New patient packet (Insurance 2021)

Demographic information (FFS)
Legal Name: First Middle Last
Name you would like to be called:
Gender:
Legal Gender:
Gender Assigned at Birth:
Pronouns: (she/her, he/him, they/them, etc.)
Ethnicity or you can leave blank:
Preferred Language:
Social Security Number
Date of birth:
Address: Street, City, Sate, Zip code
Billing address if different - if not write same
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Permission to leave messages on which phone number?
Choose one option from drop down.
Email address:
Emergency contact/next of kin:
Relationship to patient
Address of Emergency contact: street, city, state, zip
Emergency contact home/cell phone
Emergency Contact Work phone
If applicable, who has legal guardianship over the patient? Please list name and phone number
With whom may we discuss your care?

AUTHORIZATIONS

COMMUNICATION:
Allowed detailed Voicemail as indicated below (initial here).
GPC may leave detailed voice messages at my home #
GPC may leave detailed voice messages at my cell #
Allow text: GPC may text message me at my cell phone (Initial here)
I DO want email - Email consent: GPC may send my personal health information via email. I understand that email may be unencrypted and that this carries a risk of third-party gaining access. I also understand that emails may be part of my permanent medical record. I also give permission for GPC to communicate via email to my specialists and other outside providers as indicated through my signed release of information form. (initial here) or type N/A
I DO NOT want to allow email. I do not wish to have email initiated from GPC; I understand that if I email GPC they may respond to my request via email. (initial here) or type N/A
Leave blank if you DO want email
For reminder notices appointments please contact me via
For reminder to schedule an appointment, please contact me via
I wish to receive my labs, study results:
If I need a medical follow up:
For practice notifications:
GPC may speak the person indicated below (spouse, family member) about my medical (initial here)
This includes information related to mental/behavioral health, substance sexually transmitted disease, HIV status and reproductive medicine; please use this to enter in EXCLUDED information
Name and Relationship of person this information can be disclosed to
Their Phone #
I acknowledge and understand that this information will be kept in my medical record according to and the instructions above will be honored until revoked by me in writing. It is my responsibility to notify GPC and Greenlake Psychiatric should I change one or more of the telephone numbers listed above. (initial below)
CONSENT TO BE TREATED

I give permission and authorize the providers and staff of Greenlake Primary Care to examine and treat me. If treatment is for a minor, I hereby give permission for the patient to receive treatment. In the rare even that I cannot be reached, I authorize GPC to institute any necessary care for the patient, including hospitalization. This authorization is in effect until rescinded in writing.
Signature (must be signed by parent/legal guardian if patient is under the age of 18)

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Today's Date

MonthDayYear
Date
Print your name if you are signing for a minor or as legal guardian.

Greenlake Primary Care Financial Policy (updated 1/2021)

Greenlake Primary Care currently (Jan 2021) participates with a wide variety of insurance plans including: Aetna, First Choice, Labor & Industry, Medicare, Premera, Regence, Uniform, and others. We do not bill third party for motor vehicle accidents. We do not take EPO plans or HMO plans. We no longer contract with Tricare, or United Healthcare. If you do not have insurance, or if we are out of network for your insurance, you may qualify for Direct Primary Care membership. (After May 2021 – we will no longer contract with any private insurance, nor will we submit bills on your behalf. )

Know your insurance plan. Before your visit, call the toll free number on the back of your insurance card. Make sure you know if we are assigned as your primary care provider.
- Ask your insurance representative if the practitioner you wish to see is a preferred provider.
- Then please designate her/him as your primary provider.
- You may also ask whether you need a written referral to specialists, how often this needs to be renewed, and review your coverage, deductible, co-payment, and benefit limits.
Then:
- Bring your insurance card to every visit.
- Tell us if your insurance or mailing address has changed.
- Pay your co-pay at the time of your visit.
Until April 30, 2021, Greenlake Primary Care will submit your bill to your insurance company for you. We will continue to bill for Medicare. If we are out of network, you are responsible for paying at the time of service and we will submit your bill to your insurance company on your behalf as a courtesy. We make no guarantee regarding insurance reimbursement or payments.

If you do not have medical insurance, it is your responsibility to make full payment at the time of your visit for the services given. If there is financial hardship, please let us know and ask about our Direct Primary Care membership program.

