New Horizons Wellness CenterNew Patient Registration Form2018
To help us process your paperwork as efficiently as possible please complete this form in its entirety. Leaving out required information will delay you from seeing the Doctor.
If you have questions or need assistance, please ask a member of our staff.
Demographics—Please Print
Patient Name: ______Chart:______
Address: ______Apartment # ______
City: ______State: ______Zip: ______
Home Phone: ______Cell Phone: ______
Social Security#:______Date of Birth:______
E-Mail: ______
If you do not have an e-mail address, please put None. Please see page3 of this form for further details as to why we ask for your e-mail address.
Preferred method to contact you: [ ] E-mail [ ] Home Phone [ ] Cell Phone [ ] Mail
[ ] Male [ ] Female [ ] Married [ ] Single [ ] Divorced [ ] Widowed [ ] Separated
[ ] Employed [ ] Unemployed [ ] FT Student [ ] PT Student [ ] Other [ ] Retired [ ] Child
Optional Information:
[ ] Prefer not to answer Optional Information Preferred language:______
Race: ______Ethnicity: ______
Preferred Pharmacy—Please Print
Pharmacy: ______Street:______
City: ______State: ______Phone: ______
Prescription Drug Insurance—Please Print
Insurance Company: ______
Policy Number:______
Policy Holder Name: ______Date of Birth: ______
Authorization to Discuss Your Health Information
I, the undersigned, hereby give permission to NewHorizonsWellnessCenter to discuss with the following individual(s) my medical situation, medications, appointments, procedures and personal information:
______
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Signature Date
Emergency Information—Please Print
Emergency Contact: ______
Phone: ______Relationship to Patient: ______
Primary Insurance—Please Print
Please provide copies of your insurance cards to the receptionist
Insurance Company: ______
Policy Holder Name: ______Date of Birth: ______
Secondary Insurance—Please Print
Insurance Company: ______
Policy Holder Name: ______Date of Birth: ______
Authorization for Assignment of Benefits / Information Release
I, the undersigned, hereby assign to NewHorizonsWellnessCenter any insurance or other third-party benefits available for health care services provided to by the physician. I understand that NewHorizonsWellnessCenter has the right to refuse or accept assignment of such benefits. If these benefits are not assigned to NewHorizonsWellnessCenter, I agree to forward all health insurance and other third-party payments that I receive for services rendered to me immediately upon receipt. I also authorize you to release to my insurance company or their agent information concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims of benefits.
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Signature Date
Acknowledgement of Receipt of Notice of Privacy Practices
I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices. I understand that this form will be placed in my patient chart and maintained for six years.
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Signature Date
Do you have a living will or advance medical directive? YES NO
If yes, please provide a copy to the receptionist. [Office use only: Copy obtained YES No]
E-mail is needed to sign you up for the Patient Portal.
What is the Patient Portal? It is a web site that allows you to access to your information, including:
- Diagnoses, medications and immunization history
- Appointments at your practice
- Real-time updates to their medical record
- Lab results you share with them
- A health spending tool to track expenses and bills
All you need to do is give us your email and let the receptionist know you’d like to sign you up for the Patient Portal.
Other Physicians
Please list any other physicians you currently see or have seen in the past.
______Current Prior
______Current Prior
______Current Prior
______Current Prior
______Current Prior
______Current Prior
Policies on Calling in Prescriptions and Other Extra Services
It is a courtesy that we call in prescriptions rather than have you come into the office for an office visit. We provide this service at our earliest available time and it could take up to 72 hours (3 days) to process your request. If you cannot wait 72 hours, we will assume that it is an urgent request but not an emergency and you will be charged $25.00for this extra service. If it is an emergency, you will be required to make an appointment. New Horizons Wellness Center reserves the right to waive this fee.
Please note: we DO NOTcall in controlled substances such as pain medication, nerve pills or muscle relaxers. Nor will we call in Sleep medications, Antibiotics, Cough Syrup, Decongestants, Appetite Suppressants or ADD or ADHD medications. These medications require an office visit prior to being called in or prescribed.
No medication will be called in for anyone who has not been seen by Dr. Ellis within the last 6 months. Also, Dr. Ellis does not conduct phone consultations and will not prescribe medications over the phone for conditions you are not already being treated for.
If you’ve had a test done in our office, we will schedule you a follow up appointment to go over the results, this includes laboratory results. Due to changes in the HIPPA regulations, we will notgo over your results with you by phone. Please do not request your results over the phone, because we will notdo this anymore. Thank you for your cooperation in this matter.
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Signature Date
Financial Arrangements/Payment Policy
Because some patients have had questions regarding patient and insurance responsibility for services rendered, please see the following detailing our payment policy. Please initial next to each item to indicate you have read and understand our policy. If you do not understand anything below, please ask a staff member. A copy of this form will be available to you via the Patient Portal.
