SPHC New Patient Form

Patient Information

Please Complete All Fields
** Items Necessary For Your Visit **

Please have the following on hand when you arrive for your first visit:

- Current Valid Photo ID

- Current Valid Insurance Card

- Updated Medication List (If You Do Not Know What You Take, Bring The Bottles, And We'll Help You Make A Current Medication List)
Name:*

First NameMiddle NameLast Name
Date of Birth:*

MonthDayYear
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Marital Status:
SSN:
E-mail*
Home Phone:*

Area CodePhone Number
Cell Phone:

Area CodePhone Number
Briefly Describe What Brings You In To The Clinic?
How Did You Hear About South Pointe Healthcare?*
How Did You Hear About South Pointe Healthcare?*

GoogleZocDocFamily / FriendsDoctor ReferralInsurance CompanyWebMDUSCIS WebsiteYelpOther
Referring Doctor / Provider Name:*
If you already have a primary care provider, please enter name below (If not please put n/a)*

Are you a patient at Back To Action Physical Therapy?

YesNo
Are you a patient at Whole Body Balance?

YesNo
Insurance And Responsible Party Information
Check this box if you are a self pay patient that is not using insurance:

I am not using insurance
Name of Insurance or Lien policy holder:
Last NameFirst NameDate of Birth
AddressCity, State:SSN#:
Phone:Email:Date of Birth#:
Insurance Information
Insurance Name:
Address (back of card):
Phone Number

Area CodePhone Number
Member ID #:
Group #:
Effective Date:
2nd Insurance Name:
Address (back of card):
Phone Number

Area CodePhone Number
Please list any Medication or Supplements:

Medication Allergies
Allergy:
Reaction:
Family History
Mother:

LivingDeceased
Cause of Death:
Relevant Health History:
Father:

LivingDeceased
Cause of Death:
Relevant Health History:
Sibling:

LivingDeceased
Cause of Death:
Relevant Health History:

Emergency Contacts
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Emergency Contact Address
Next of Kin Name*

First NameLast Name
Next of Kin Phone*
Next of Kin Address

HIPAA Release Form
I, (Patient's name) First Name Last Name give my permission for South Pointe Healthcare At Coal Creek, to release the information listed in Section II of this document with the person(s) or organization(s) I have specified in Section II of this document.
I would like to give the above healthcare organization permission to (Check off as appropriate):

I do not wish to disclose any of my health information.Only Disclose the following ____________________________Disclose my complete health record including, but not limited to, diagnoses, lab test results, treatment, and billing records for all conditions.Disclose my complete health record except for the following information ______________________________________
Only disclose the following:
Disclose my complete health records except for the following:
Who Can Receive My Health Information
I give authorization for the health information detailed in section II of this document to be shared with the following individual(s) or organization(s).
Name:
Organization:
I understand that the person(s)/organization(s) listed above may not be covered by state/federal rules governing privacy and security of data and may be permitted to further share the information that is provided to them. I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to:

Name: South Pointe Healthcare

Address: 150 Old Laramie Trail Suite 210, Lafayette, CO. 80027

In the event that my personal information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data.

I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.

Please note South Pointe Healthcare's email address has changed. All emails will forward to "frontdesk@southpointehealthcare.com".
Printed Name: First Name Last Name
Date:
Signature*

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**If this form is being completed by a person with legal authority to act an individual's behalf, such as a parent or legal guardian of a minor or health care agent, please complete the following information:
Name of person completing this form:
First Name Last Name
Signature

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Financial Policy
Patient Responsibility: Patient understands that it is his/her obligation to know his/her insurance requirments and ensure that they have been fulfilled, including having a valid authorization for service in place prior to his/her Medical services South Pointe Healhcare will check for eligibility as a courtesy, however this is not a guarantee of payment/coverage by the insurance company. Insurances that fail to pay for claims filed, regardless of the reasoning, will lead to the Patient and/or Guarantor being responsible for payment of the remaining uncovered charges. Insurance has to be present and active at the time of service, along with a valid U.S issued photo identification. If insurance information is presented after treatment we will file a claim to your insurance company on your behalf. However, you will be held liable for the charges if the insurance denies the claim because of late presentation of coverage or for lack of timely authorization due to late presentation of coverage.

Insurance Payments: We participate with most insurance plans in the area. Some services may not be covered by your insurance policy. Your insurance coverage is a contract between you and your insurance plan. Co-payment, deductibles, co-insurances and servicees are not coveered by your insurance plan or outstanding balances are all patient's responsibility to pay in full.