Please note:
- For your convenience we accept Visa and Master Card.
- Checks returned for insufficient funds will result in an immediate charge of $35.00 against your account.
- There will be a charge of $50.00 for no shows or late cancelations (less than 24 hours in advance) for primary care appointments and $75 for psychiatric appointments.
Questions about your account can be answered by Physician Billing Partners at (206) 932-9025
Release of Insurance Benefits: I authorize Greenlake Primary Care to request and directly collect, on my behalf, all public and private insurance coverage benefits due for products and services provided by Greenlake Primary Care. I authorize insurance benefits to be paid directly to the provider or GPC. If insurance benefits are paid directly to me and owed to GPC, I will endorse these checks for such payments to Greenlake Primary Care. (initial below)
Release of Health Information to Insurer: I authorize Greenlake Primary Care, to release any health care information necessary to facilitate the processing of claims and audit of payments, for the services provided to me or my child by Greenlake Primary Care. This authorization is in effect until rescinded in writing.(Initial)
Financial Responsibility: I am financially responsible for any co-payments, deductibles, balances due, and charges for services not covered by my insurance plan. If my insurance or plan is out of network, I understand that payment is due at the time of service. As a courtesy, GPC will submit a bill on my behalf to my insurance company and this is not a guarantee of payment.I have read and understand this policy. A copy will be kept in my chart and a copy may be furnished to me at my request.(Initial below)
I have read and understand this policy. A copy will be kept in my chart and may be furnished to me at my request. All authorizations are in until rescinded in writing
Signature

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Today's date

MonthDayYear
Date

Credit Card and/or ACH withdrawl Authorization:
I authorize Greenlake Primary Care to charge my credit card or ACH account on file for all charges as well as any co-pays, or balances that are due. These include charges collected for labs, medications, late fees as above, and other incidentals that will be explained to me prior to any payments being rendered. Credit card numbers and ACH will be entered directly by me or staff into the secure payment system HINT or directly into our online credit card terminal through Transaction Express. No card numbers or bank information will be stored in my chart or in the office and the card number or bank account information cannot be accessed once entered.
- I can ask and receive a statement of my account which the practice will provide within 5-7 business days
- Start date of authorization is pursuant to start date of my signature below.
- The credit card and/or ACH authorization is in effect until rescinded in writing.
Signature

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Name on Credit Card

BILLING INFORMATION
INSURANCE INFORMATION
Primary Insurance
Group Number
Secondary Insurance
Group Number
If you are not the primary insured please fill in the following information.
For minor children the Parent with the first birth month (i.e. January vs February) will be considered “primary insurance” holder for all doubly covered children.
Guarantor For Primary Insurance

First NameLast Name
Relationship to patient:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Guarantor Date of Birth

MonthDayYear
Date
Guarantor Social Security Number
Guarantor for Secondary Insurance

First NameLast Name
Relationship to Patient
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Guarantor Date of Birth

MonthDayYear
Date
Guarantor Social Security

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
GREENLAKE PRIMARY CARE

We want to inform you of the rights you have as a patient under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), as updated by the 2013 HIPAA Final Omnibus Rule.

In summary under HIPAA, I understand that my personal information may be used to:

·       Provide and coordinate my treatment among a number of healthcare providers who may be involved in my treatment directly or indirectly
·       Obtain payment from third-party payers for my healthcare services
·       Conduct normal healthcare operations such as quality assessment and improvement activities

I have been informed of Greenlake Primary Care’s (GPC) Notice of Privacy Practices and understand that I may request a copy of this Notice for my own use.

I understand that GPC have the right to change their Notice of Privacy Practices and that I may contact this office to obtain a current copy.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations.

I further understand that GPC are not required to accept my requested restrictions, but if they are accepted then I understand that they will honor my request unless it is an emergency.

I further understand that I have the right to not sign this acknowledgement and may still receive treatment at GPC.

Our Notice of Privacy Practices describes in more detail how your health care record may be used and disclosed, and how you can access your information. Copies are available at our office or on our website: www.greenlakeprimarycare.com.

I acknowledge that I have had the opportunity to review the Notice of Privacy Practices. This signed acknowledgement will be retained in my medical record, in accordance with HIPAA Privacy Act regulations.
Signature

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