SoFHA
Patient Forms

Patient Paperwork

Description:

The Walk-In Clinic new patient paperwork.

Code:

12.001

Issued:

04/21/2020

Revision:

Revised:

N/A

Patient Information

Name First, MI, Last

Date of Birth

Social Security

Address Line 1

Address Line 2Optional

City

State

Zip Code

Education

Main Number

Mobile NumberOptional

Work NumberOptional

Email Optional

Primary Care PhysicianOptional

Marital Status:

Single

Married

Divorced

Widowed

How did you hear about us?

Are you responsible for your own financials?

Yes

Insurance Information

Primary Insurance

Identification Number

Group Number

Subscriber Name

Relation to Patient

Subscriber Date of Birth

Subscriber SSN

Subscriber Gender

Secondary Insurance

Identification Number

Group Number

Subscriber Name

Relation to Patient

Subscriber Date of Birth

Subscriber SSN

Subscriber Gender

Employer Information

EmployerOptional

Occupation

Address Line 1

Address Line 2Optional

Employer City

Employer State

Employer Zip Code

Health History

Reason for Visit

Traveling

Medications

Allergies

Current Symptoms

General Gastrointestinal Eyes, Ear, Nose, Throat Muscle/Joint/Bone

Pain, weakness, numbness in:

Arms

Back

Feet

Hands

Hips

Legs

Neck

Shoulders

Genito-Urinary

Blood in Urine

Frequent Urination

Lack of Bladder Control

Painful Urination

Cardiovascular

Chest Pain

High Blood Pressure

Irregular Heart Beat

Low Blood Pressure

Poor Circulation

Rapid Heart Rate

Swelling of Ankles

Varicose Veins

Skin

Bruise Easily

Hives

Itching

Change In Moles

Rash

Scars

Sore Won't Heal

Gender

Male

Female

Conditions

Family History

Father

Age

State of Health

Mother

Age

State of Health

Brother #1

Age

State of Health

Brother #2

Age

State of Health

Brother #3

Age

State of Health

Sister #1

Age

State of Health

Sister #2

Age

State of Health

Sister #3

Age

State of Health

Diseases

Hospitalizations

Pregnancy History

Serious Illnesses / Injuries

Have you ever had a blood transfusion?

Yes No

Do you have an advance directive (living will)?

Yes No

Health Habits

Check if used:

Caffeine

Tobacco

Drugs

Alcohol

Other

Adult Vaccinations

Tetanus Date Received

Pneumonia Date Received

MMR Date Received

Hepatitis Date Received

Last Treating Physician

NameOptional

Address Line 1

Address Line 2Optional

City

State

Zip Code

Registration, Billing and Collection Payment Policy

We are participating with Medicare, Tennessee Medicaid, and most Managed Care plans in the area. We will file these claims for you. Patients are expected to pay any deductibles, coinsurance or copay amounts owed at the time of service.

If you are a Medicare patient and do not have a supplemental plan or a Medicare Advantage plan, you are responsible for payment of the annual deductible, co-insurance and non-covered services at the time of service.

Patients with a third party coverage with whom we do not contract are responsible for payment in full at the time of service. As a courtesy, we will file your charges with this third party payer upon receipt of payment in full. Otherwise, we will provide you with a completed third party payer claim form to use in filing your insurance.

Patients with a High Deductible Health Plan that have not met their annual deductible amount on the date of service will be asked to pay SoFHA’s estimate of the allowed charges at the time of service. You will be billed for any additional deductible amounts after the insurance processes the claim.

Patients without verifiable insurance will be responsible for payment of all services rendered at the time of service.

We accept cash, check, Visa, MasterCard, Discover, American Express and Care Credit. In an effort to simplify the payment process, we provide a convenient, highly secure Credit/Debit/HSA card and Bank ACH payment program. You will be asked to provide a card-on-file (card/ACH-based) assurance at the time of service. After the insurance claim has been filed (if applicable), we will send you an electronic bill of your final financial responsibility. Your card-on-file will be charged for your out-of-pocket responsibility after the notice period and an electronic receipt will be emailed to you.

