New Patient Forms

Primary Insurance Information
Name of Policy Holder
Policy Holder's Date of Birth

MonthDayYear
Date
Relationship to Patient
Insurance Company
ID Number
Group Number
Secondary Insurance Information
Name of Policy Holder
Policy Holder's Date of Birth

MonthDayYear
Date
Insurance Company
Relationship to Patient
ID Number
Group Number

Responsible Person

(If patient is under 18)
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to Patient
Phone Number
Employment Information
Employer
Occupation
Address

(Address)

Street Address Line 2

(City, State, Zip Code)State / Province

Postal / Zip Code
Employment Status

EmployedStudentOther
Emergency Contact
Name
Phone
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Patient

HIPAA Consent and Consent to Treat
I voluntarily consent to receive medical and health care services that may include diagnostic procedures, examinations and treatment
Consent to Obtain Prescription History
This consent form authorizes Contemporary Medicine Associates ("CMA") to obtain and review my prescription history. Detailed prescription history provides your physician with information about medications being prescribed by other providers involved in your medical care. This information will improve the accuracy of our medication list in your medical chart and decrease any adverse drug reactions or inaccurate medication information such as medication names or dosages.

By signing this consent form, you agree that CMA can request and use your prescription medication history from other healthcare providers, pharmacies, and benefit payers (such as your insurance company) for treatment purposes.

Understanding the above, I hereby provide informed consent to CMA to request, view, and use my external prescription history for treatment purposes.
HIPAA
I have reviewed this office’s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I can request a copy of this notice at any time. I have the right to review the notice prior to signing this consent. I have had the opportunity to receive and review the Notice of Privacy Practices of Contemporary Medicine Associates.
APPROVED HIPAA CONTACTS

Disclosure of Protected Health Information
Keeping information private is important to us and by default we will only disclose information related to the patient’s billing account and medical conditions to the patient or legal guardian. Please note, to share protected health information with your spouse they must be listed as an approved contact.

The following names are people I would like to be involved in or have access to my protected health information on a routine basis. I give permission for CMA to share my protected health information with:
Name
Date of Birth

MonthDayYear
Date
Phone
Relationship
CONSENT AND AGREEMENT
I have carefully reviewed this document and agree to fully comply with guidelines defined herein related to the Assignment of Benefits, Financial Policy, HIPAA Policy, and Approved HIPAA contacts. The duration of this authorization is indefinite unless otherwise revoked in writing. I understand that requests for health information from persons not listed on this form will require my specific authorization prior to the disclosure of any personal health information.
Patient's Name (Please Print)*
Patient's Date of Birth*

MonthDayYear
Date
Signature of Patient, Parent, or Legal Guardian*

Clear
Date*

MonthDayYear
Date

Patient Portal Communication Consent
To sign up for access to your health information through our secure patient portal complete the first portion of this form
I want CMA to communicate my information with me or those that I grant access to my record through the secure patient portal system that is designed to keep my personal information safe.

YESNO
Email Address
**Please provide the email address you would like to use to be notified of secure messages**
- I understand that I must be 18 years or older to be signed up to access my record through the patient portal. If I am under 18 years of age and have become legally emancipated, I must provide legal documentation to be provided access to my record through the patient portal.
- I understand that the patient portal is intended as a secure online source of confidential medical information. If I share my user ID and password with another person, that person may be able to view my or my family member's health information.
- It is my responsibility to select a confidential password, to maintain my password in a secure manner, and to change my password if believe it may have been compromised in any way.
- I understand that the patient portal contains selected, limited medical information from my or my family member's medical record and that it does not reflect the complete contents of my medical record. I also understand that a paper copy of my records may be requested from the clinic.
- I understand that my activity within the patient portal may become part of my medical record.
- I understand that access to the patient portal is provided by CMA as a convenience to its patients and CMA has the right to deactivate access to the portal at any time for any reason. I understand that use is voluntary, and am not required to use the portal.
- By signing below, I acknowledge that I have read and understand this Patient Portal Communication Consent and agree to its terms.
Patient Signature

Clear
Date

MonthDayYear
Date

Financial and Office Policies
Thank you for choosing us as your healthcare providers. We are committed to providing you with quality and affordable healthcare. The following are our Financial and Office Policies. Please read, initial on the right and sign at the bottom. Please ask us any questions that you may have.
Patient Responsibility: We participate in many insurance plans. We recommend you become familiar with your insurance benefits and confirm our participation with your plan. Most misunderstandings about insurance can be avoided if you understand what your policy covers. Please contact your insurance company with any questions you may have regarding your coverage.
Initials*
Insurance Carriers Requiring Referral: If you are referred to a specialist and your insurance carrier requires a referral number, please give our office at least a 48-hour notice to complete that referral.
Initials*
Proof of Identity and Insurance: All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your valid government issued identification and a current, valid insurance card, if applicable. Please bring these items with you to each visit. Payment in full is required if we are unable to verify your current insurance information.
Initials*
Payments due at the time of service: Co-pay, deductible, co-insurance, and cash pay services. A Good Faith Estimate (GFE) is available and will be supplied if applicable.
Initials*
Nonpayment & Returned Checks: Unpaid accounts will be referred to an outside collection agency and could result in dismissal from the practice. There will be a $25 fee for all returned checks.
Initials*
Late Arrivals: Please arrive at least 10 minutes prior to your scheduled appointment time. If you arrive late to your appointment, our office may have to reschedule your appointment to a new time or date. If the appointnment is rescheduled due to late arrival, this constitutes as a no show and will result in a $250 no show fee.
Initials*
No shows: Please notify us 24 hours in advance if you must cancel or change your appointment time. Failure to do so will result in a $250 no show fee that is not covered by your insurance. A third no show may result in dismissal from the practice.
Initials*
Form completion. All forms requiring medical review and physician signature – including school, day care, and camp physicals, prior authorizations, FMLA, disability or other paperwork – may be subject to an administrative fee of $35.00.
Initials*
Policy: I have read and understand the Financial and Office Policies of CMA and agree to abide by its guidelines
Initials*
Signature*

Clear
Date*

MonthDayYear
Date

	Name	Strength	How Often
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10

Patient Information

Primary Insurance Information

Secondary Insurance Information

Responsible Person

Employment Information

Emergency Contact

HIPAA Consent and Consent to Treat

Consent to Obtain Prescription History

HIPAA

APPROVED HIPAA CONTACTS

CONSENT AND AGREEMENT

Patient Portal Communication Consent

Financial and Office Policies

Patient Medical History

Family History

Social History

Routine Health Screening

Medications