NP Paperwork Packet

Family Medicine Associates collects all patient responsibility up front. Deductibles/coinsurance/copays. Please be prepared to pay at time of service. *

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HOW DID YOU HEAR ABOUT US

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BOTH FIRST AND LAST NAME *****BOTH ARE REQUIRED****( or you will have to redo paperwork)*
Social Security#*
Date of Birth*

MonthDayYear
Date
Sex*
Home#*
Work#
Cell#*
Address*
Apt/Lot#
City*
State*
Zip*
Marital Status
Race
Ethnicity
Language*
Insurance Information: Please also provide a copy of your insurance card to a member of our staff.
Insurance Company Name (not your Employer)*
Member ID*
Group #
Responsible Party: (person who carries insurance or parent of minor child) if different than above
Name
Date of Birth*

MonthDayYear
Date
Social Security#*
Relationship To Patient: Self / Spouse / Parent/Other
Relationship To Patient: Self
Address
Apt/Lot#
City
State
Zip
Home#
Work#
Cell#
Pharmacy Information: Primary Pharmacy*
Phone#*
Address (Major Cross Streets)*
Notify in case of emergency*
Phone*
Relationship
Authorization to Discuss Medical Care*
Did you know we have an online portal? This portal allows you to have online access to our office, ask questions, look at your lab results, get appointment reminders, and more!
We just need your email address*
example@example.com
Appointment reminders will be call or text message. Please let us know which you prefer.
Please choose all options*

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I understand that I am responsible for all charges incurred by me or my family regardless of insurance coverage and that paym ent is due at the time of services rendered. I also request that payment under my medical insurance program be made directly to Family Medicine Associates, P.C. on any unpaid bills for service furnished. I authorize the release of any medical information to process this claim and future claims.
Signature*

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Date

MonthDayYear
Date
Signature

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Payment Policy: Please read, initial in front of each number and sign at the bottom

Thank you for choosing us as your primary care provider. We are committed to providing you with quality and a ffordable health care.

Becausesome of our patients hav had questions regarding patient and insurance responsibility forservices rendered, we have been advised

to develop this payment policy. Please read it, a sk us any questions you may have, Initial each space and sign at the bottom. A copy will be provided to you upon request.
1. Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan, we do business with, payment in full is expected at each visit. If you are insured by a plan, we do business with, but do not have up to date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. Initial*
2. Co Payments and deductibles. All co payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. We may make exceptions on a case by case basis. Should we make an exception and you are billed for you co pay or deductible there will be a $5.00 billing fee. In addition, any balance over 30 days will be assessed a $5.00 service charge, per month. Initial*
3. Non covered services. Please be aware that some and perhaps all of the services you receive may be non covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit. Our office does our best to know what is and what is not covered but it is your responsibility to know what your insurance will cover. Initial*
4. Insurance Denial. Charges denied for any reason by the Explanation of Benefits of your insurance company are due upon receipt. If you are not in agreement with your insurance company, you must pay for the services rendered and wait for reimbursement from your insurance company. We will be glad to resubmit the claim for you or help you if we can. Initial*
5. Proof of Insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy currentvalid insurance to provide proof of insurance. If you fail to provide us with the correctinsurance information in a timely manner, you may be responsible for the balance of a claim. Initial*
6. Claims Submission. We will submit your claims and assist you in any way we can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insur ance benefit is a contract between you and your insurance company; we are not party to that contract. Initial*
7. Coverage Changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you. Initial*
8. Nonpayment. You will receive a $5.00 statement charge for each statement that has to be sent. If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. All accounts that are turned over to collections will be charged a non negotiable Collection fee of 35% of full account. THESE ARE NON NEGOTIABLE. Initial*
9. No Shows. If you no show (do not call and cancel) or give 24 hours' notice you will be charged a $100.00 fee for New Patients and Physicals, $75.00 for Established. In addition, if you no show (do not call and cancel) three times you and your family WILL be released from our office. Initial*
I have read and understand the payment policy and agree to abide by its guidelines*
Signature*

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Date

MonthDayYear
Date
FAMILY HISTORY
Father's History

Please mark all that apply
Alive or Deceased*
Age or Age at Death*
Alzheimer's DiseaseAsthmaBlood DisorderDepressionDiabetesEpilepsyHeart DiseaseHigh Blood PressureKidney DiseaseMental IllnessStrokeThyroid DisorderCancerHigh cholesterol
Mother's History

Please choose which apply
Alive or Deceased*
Age or Age at Death
Alzheimer's DiseaseAsthmaBlood DisorderDepressionDiabetesEpilepsyHeart DiseaseHigh Blood PressureKidney DiseaseMental IllnessStrokeThyroid DisorderCancerHigh cholesterol
Paternal Grandfather