Please realize, however, that:

Your insurance is a contract between you and your insurance company. We are not a party to that contract. You are responsible to know your insurance benefits and the portion you will be liable for.
Depending on the specifics of the agreement we have with your insurance company, any portion of our fees not covered may be the responsibility of the patient/guarantor.
Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. Any service not covered is the responsibility of the patient/guarantor.

Regardless of insurance payment, the patient and/or guardian remains responsible for all financial obligations incurred at the time of service. We realize that some balances may not be able to be paid in full at time of service and we will be happy to assist you in making payment arrangements.

By signing this financial policy acknowledgement of the financial responsibility is accepted. This will remain in effect until revoked in writing.

Acknowledgement of Notice of Privacy Practices

May we call the telephone number you have provided and leave a message on an answering machine or with a family member/friend regarding your appointment or test results? Yes No

If no, what other number (i.e. cell phone, private work number) may we try to reach you to leave a message?

Other Phone Number

Cell Phone

Work Phone

May we mail your appointment or test results to your home address?

Yes No

Emergency Contact Number other than YOUR home phone number: (Please note, you are giving permission for this emergency contact to receive your personal health information if necessary.)

Emergency Contact NameFirst, MI, Last

Emergency Contact Phone Number

I have been given the opportunity to review the Notice of Privacy Practices and understand that the Notice describes how my protected medical information may be used and disclosed and how I may get access to this information. I have also been given the opportunity to take a copy of the Notice of Privacy Practices for further review.

If for some reason the facility needs to relay my protected health information, i.e. lab results or billing issues, you can either leave or discuss the information with the following individual(s):

NameOptional

Relationship

Contact Number

NameOptional

Relationship

Contact Number

NameOptional

Relationship

Contact Number

NameOptional

Relationship

Contact Number

ACCESS YOUR MEDICAL INFORMATION ONLINE, 24/7 ANYWHERE, ANYTIME!

YES! I would like to enjoy the benefit of accessing my personal health information, or that of my child, online through FollowMyHealth®

Teaching Physicians: This practice may participate in training new physicians. If so, you may be seen by a physician who is a member of a James H. Quillen College of Medicine Facility. The teaching physicians who work in this office are responsible for teaching residents (postgraduate trainees). Not only will you be seen by your own physician, you may also be seen by one or more residents. We believe this adds to the depth and level of care the patient receives since patients are seen by one or more physicians and then discussed in detail. We are pleased with your willingness to participate in our teaching program. Your care will encompass a team approach to healthcare with involvement of your physician and residents.

Voluntary Questionnaire

You are not required to answer these questions.

Our electronic medical records system maintains certain demographic information used for a variety of purposes, including reference ranges for patient care and government reporting of statistical information. We ask all new patients to voluntarily self-identify the information below and are asking our current patients to confirm it so we may verify our records. Completion of this form is completely voluntary and is not required. The use of information you provided will be consistent with patient care and privacy practices.

Ethnicity Categories

Hispanic or Latino – person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race

Non-Hispanic or Latino – person not of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race

Race Categories

Select all that apply.

Black, African American – person having origins in any of the black racial groups of Africa, including those who consider themselves to be Haitian

Asian – person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam

White – person having origins in any of the original peoples of Europe, North Africa, or the Middle East

American Indian, Alaska Native (not Hispanic or Latino) – person having origins in any of the original peoples of North and South America (including Central America and who maintain tribal affiliation or community attachment

Native Hawaiian, other Pacific Islander (not Hispanic or Latino) – person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands

Signature

By typing your name and initials in the signature fields below, you consent to all of the agreements listed in this form. You furthermore agree that your submission of this form, via the "Submit Form" button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.

Patient/Guardian Signature

Patient/Guardian Initials

Patient Information

How did you hear about us?

Insurance Information

Employer Information

Health History

Current Symptoms

Conditions

Family History

Health Habits

Adult Vaccinations

Last Treating Physician

Registration, Billing and Collection Payment Policy

Acknowledgement of Notice of Privacy Practices

ACCESS YOUR MEDICAL INFORMATION ONLINE, 24/7 ANYWHERE, ANYTIME!

Voluntary Questionnaire

You are not required to answer these questions.

Ethnicity Categories

Race Categories

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Signature