Co-Payments are due at the time of service: It is your contractual obligation with you insurance company to pay the copay portion of the visit at time of service. Patients unable to pay their copay, will have their appointment rescheduled.

Missed Appointments: We charge a $50.00 fee for any office appointments missed or cancelled under 24 hour's notice. Late appointments and same day reschedules are considered missed appointments and are subjected to a missed appointment fee. These fees are patient responsibility and will not be submitted through insurance or liens.

Medical Records: We offer patient free electronic records via a secure email. You will be subjected to a fee for any printed records. We wll fax all records for free to any Physician's office or other medical facuility as a courtesy. A signed HIPAA authorization will be required to send your records to any third party requester.

Past Due Balances: After 90 days your account will be considered past due and can be turned over to a third-party collection agency. If it becomes necessary to turn your account over to a third-party collection agency due to your non-payment you will be dismissed from the practice. We ask that you handle any outstanding balances within 90 days. Please reach out to our billing department or Practice Manager for needed payment arrangements.

Self-Pay: Patients who are not billing a third party or health insurance must pay in full at the time of servce.
Your signature on this page constitutes as an acknowledgement and understanding of this policy. I have read and agree to the above policies and authorize payment directly to South Pointe Healthcare.
Date: mm/dd/yyyy
Signature*

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Consent And Understanding

This consent is required by the Health Insurance Portability and Accountability act of 1996 to inform you of your rights for privacy with respect to your health care information.
Consent Related to Privacy Notice:

I have had a chance to review the Practice Privacy Notice as part of this registration process. I understand that the terms of the Privacy Notice may change and I may need to obtain these revised notices by contacting the practice by phore or in writing. I understand I have the right to request how my protected health information )PHI) has been disclosed. I also have the right to restrict how the information is disclosed, but this practice is not required to agree to my restrictions. IF it does agree to my restrictions on PHI use, it is bound by that agreement.

Consent For Care:

I, with my signature, authorize South Pointe Healthcare, and any employee working under the direction of the physician, to provide medical care for me, or to this patient for which I am the legal guardian. This medical care may include services nad supplies realted to my health (or the identified person) and may include (but not limited to) preventative, diagnostice, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function ofthe body and the sale of dispensing of drugs, devices, equiptment or other items required and in accordance with a prescription, This consent includes contact and discussion with other health care professionals for care and treatment.
By signing this I agree that I have read and understand the Consents as above stated:
Patient name if different from Responsible Party:
   First Name   Last Name
Date:      mm/dd/yyyy
Signature*

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Uninsured Patient Provider Agreement
Name: First Name Last Name
Date of Birth: mm/dd/yyyy
I confirm that I DO NOT have any Government issued or Commercial insurance. Per Government guidelines and our contractual agreement with the insurance Companies, South Pointe Healthcare must bill insurances before accepting self-pay
Initials*
I understand that if I withhold any active insurance information I may be discharged or Initial reported for fraud
Initials*
I understand that all payments for services rendered are due at the time of my Initial appointment or my appointment may be rescheduled.
Initials*
Printed Name of Patient or Personal Representative:
First Name Last Name
Date: mm/dd/yyyy
Signature of Patient or Personal Representative*

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Deductible Payment Policy

*Only relevant for patients with deductibles.

A Deductible is a predetermined amount between you and your insurance provider for the amount you owe during a coverage period for covered healthcare services before your insurance plan begins to pay for your services received. Once you max out your deductible, you are responsible for any copayments or coinsurance for your particular HealthCare policy.

All health care plans that require a deductible will require a payment of $100.00 due at the time of service.

Our billing department will bill the insurance for services rendered and apply the $100.00 payment.

Please keep in mind charges will be the patient's responsibility and billed accordingly.

South Pointe Healthcare is happy to check oce visit benefits with your insurance plan. We recommend patients become familiar with coverage benefits.

By signing this, you acknowledge you will be charged $100.00 per visit due at the time of service, until your deductible has been fully met.
Print Name of Responsible Party

First NameLast Name
Signature

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Date

MonthDayYear
Date
Should be Empty:

Patient Information

Insurance And Responsible Party Information

Insurance Information

Medication Allergies

Family History

Social History

Pharmacy of Choice

Medical History

Emergency Contacts

HIPAA Release Form

Financial Policy

Consent And Understanding

Uninsured Patient Provider Agreement