SoFHA
Patient Forms

Patient Paperwork


Description:

The FirstChoice Internal Medicine new patient paperwork.


Code:

8.001

Issued:

03/27/2019

Revision:

2

Revised:

05/08/2019

Please fill out a new patient request form with your preferred provider of choice, if you have not filled out already before completing the new patient paperwork.

Please submit the new patient paperwork at least 48 hours before your scheduled appointment.

New Patient Request Form


Personal History


















Social History









Habits









Allergies / Reactions




Immunizations









Health Maintenance








Past Surgical History


Medications



Family History

Father





Mother





Maternal Grandfather





Maternal Grandmother





Paternal Grandfather





Paternal Grandmother





Brother #1





Brother #2





Sister #1





Sister #2







Past Medical History




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

Race Categories

Select all that apply.


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

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






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.)




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):

















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




Signature

By typing your name 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.