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 (updated 3/2021)
Greenlake Primary Care (GPC) contracts with Medicare for Part B and Molina AppleHealth; we will bill for covered services on your behalf. We do not bill third party for motor vehicle accidents. We do not take EPO plans or HMO plans, or any other insurance plans.
Know your insurance plan. Before your visit, call the toll free number on the back of your insurance card.
• Ask your insurance representative if you have out of network benefits.
• Make sure that you do not have an EPO or HMO plan that prohibits out of network providers
• 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.
Greenlake Primary Care will submit your bill to Medicare and Molina AppleHealth. For all other insurance products, we are out of network and you are responsible for paying at the time of service. We make no guarantee regarding out of network insurance reimbursement or payments.
Questions about your account can be answered by Naomi Busch, MD at 206 524 5656
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. A third no show within 12 months may result in dismissal from the practice.
Credit Card Authorization:I authorize Greenlake Primary Care to charge my credit on file for both my monthly Concierge fee as well as any 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 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 signed membership agreement.● The authorization is in effect until rescinded in writing. 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 your medical problems and the month/year it begancondition month/year begancondition month/year began condition month/year began condition month/year began condition month/year began condition month/year began condition month/year began condition month/year began condition month/year began
Please list any surgeries, injuries, and hospitalizations with approximate datesurgery/hospitalization date surgery/hospitalization date surgery/hospitalization date surgery/hospitalization date surgery/hospitalization date surgery/hospitalization date
Medication/Supplement - Dose - Frequency or Numbermedication-dose-frequency medication-dose-frequency medication-dose-frequency medication-dose-frequency medication-dose-frequency medication-dose-frequency medication-dose-frequency medication-dose-frequency medication-dose-frequency medication-dose-frequency
Allergies to Medications/Foodmedication/food and reaction medication/food and reaction medication/food and reaction medication/food and reaction medication/food and reaction medication/food and reaction
Family History for genetic (first-degree) relativesFather living (Y/N) - age or age at death health problems list medical problems Mother living (Y/N) - age or age at death health problems list medical problems Brother living (Y/N) - age or age at death health problems list medical problems Brother living (Y/N) - age or age at death health problems list medical problems Sister living (Y/N) - age or age at death health problems list medical problems Sister living (Y/N) - age or age at death health problems list medical problems
Preventive Care enter dates for any you have hadmammogram date pap smear date bone density (DEXA) date abdom aneurysm test date EKG date heart stress test date heart catheterization date eye exam date
Preventive Care continuedcolonoscopy date stool colon cancer test date endoscopy date chest X-Ray date chest CT date Tb test date Hepatitis C test date HIV test date
Vaccines - enter dates for any you have receivedFlu date Pneumococcus date Tetanus date Hepatitis B date Shingles date HPV date COVID #1 date COVID #2 date
If applicablenumber of pregnancies/births #/#Problems with periods days of flow age of start of periods # age at menopause (if applicable) age Hot flashes Abnormal pap
Social, Educational, and Work History
Review of Systems