_____ Insurance: We are in network with most major insurance companies. Knowing your insurance benefits is your responsibility. If you have questions about what your insurance will or will not cover, please contact your insurance company regarding any questions about coverage. If we are not in network with your insurance company, then the self-pay rates will apply and are expected to be paid at the time of the visit.
_____ Co-pays and deductibles: All co-pays and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit.
_____ 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 your insurance company. You must pay for these services in full at the time of the visit.
_____ Proof of Insurance: All patients must complete our patient information form, provide a copy of your picture ID and valid insurance card (if you have insurance). If you fail to provide us with these, you will be responsible for the balance of the charges.
_____ Claims submission: We will submit your claims and assist you in any way we reasonably 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 requests. Please be aware that your balance is your responsibility whether or not your insurance company is supposed to pay or not. If your insurance company does not pay your bill within 45 days, it will be billed to you for payment.
_____ Coverage changes: If your insurance changes, please notify us before you next visit so we can make the needed changes.
_____ Nonpayment: If your account is over 90 days past due, you could be turned over to collections. Additionally, your account balance will be assessed a collection fee of up to 35% of the unpaid balance. You will be responsible for reasonable attorney fees and additional collection costs. If your balance remains unpaid for greater than 120 days, you may risk being dismissed from the practice for nonpayment.
_____Office Appointment Policy: Our office works on scheduled appointments. We reserve the time for you and your medical treatment. Our policy is to charge for missed appointments not canceled within a reasonable amount of time. You will be charged $25.00. These charges will be your responsibility and billed directly to you. In addition, if you arrive 15 minutes late for your appointment you may be asked to reschedule your appointment for a later date. Please keep your regularly scheduled appointment.
I have read and understand the payment policy and agree to abide by these guidelines.
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Signature Date
Fees for Filling out Forms and Other Paperwork
Our office does charge for completing forms regardless of the type of form or paperwork. This includes but is not limited to: letters that require research, FMLA paperwork, surgical clearances, short term disability paperwork and utility assistance paperwork.
Most forms brought in to our office to be completed by the doctor or nurse practitioner ask for information not normally gathered during an office visit. In order to assure the forms are accurate, you are required to make an appointment to have these forms completed. The charge for this is $45.00 for forms that are 5 pages or less and $65.00 for forms that are greater than 5 pages.
When an appointment is not required, we will still charge a fee for completing paperwork or writing letters as outlined above. The cost is based on the amount of research that must be done in order to complete the form. The fee for this is $5.00 for the first page and $1.00 per page after that. If the form is in-depth and requires research on the part of the staff or practitioner, there will be a $25.00 research fee.
Since insurance does not usually pay for completing forms, you will be required to pay up-front for this service. Once you leave your forms with us, you cannot get them back without paying the outlined fee.
Please allow FIVE business days to complete your paperwork.
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Signature Date
E-mail Policy
Introduction: E-mail is one of several options available for doctor-patient communication. E-mail sends written messages through the internet. The main advantage of E-mail is convenience. Each person can read and respond to their E-mail at a time convenient to him or her. The main disadvantages are a potentially slow response time and a potential lack of privacy. All E-mail communication will be placed into your medical record and treated like the other information contained in your record.
Policies: Patients of New Horizons Wellness Center have the option of communicating with our office staff by E-mail and through our patient portal messaging system. Prior to doing this, you need to read through this policy sheet carefully and sign it below. First of all, you must always include your full name in any E-mail messages. Many E-mail programs don't automatically include your name so you must be sure to include it.
Occasionally, E-mails get lost while traveling between the sender and the recipient. It generally takes 2-3 business days for our office to answer E-mails. If this is too long for you to wait for an answer, then please call the office at 334-347-4343. If our office's response will take longer than normal due to something like vacation, the automatic notice will let you know.
E-mail is only appropriate for certain types of doctor-patient communication. Specifically, E-mail is useful for fairly simple, non-urgent questions. One example of an appropriate E-mail question is asking if an over the counter medicine is OK to take with your prescription medications. Another example is asking about a news story that seems to say one of your medications is dangerous. Please do not use E-mail for standard medication refill requests. You will get a faster response if you have your pharmacy fax a refill request to the office instead. You can use E-mail to request a paper prescription to be mailed to you, but expect this to take several days.
Our office has the exclusive right to decide what is and is not appropriate for E-mail. If our office decides that your question is not appropriate for E-mail, you will be informed. This will generally be by E-mail but may be by phone or some other method.
