New Patient Registration

We've tried to make these forms as simple as possible. Your attention in accurately reporting this information is greatly appreciated, and will allow us to provide you the best quality care possible!

It will assist you to have all medical information
available before starting this form.

By signing your initials below, you are confirming that, to the best of your knowledge, the information provided on this medical history has been accurately answered.  You understand that providing incorrect or incomplete information can be dangerous to your (or the patient's) health.   It is your responsibility to inform our clinic of any changes in my medical status, treatments or conditions.

We will need a copy of a valid identification and BOTH SIDES of your Insurance Card before we can schedule your appointment.  

• You can take photos using your phone or computer camera below,
• You can upload a file with the photos or scans, also below,
• You can bring these cards to our clinic and we'll copy them for you.

PATIENT AGREEMENT
Payment is due at time services are rendered. By signing below, you agree to and understand the following policies:

Consent for Medical Treatment
1. I voluntarily consent to any and all health care treatment and diagnostic procedures provided by Adler Family Practice, its clinicians and other personnel. I am aware that the practice of medicine and other health
care professions is not an exact science and I further state that I understand that no guarantee has been or can be
made as to the results of the treatments or examinations at Adler Family Practice.
2. I consent to the use and disclosure of my/the patient's protected health information for purposes of obtaining
payment for services rendered to me/the patient, treatment and health care operations consistent with the
Adler Family Practice Notice of Privacy Practices.
3. I authorize payment of medical benefits to Adler Family Practice providers or their designee for services rendered.
4. I give permission to obtain all my medication/prescription history when using an electronic system to process
prescriptions for my medical treatment.

Electronic Communication
By supplying my phone number, email address, and any other personal contact information, I authorize my health care provider to employ a third-party automated messaging system to use my personal information, the name of my care provider, the time and place of my scheduled appointment(s), and other limited information, for the purpose of notifying  me of a pending appointment, missed appointment, overdue wellness visit, or any other reasonable healthcare related  communication.

Testing and Results 
I understand the clinic normally use Tricore Laboratories. If I or my insurance company prefers another lab, it is
my responsibility to inform a medical staff member before the specimen is collected so I am not billed for out of network lab.   I understand it may take up to 7 days to get lab results and 2 days to get imaging results, and that test results that are considered to be within acceptable limits will be provided to me on my AFP Patient Portal when received and that I will not be notified by phone or regular mail.  I understand there is an appointment required to discuss test results, for new medical concerns or symptoms, for prescriptions that are new or need to be restarted if no longer taking.  I also consent for AFP providers to request pharmacy and medication history reports as available to them.

Discharge from Practice
AFP Providers reserve the right to discharge persons from their practice for poor therapeutic relationship, non-compliance with treatment plans that pose an increased health risk, non-payment of fees, appointment attendance issues, or for any other aberrant clinical or business issues.

Consent for Telemedicine Appointments

What is telehealth?
Telehealth is a way to visit with healthcare providers, such as your doctor or nurse practitioner.
You can talk to your provider from any place, including your home. You don’t come into our clinic.

How do I use telehealth?
You talk to your provider by phone, computer, or tablet.
You and your provider can see each other.

How does telehealth help me?
You don’t have to go to a clinic to see your provider.
You won’t risk getting sick from other people.

Can telehealth be bad for me?
You and your provider won’t be in the same room, so it may feel different than an office visit.
Your provider may make a mistake because they cannot examine you as closely as at an office visit. (We don’t know if mistakes are more common with telehealth visits.)
Your provider may decide you still need an office visit.
Technical problems may interrupt or stop your visit before you are done.

Will my telehealth visit be private?
We will not record visits with your provider.
If people are close to you, they may hear something you did not want them to know. You should be in a private place, so other people cannot hear you.
Your provider will tell you if someone else from their office can hear or see you.
We use telehealth technology that is designed to protect your privacy.
If you use the Internet for telehealth, use a network that is private and secure.  
There is a very small chance that someone could use technology to hear or see your telehealth visit.

What if I want an office visit, not a telehealth visit?
For now, almost all visits are by telehealth. You cannot schedule an office visit now, unless it is approved beforehand by AFP providers, usually due to medical necessity or technical problems.
You must wait until the office opens for all other appointments. We do not know when that will be.

What if I try telehealth and don’t like it?
You can stop using telehealth any time, even during a telehealth visit.
You can still get an office visit if you no longer want a telehealth visit. But until the office opens for all appointments, you will get an office visit only for one of the reasons listed above. If you decide you do not want to use telehealth again let your AFP provider or staff that you would like in-clinic appointments going forward. 

How much does a telehealth visit cost? 
What you pay depends on your insurance.
A telehealth visit will not cost any more than an office visit.If your provider decides you need an office visit in addition to your telehealth visit, you may have to pay for both visits.

Do I have to sign this document?
No. Only sign this document if you want to use telehealth.

What does it mean if I sign this document?  
If you sign this document, you agree that:
You've reviewed the information in this document.
You can have your questions about telehealth answered by AFP staff or providers prior to your first telehealth appointment.
You want a telehealth visit.

Thank you for providing this information to join our practice!

If you are planning on a Telemedicine first appointment, please log into your Patient Portal well in advance of your appointment to ensure you can use our video technology tools.

Please note that this information may not be entered into your Patient Portal by the time of your appointment.  You may skip past reentering this information in your Patient Portal, it will be entered as soon as possible.