomes the patient's responsibility. Sign Below.*

Clear

No Show or Improper Cancellation Policy

Apple Ridge Family Medicine
Name of Patient*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Name of person completing form if patient requires power of attorney, or is a minor

First NameLast Name
We understand that things happen where you can’t make your appointment. We do ask for a 24 hour notice in cancellations and rescheduling’s. If you do not show for your appointment, please note this is how Apple Ridge will handle no shows and improper notice of cancellations.

You are allowed the following within a 365 day period. The policy resets 365 days from the first offense.

·       Your first ‘No Show’ is a verbal warning. One of our staff members will call you and alert you to the no show. If this is an improper cancellation notice, you will receive the verbal warning at the time of your phone call.

·       Your second ‘No Show’ or improper cancellation notice would be a charge of $50 dollars. You would be verbally notified of this charge.

·       Your third ‘No Show’ or improper cancellation notice would result in a discharge from the practice. This is not guaranteed to be told you verbally. You would receive a letter within 3-4 business days of the third ‘No Show’. That letter explains to you the policy and that you will receive thirty (30) days of emergency care by the practice. This would be the time we advise you to search for another physician.

Please note we have a policy that if you arrive 10 minutes late for an appointment, you will be asked to reschedule. This does not fall into the ‘No Show’ or improper cancellation notice policy. We will simply need to reschedule your appointment. We will do our best to accommodate you based on the physician’s schedule. This policy is in place to not disrespect other patient’s appointment times.
Today's date*

MonthDayYear
Date
I understand the above policy. Sign Below.*

Clear

Authorization for Release of Medical Information
I authorize Apple Ridge Family Medicine, 1311 Biglerville Road, Gettysburg, PA 17307 to obtain my previous medical records. Please include my entire record from your facility, along with any old records you may have from previous physicians. The phone number to this facility is 717-334-8165 and the fax number is 717-338-9070.
Name of the patient*

First NameLast Name
Date of Birth of patient*

MonthDayYear
Date
Phone Number of patient/guardian*

Area CodePhone Number
Name of Facility Releasing Records*
Address of Facility Releasing Records

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Facility Releasing the Records

Area CodePhone Number
Fax Number of Facility Releasing the Records

Area CodePhone Number
Special Records: Include the following medical records ifsuch information is included in your records. Please check all boxes that may apply. Checking the boxes is not a representation that such information exists.

Include Drug and Alcohol Treatment Records (protected by thePennsylvania Drug and Alcohol Abuse Control Act, 71 P.S. 1690.108)Include Mental Health Records (protected by the MentalHealth Procedure Act, 50 P.S. 7111)Include AIDS/HIV – Related Records (protected byConfidentiality of HIV- Related Information Act, 35 P.S. 7607)Include Sexual Abuse/Assault and Domestic ViolenceCounseling Records (protected by 42 Pa.C.S.A. 5945.1 and 23 Pa.C.S.A. 6116,respectively.)
Purpose of Release of Information : Transfer of Primary Care
This authorization will expire in 1 year from date of Signature

I understand that I may revoke this authorization at any time by notifying my provider or by notifying the provider or entity that is authorized to receive this records. I understand that revocation will not have any effect on the actions taken prior to any revocation and will not apply to information that has already been released in response to this authorization.

The authorization is voluntary. I can refuse to sign this authorization.

I understand that if the organization authorized to receive the information is not a health plan or a health care provider, the information may no longer be protected by federal privacy regulations.

I understand that this information may be re-release by the recipient and no longer protected.

I understand that the provider named above may not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.

If mental health records are being release as permitted by the Mental Health Procedures Act, I understand that I have a right, subject to 55 Pa. Code 5100.33 to inspect the material being released.

If AIDS of HIV- related information is being released, this information has been disclosed to you from records protected by Pennsylvania law. Pennsylvania law prohibits you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains, or is authorized by the Confidentiality of HIV- Related Information Act. A general authorization for the release of medical or other information is not sufficient for this purpose.

By signing below, I certify that I understand the nature of this release.
Today's date*

MonthDayYear
Date
By signing below, I authorize the release of the medical information requested and specifically waive the confidentiality protection afforded by Pennsylvania statutory law for the Special Records indicated above. The waiver is applicable only to this request and is not meant to be a general waiver.*

Clear
Name of person completing form if patient requires power of attorney, or is a minor

First NameLast Name
Relationship to patient: Choose one*

SelfParent/Legal Guardian of MinorLegal Guardian/POA of Adult
Should be Empty:

Patient Health Survey- Initial Visit

Review of Symptoms- Please check all that currently apply.

New Patient Registration Form

Insurance Information

HIPAA Privacy Standards form

Authorization to share Personal Health Information with Certain Individuals

Statement of Patient Financial Responsibility

No Show or Improper Cancellation Policy

Authorization for Release of Medical Information