PCA New Patient Packet

Patient Registration
Check the box of which service(s) you are interested in?

Primary CareBehavioral Health/AwareCareFootCare
Patient Name*
DOB*

MonthDayYear
Date
SSN*
We do not release this information to any outside parties. It is needed for the sole purpose of verifying insurance benefits.
Sex

MaleFemale
Mobile / Cell*
Home Phone
Please enter a valid phone number.
Email
example@example.com
Physical Address*
Street, City, State, Zip Code
Mailing Address IF DIFFERENT

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.
PRIMARY INSURANCE
Insurance Company*
Policy No./Member ID*
SECONDARY INSURANCE
Insurance Company
Policy No./Member ID

Patient Consents & Acknowledgment
GENERAL CONSENT TO CARE

I, the undersigned, for myself or a minor child or another person for whom I have authority to sign, hereby consent to medical care and treatment, as ordered by a provider, while such medical care and treatment is provided through Primary Care Anywhere on an outpatient/ office visit basis. This consent includes my consent for all medical services rendered under the general or specific instructions of a provider; including treatment by a mid-level provider (Nurse Practitioner or Physician Assistant), and other health care providers or the designees under the direction of a physician, as deemed reasonable and necessary.

I agree and acknowledge that Primary Care Anywhere is not liable for the actions or omissions of, or the instructions given by the physicians/providers who treat me while I am a patient. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the result of treatments or examinations at Primary Care Anywhere facilities.

NOTICE PRIVACY ACKNOWLEDGMENT

Primary Care Anywhere "Notice of Privacy Practices" provides information about how Primary Care Anywhere may use and disclose your protected health information. You have the right to review the Notice before signing this acknowledgment. A copy of the current Notice will be provided to you at your request. The Notice contains the effective date and as provided in our Notice, the terms of our Notice may change.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations, as described in our Notice. You have the right to revoke this consent, in writing, except where we have already made disclosures on your prior consent. This Privacy Acknowledgement does not give us consent to release records to anyone except to whom is mentioned. A signed medical release authorization form must be completed prior to us releasing records on your behalf.

TELEMEDICINE

I understand that telemedicine (defined as the use of medical information exchanged from one site to another via electronic communications for the health of the patient, including consultative, diagnostic, and treatment services) may be employed to facilitate my medical care. All electronic transmission of data will be restricted to authorized recipients in compliance with the Federal Health Insurance Portability and Accountability Act (HIPAA) and applicable state privacy laws.

TO THE PATIENT

You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

SIGNED CONSENT

By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.
CHRONIC CARE MANAGEMENT (CCM) CONSENT

CCM Services are available to you because you have been diagnosed with two (2) or more chronic conditions which are expected to last at least twelve (12) months and which place you at significant risk of further decline.

CCM Services include 24-hours-a-day, 7-days-a-week access to a health care provider in PCA’s practice to address acute chronic care needs; systematic assessment of your health care needs; processes to assure that you timely receive preventative care services; medication reviews and oversight; a plan of care covering your health issues; and management of care transitions among health care providers and settings.

PCA will discuss with you the specific services that will be available to you and how to access those services.

CCM COST
ONLY your insurance will be charged and you will NOT be charged to apply or receive any CCM Services.

PCA OBLIGATIONS
When providing CCM Services, the Provider must:
- Explain to you (and your caregiver, if applicable), and offer to you, all the CCM Services that are applicable to your conditions.
- Provide to you a written or electronic copy of your care plan.
- If you revoke this Agreement, provide you with a written confirmation of the revocation, stating the effective date of the revocation.
BENEFICIARY RIGHTS

You have the following rights with respect to CCM Services:
- PCA will provide you with a written or electronic copy of your care plan.
- You have the right to stop CCM Services at any time by revoking this Agreement effective at the end of the current month. You may revoke this agreement verbally (by calling 409.767.9285) or in writing to (4347 Phelan Blvd, Ste 100, Beaumont, TX 77707).
- Upon receipt of your revocation, the Provider will give you written confirmation (including the effective date) of revocation.
I agree to participate in the Chronic Care Management program.*

YESNoNot Applicable
Patient Signature*

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Date*

MonthDayYear
Date

Patient Financially Responsibility
Thank you for choosing Primary Care Anywhere (PCA) for all your medical needs. We look forward to providing you a complete package of medical treatment. We file your charges to your insurance carrier as a benefit to you. It is, however, the patient’s responsibility to know & understand what service is covered under the policy. In order to help keep healthcare costs down, we ask the following payments be made on your account prior to being seen by your medical provider. For your convenience we do accept cash, check and most all major credit cards. There is a $25 return check fee.

INDIVIDUAL’S FINANCIAL RESPONSIBILITY
- I understand that I am financially responsible for my health insurance deductible, coinsurance or non-covered service.
- Co-payments are due at time of service.
- If my plan requires a referral, I must obtain it prior to my visit.
- In the event that my health plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the costs of all services provided.
- If I am uninsured, I agree to pay $100.00 for the medical services rendered to me at time of service.
INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS

I hereby authorize and direct payment of my medical benefits to Primary Care Anywhere on my behalf for any services furnished to me by the providers.
PAYMENT METHOD
Would you rather pay with a Credit Card or ACH Payment (ie virtual check)?*

Credit CardACH Payment
Name on Credit Card*
Credit Card No.*
Expiration Date*
CVV2*
Zip Code*
Bank Name*
Account Type*

CheckingSavings
Account Holder Name*
Account #*
Routing #*
I have read & understand my financial obligations. I understand that this office will file an insurance claim on my behalf based on the information I provide. Both Primary Care Anywhere (PCA) and I will receive an EOB (explanation of benefits) from my insurance carrier(s) that will detail any payments, deductions & adjustment per my plan’s guidelines. I understand that I will be fully responsible for payment of any & all medical services denied by my insurance company as applicable by state and/or federal law.

I agree and understand that I may be charged the amount of my co-pay, coinsurance, or $100.00 after my visit depending on my insurance coverage-or lack thereof.

Furthermore, I hereby authorize Primary Care Anywhere (PCA) to debit the account as indicated above. In the case of an ACH Payment, I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as 24 hours after notification of group health plan approval. I understand that it is my responsibility to monitor my bank charges and verify that payments are processed properly. I agree not to dispute this billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.
Signature*

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Patient Registration

PRIMARY INSURANCE

SECONDARY INSURANCE

Patient Health Questionnaire

MEDICATIONS

MEDICAL HISTORY

Patient Consents & Acknowledgment

Medical Records Release

Patient Financially Responsibility

PAYMENT METHOD

Please press 'Submit' button to send your application. Thank you!