Please choose all that apply
Alive or Deceased*
Age or Age at Death
Alzheimer's DiseaseAsthmaBlood DisorderDepressionDiabetesEpilepsyHeart DiseaseHigh Blood PressureKidney DiseaseMental IllnessStrokeThyroid DisorderCancerHigh cholesterol
Paternal Grandmother

Please choose all that apply
Alive or Deceased*
Age or Age at Death
Alzheimer's DiseaseAsthmaBlood DisorderDepressionDiabetesEpilepsyHeart DiseaseHigh Blood PressureKidney DiseaseMental IllnessStrokeThyroid DisorderCancerHigh cholesterol
Maternal Grandfather

Please choose all that apply
Alive or Deceased*
Age or Age at Death
Alzheimer's DiseaseAsthmaBlood DisorderDepressionDiabetesEpilepsyHeart DiseaseHigh Blood PressureKidney DiseaseMental IllnessStrokeThyroid DisorderCancerHigh cholesterol
Maternal Grandmother

Please choose all that apply
Alive or Deceased*
Age or Age at Death
Alzheimer's DiseaseAsthmaBlood DisorderDepressionDiabetesEpilepsyHeart DiseaseHigh Blood PressureKidney DiseaseMental IllnessStrokeThyroid DisorderCancerHigh cholesterol
Do you have any of the following

Please Choose all that apply
Alzheimer's DiseaseAsthmaBlood DisorderDepressionDiabetesEpilepsyHeart DiseaseHigh Blood PressureKidney DiseaseMental IllnessStrokeThyroid DisorderCancerHigh CholesterolOther
THE FOLLOWING MUST BE ENTERED COMPLETELY, IF IT DOES NOT PERTAIN TO YOU, YOU MUST PUT N/A OR NON. Otherwise,you may need to redo paperwork PLEASE LIST ALL MEDICATIONS AND STRENGTH
Medication, Strength, Directions and Use*
Medication, Strength, Directions and Use *
Any additional, please list*
Drug Allergies: (Include reaction)*
Surgical/Hospitalizations History:
List all Surgeries and there dates*
PLEASE PUT APPROXIMATE DATE THAT YOU LAST HAD THE FOLLOWING, OR PUT NEVER OR N/A
Colonoscopy*
Bone Dexa*
Treadmill*
Last Physical: Last Cholesterol Check:
Last Physical*
Last Cholesterol Check*
Last EKG*
Last mammogram*
Last Spirometry*
Past PSA*
Last MRI*
Last CT Scan*
Do you see a any other Doctors:
If Yes, Who
Living with
Occupation
Tobacco Use*
How much per day
How much per year
Alcohol Use*
How Often
# of Drinks/Type
Illegal Drug Use*
Type/Amount/How Often
Caffeine*
How many cups per day
Type
Excercise*
How often/Type
Immunizations: Please Include Dates:
Tetanus/Pertussis*
Pneumonia*
Influenza*
Patient Name*
Date

MonthDayYear
Date
Authorization to Release Information to Family Members

Many of our patients allow family members such as their spouse, parents or others to call and request the results of tests and procedures. Under the requirements for H.I.P.P.A. we are not allowed to give this information to anyone without the patient's consent. If you wish to have your test results released to family members you must sign this form. Signing this form will only give consent to release laboratory and radiology results to the family members indicated below. This consent form will not allow Family Medicine Associates, PC to release any other information to these family members.

You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.
Name
Relation
Phone
Name
Relation
Phone
Patient/Guardian Signature*

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Date

MonthDayYear
Date
Authorization to Leave Messages with Household Members/Answering Machine

From time to time it is necessary for representatives of Family medicine Associates, PC to leave messages for patients. The purposes of these messages is to remind patients that they have an appointment, to notify the patient that the medical staff would like to discuss lab or procedure results, to leave normal results, or to ask the patient to call FMA regarding an issue or concern. The purpose of this consent is to leave messages with members of your household or on your answering machine.

You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.
Patient/Guardian Signature*

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Date

MonthDayYear
Date
Take a picture of the front of your insurance card
Take a picture of the back of your insurance card
Type a question
Should be Empty:

FAMILY HISTORY

Father's History

Mother's History

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Do you have any of the following

THE FOLLOWING MUST BE ENTERED COMPLETELY, IF IT DOES NOT PERTAIN TO YOU, YOU MUST PUT N/A OR NON. Otherwise,you may need to redo paperwork PLEASE LIST ALL MEDICATIONS AND STRENGTH