Confidentiality: Sometimes, members of the office staff may become involved in answering your question. For example, our office may ask one of the staff members to look up some information to help answer your question. A copy of any E-mail messages sent by either you or our office will be placed into your permanent medical record.
E-mail messages travel through the internet. This means that the message is passed along a series of computers a bit like a bucket brigade. It is possible for someone to read the E-mail as it passes between computers. This is very unlikely, but it is possible. So, don't put anything into an E-mail that you feel must remain absolutely confidential between you and the doctor. A good "rule of thumb" is don't discuss anything by E-mail that you would not want to discuss on a cell phone in a crowd of strangers.
If you have any questions about these policies, please ask one of the office staff. If you feel that you understand all of these policies and you would like to add E-mail to the ways you communicate with the doctor, then print this page out, sign and date below and return this form to one of the office staff.
Signed ______Date ______
Name: ______
Chart: ______
Date: ______
Adult Health History Form
Your answers on this form will help your health care provider better understand your medical concerns and conditions better. If you are uncomfortable with any question, do not answer it. If you cannot remember specific details, please provide your best guess. Thank You!
PERSONAL MEDICAL HISTORY: Please check all that apply on the second page of this form.
SURGICAL HISTORY: Please list all prior operations with dates:
Operation / Date / Operation / Date1
Patient Name:______Chart Number:______
SOCIAL HISTORY
Tobacco Use:
Cigarettes □ Never □ Quit Date______
__ Current Smoker: Pack per day____ # of years___
Other Tobacco: □ Pipe □ Cigar □ Snuff □ Chew
Alcohol Use:
Do you drink alcohol? □ No □ Yes—drinks/week_____
Is your alcohol use a concern for you or others?
□ No □ Yes
Drug Use:
Do you use any recreational drugs? □ No □ Yes
Have you ever used needles to inject drugs? □ No □ Yes
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Patient Name:______Chart Number:______
IMMUNIZATIONS:
Please list your most recent immunizations. Please include your best estimate of the month and year of each immunization:
Hepatitis A______Hepatitis B______Tetanus (Td)______
Measles______Mumps______Rubella______
MMR______Varicella (chicken pox) shot______
Pneumovax (Pneumonia)______
Other ______
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Patient Name:______Chart Number:______
PERSONAL/FAMILY HISTORY:Please indicate with a check mark yourself or family members who have had any of the following conditions:
Medical Condition / Self / Mom / Dad / Sister / Brother / Daughter / Son / Other close relative
Alcoholism (ETOH Abuse)
Allergies
Anemia
Anxiety
Arthritis
Asthma
Bleeding problem
Cancer, Breast
Cancer, Other
CHF
Crohn’s Disease
Colon Polyps
COPD
Coronary Artery Disease
Degenerative Disc Disease
Depression
Diabetes, Type 1
Diabetes, Type 2
Diabetic Nephropathy
Diabetic Neuropathy
Diabetic Retinopathy
Diverticulosis
Erectile Dysfunction
Fibromyalgia
Gastric Bypass
GERD
Glaucoma
Heart Attack
Heart Disease
High Cholesterol
Hypertension (HTN)
Hyperthyroidism
Hypothyroidism
IBS
Migraine Headaches
Mitral Valve Prolapse
Obesity
Osteoporosis
Ovarian Cysts
Prostate Cancer
PUD
Rheumatoid Arthritis
Seizures/Epilepsy
Sleep Apnea
Stroke
Other:
Patient Name:______
Street Address: ______
City: ______State:______Zip:______
Date of Birth:______Phone Number:______
I hereby authorize______(Insert name of physician or practice where youwere a patient.) to release information from my medical records as indicated to:
New Horizons Wellness Center, LLC
1018-A Rucker Blvd.
Enterprise AL 36330
Please note, if records are greater than 20 pages, please mail, do not fax.
Information to be released: (Staff Use Only)
___History___Physical Exam ___Lab Reports ___X-Ray Reports
___Other:______
For the dates of:______to ______.
Read and Initial Below:
_____I understand that this authorization will expire one year from the date signed unless otherwise indicated:______
_____I understand that by authorizing this release of health information it may or may not contain records relating to substance abuse to include drug or alcohol abuse, mental health including psychotherapy notes, sexual abuse, HIV or AIDS related to testing or treatment.
_____I understand that I may revoke this authorization at any time by notifying the providing organization in writing, and it will be effective on the date notified except to the extent action has already been taken in reliance upon it.
_____I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by Federal Privacy Regulations.
_____I understand that by authorizing this release of information, my healthcare and payment for my healthcare will not be affected if I do not sign this form.
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Signature Date
1018 A Rucker Blvd | Enterprise, Alabama | p:334-347-4343 | f: 334-393-9611 |
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Patient Name:______Chart Number:______