initial here GPC may leave detailed voice messages at my home phoneinitial here GPC may leave detailed voice messages at my cell phone initial here GPC may text message me at my cell phoneinitial here GPC may use Spruce to message and text with me
Choose one initial Allow email: GPC may send my personal health information via email. I understand that email may be unencrypted and that this carries risk of a 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 with my specialists and other outside providers as indicated through my release of information form. -OR- initialDo not 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 GPC may speak to the person indicated below about my medical condition. This may include information related to mental/behavioral health, substance abuse, sexually transmitted disease, HIV status and reproductive medicine unless specified below field. Name/Relationship: Name/RelationshipPhone #: Area Code Phone Number
Greenlake Primary Care Financial Policy
Greenlake Primary Care does not participate with any private insurance which means we will not bill any private insurance on your behalf.
As a patient, you can expect that we will:
As a patient or guarantor, this is what we ask of you:
For your convenience we accept both Visa and Master Card, and ACH payments (through HINT only).
Checks returned for insufficient funds will result in an immediate charge of $35.00 against your account.
We require at least 24-hour notice if you are unable to keep your appointment. Missing an appointment without notice and/or late cancel is considered a no show. Repeated no shows may result in a charge of up to $50.00 ($175 for psychiatric appointments A third no show within 12 months may result in dismissal from the practice.
Questions about your account can be answered by
Naomi Busch, MD (206)524-5656
Credit Card Authorization:
I authorize Greenlake Primary Care to charge my credit on file for both my monthly fee as well as incidental charges. 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 is stored in my chart or in the office and the card number, cannot be accessed once entered.
I understand that Greenlake Primary Care does not bill insurance, and therefore will not release my information to any health insurance company unless directed by me with written notification.
When patients turn 18 years old, they become the guarantors of their account. They will be asked to review their own financial agreements the first time they have a visit after turning 18.
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.
Please list all those living in the child's home:1.Name Relationship Date of Birth Health Problems Occupation 2.Name Relationship Date of Birth Health Problems Occupation 3.Name Relationship Date of Birth Health Problems Occupation 4.Name Relationship Date of Birth Health Problems Occupation 5. Name Relationship Date of Birth Health Problems Occupation 6.Name Relationship Date of Birth Health Problems Occupation
Birth weight weight Was baby born at ? Yes No If not how early? # weeks early Vaginal delivery Cesarean Complications of pregnancy or birth? During pregnancy did mother use tobacco? Yes No During pregnancy did mother drink alcohol? Yes No During pregnancy did mother use drugs or medication? Yes No Please explain if yes to above questions: How is/was baby fed? Formula Breastmilk If breastfed, how long?
General Health and Development
Please list any medications your child takes including dose and frequency:medication, dose, frequency medication, dose, frequency medication, dose, frequency medication, dose, frequency
At what age did your child:Sit alone Walk alone Say words Toilet train (daytime)
Do you have concerns about your child's diet? Yes No Milk intake now: cow's milk (whole, 2%, 1%, skim), soy, rice, other Average cups per day: #cups
Safety and Environment
Does your child attend school or preschool? Type option 1 Type option 2 Name of school: Grade: Is there an IEP or 504? Type option 1 Type option 2 Any concerns about school? What type of exercise and sports does your child do? How often do they exercise?
Has your child been seen by a dentist? Yes No Does your child have cavities? Yes No Date of last visit Date Do any household members smoke? Yes No Does your child use a bicycle helmet Type option 1 Type option 2 Are there any guns at home? Type option 1 Type option 2 Hours of TV daily? Hours of computer daily Hours of video games daily? When riding in the car, what does your child use?Type option 1 Type option 2 Booster seat Seatbelt
Review of Systems
Advanced Consent to Treat Minors
As a general rule, we require the consent of a parent or legal guardian to provide health care services to a minor child (under the age of 18). We understand that there may be times when a parent or guardian is not able to accompany a child to an appointment. However, we cannot provide care to a child who comes to our clinic alone or accompanied by an adult other than a parent or legal guardian if we cannot reach you or don’t have advanced consent to provide treatment.
Signing the Advanced Consent to Treat Minors form below ensures that we can provide care to your child under these circumstances. This signed form will be kept in your child’s medical record. Consent remains in effect until revoked in writing. Any member of our staff can provide the form to revoke consent.
Under Washington State law, minors have the right to consent to certain health care without a parent or guardian’s consent:
If the minor is an emancipated (legally independent) or married to someone at or above age 18. In the event emergency care is required. For birth control and pregnancy-related care at any age. For outpatient drug and alcohol abuse treatment beginning at age 13. For outpatient mental health treatment beginning at age 13. For sexually transmitted diseases, including HIV, beginning at age 14.
While we encourage minor patients to involve a parent, guardian or other trusted adult in all aspects of health care, if a minor consents to care as allowed by law, he or she can request confidentiality. That would prohibit us from releasing this information to anyone, including a parent or guardian, without the minor’s express written consent.
If you have questions regarding any of this information, please contact your child’s primary care provider.
I am the parent or legal guardian of this minor and authorize and consent to routine and emergency medical treatment for my child when deemed necessary by qualified medical personnel at Greenlake Primary Care. This authorization will be in effect until revoked in writing by me.