New Patient Form
Centivo member ID number
*
Patient name
*
Legal First Name
Legal Middle Name
Legal Last Name
Suffix
I prefer to be called
Optional: Please write your preferred name if it is different from your legal name.
Patient date of birth
*
-
Month
-
Day
Year
Phone number
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Language
*
I prefer to be contacted by
*
Phone call
Email
Text message
Other
How did you hear about Centivo Virtual Primary Care?
Open Enrollment material from employer
Welcome Kit from Centivo
Outreach from the Virtual Primary Care Team
Email
Letter / Postcard
Word of mouth
Website
Other
Select all categories that describe you
*
White
Hispanic, Latino, or Spanish origin
Black, African, or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Some other race, ethnicity or origin
Decline to answer
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Decline to specify
Gender
*
Please Select
Woman
Man
Transgender
Non-binary/Non-conforming
Option not listed
Prefer not to answer
Preferred pronouns
*
Please Select
She/Her/Hers
He/Him/His
They/Them
Sexual orientation
*
Please Select
Asexual
Bisexual
Gay
Lesbian
Straight
Queer
Option not listed
Prefer not to say
Living arrangement
*
Please Select
Live alone
Live with spouse and/or immediate family
Live with one non-relative
Live with more than one non-relative
Prefer not to answer
Occupation
*
Education level
*
Some High School
High School Graduate
Some College
College Graduate
Masters or Higher Degree
Vocational Training
Other
Emergency contact name
*
Relationship to emergency contact
*
Please Select
Spouse/Partner
Friend
Parent
Child
Other
Emergency contact phone number
*
Please enter a valid phone number.
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Consent for Care & Treatment
Consent for Treatment
*
I hereby consent to receive health care from Centivo Virtual Primary Care physicians, employees and such associates, assistants and other health care providers as my care team deems necessary. Centivo Virtual Primary Care uses Telehealth technology to provide care. While much medical care can be delivered in this fashion, limitations exist. If your provider determines that in-person care is medically necessary, you will be advised accordingly.
Telemedicine Information
*
Receiving care through Telehealth has several advantages including convenience, enhanced access to your care team and the ability to receive care at home or at work. There are unique considerations and risks, however, that must be accepted in order to consent to care: 1) Information received during the visit may be insufficient to allow for appropriate decision making, and in-person care would be needed. 2) Failure of equipment (servers, devices) or infrastructure (communication lines, power supply, software failures) could result in delays in the provision of care. 3) Protection of patient privacy is essential, and we make every effort to safeguard your personal health information. It is our patients’ responsibility to create a private and secure environment in which to meet with our providers. I understand that I may revoke this consent at any time, except for services I have already received.
Electronic Health Information Exchange
*
I understand that Centivo Virtual Primary Care may make my protected health information available electronically through an electronic health information exchange to other healthcare providers that request my information for their treatment purposes. In all cases, the requesting provider must have or have had a treating relationship with me. Participation in an electronic health information exchange also lets Centivo Virtual Primary Care providers see other providers’ information about me for their treatment purposes.
Financial Responsibility and Benefit
*
I hereby authorize and instruct my insurance carrier or other third party payer to submit payment to Centivo Virtual Primary Care for any health care services otherwise payable to me. I agree to pay all charges for any health care services that are not covered or collected from my insurance carrier or other third party payer, including any deductibles and coinsurance amounts.
Acknowledgement of Rights & Responsibilities and Notice of Privacy Practices
*
I acknowledge that I have been given a copy of the following: 1) Patients’ Rights and Responsibilities – defines my rights and responsibilities as a patient that receives health care services from Centivo Virtual Primary Care. 2) Notice of Privacy Practices – provides information about how Centivo Virtual Primary Care and its workforce may use and/or disclose my protected health information for treatment, payment, health care operations and as otherwise permitted by law.
Upload a photo of your drivers license, passport, or other photo ID for your medical record
*
Browse Files
Drag and drop files here
Choose a file
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Is Centivo your ONLY health insurance?
*
Yes
No
Is Centivo your PRIMARY health insurance
*
Yes
No
Signature
*
Today's date
*
-
Month
-
Day
Year
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Pharmacy Details
What is the name of your preferred pharmacy?
Optional
Pharmacy address
Address or major cross streets
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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New Patient Questionnaire
How much of a priority is health right now?
Very low
1
2
3
4
Very high
5
1 is Very low, 5 is Very high
How motivated are you to take steps to maintain and improve your health?
Not at all motivated
1
2
3
4
Very motivated
5
1 is Not at all motivated, 5 is Very motivated
Do you have any specific health goals?
What barriers get in the way of you getting the care you need?
Other
Time
Money
Education
Language
Low motivation
Stress
Disability
Transportation or access to care
No support system
I have no barriers
On a scale of 1-10, how would you rate your health:
1
2
3
4
5
6
7
8
9
10
Physical Health
Mental Health
Eating Habits
Exercise Habits
Sleeping Habits
Energy Level
Is there anything else you would like your Care Team to know about you?
Submit
Should be Empty: