Keweenaw Holistic Family Medicine Patient Registration Form

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1 Keweenaw Holistic Family Medicine Patient Registration Form How did you first learn of our Clinic? Circle one: Attended Lecture Internet KHFM website Newspaper Sign in window Yellow Pages Physician Friend or Family Member: Other: PATIENT NAME: LAST FIRST MIDDLE INITIAL DOB: SS# GENDER: STREET ADDRESS: CITY/STATE/ZIP: Home Phone: Cell Phone: Work: Preferred Contact Number (circle one): Home Phone Cell Phone Work Address: I approve as a method of communication with Keweenaw Holistic Family Medicine: (circle one) YES or NO Is it OK to leave voice messages regarding results, appointments and general communications? (circle one) YES or NO Emergency Contact Information: Name: Phone: Address: Relationship to Patient: Check Here if Address is same as Patient I agree to let Keweenaw Holistic Family Medicine give medical information such as laboratory, pathology, x-ray and office visit findings, normal or abnormal to the following people: 1 Relationship 2 Relationship 3 Relationship

2 Patient Insurance Information **Please bring your insurance card with you** Patient Name: Address: City/State/Zip: Phone Number: Gender: Patient Relationship to Subscriber: DOB: Patient is primary subscriber Insurance Subscriber Information Subscriber's Full Name Subscriber's Address: City/State/Zip: Address same as Patient Address Subscriber's DOB: Subscriber's Phone Number: Primary Insurance: ID/Policy#: Group # Co-Pay Amount: $ Secondary Insurance Secondary Ins. ID & Policy No. **A copy of your insurance card is required** Without a copy of the card, we cannot bill your insurance and you will be responsible for payment I authorize the release of any information concerning my (or my child's) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefit otherwise payable to me directly to Keweenaw Holistic Family Medicine. Signature: Date:

3 Keweenaw Holistic Family Medicine, P.C Calumet Ave. Calumet, MI Authorization to Release Information Patient's Full Name: Former Name (if applicable) DOB: SS# Phone I authorize information to be released (circle one) TO or FROM Keweenaw Holistic Family Medicine Dr. Jill Kalcich Calumet Ave., Calumet, MI Fax: FROM or TO: (Clinic /Hospital Name): Physician Name: Address: Phone: Reason for disclosure: Fax: Please include (check all that apply): Entire Record Partial Record: Dates From To Recent history and physical Recent admit and discharge from hospital Lab Results: Date Type of test X-Ray/Imaging: Date Type of test I understand that the information disclosed may include information regarding sexually transmitted disease, AIDS, HIV, behavioral health, mental health and treatment for drug or alcohol abuse. I understand that I may revoke this authorization at any time and that I must do so in writing. I understand that my health information may have already been released upon Keweenaw Holistic Family Medicine's receiving of the revocation of authorization. I understand that this authorization will become part of my medical record. Patient/Guardian Signature: Date:

4 Signature Page **Please print this page, review the contents thoroughly, sign, and bring with you to your first appointment.** Consent to Treatment: I authorize Keweenaw Holistic Family Medicine and Dr. Jill Kalcich to provide ongoing medical care, treatment and procedures as needed. I understand that no guarantees can or will be made as to results of care, treatment, or medication prescribed. If the patient is a minor, then proxies for medical consent (others who may bring the child in for medical visits) including the following in addition to the parents or legal guardians of the child: Financial Agreement: I understand and agree that I am financially responsible for all services provided. As a courtesy, Dr. Kalcich will bill my insurance carrier one time, per visit, using appropriate diagnosis codes unless otherwise informed (yearly physical, well child, etc). Regardless of outstanding insurance claims, full payment is due within 60 days of the date of service. I understand patients with delinquent accounts of over 60 days will be discharged if no payment arrangements have been made. Co-pays are due at the time of service. If collection procedures are required, I am responsible for their cost. Some services may not be covered by insurance policies and they remain in the patient's financial responsibility. I understand there is a $50 fee if I do not show up for an appointment or cancel with less than 24-hours notice. Assignment of Benefits: I authorize my insurance benefits be paid directly to Keweenaw Holistic Family Medicine. I certify that all information given in applying for payment under my health insurance plan is correct, and authorize verification of coverage by Dr. Kalcich or staff. Photocopy of this authorization shall be considered as effective and valid as the original. Consent to Release of Information: I authorize Keweenaw Holistic Family Medicine to release, upon request, to my insurance carriers or other reimbursing agencies information about my identity, treatment, diagnosis, prognosis, and/or other services rendered including information about substance abuse, HIV/AIDS, or other sexually transmitted or reportable diseases as permitted by law, thus releasing Keweenaw Holistic Family Medicine and Dr. Jill Kalcich and staff of any liability for furnishing such information. I understand that information may be released through electronic or paper media. Notice of Health Information Practices: I acknowledge that I have been provided with access to or a copy of the Notice of Privacy Practices (posted on the website).

5 Approved Methods of Communication: (please circle your Choices) I do / do not consent to the leaving of voice mail regarding medical results and appointment reminders. I do / do not consent to the leaving of regarding medical results and the receipt of electronic forms and appointment reminders. Acknowledgement of Practice Policies: I hereby acknowledge that I have reviewed or will immediately review the practice policies as posted at and agree to abide by these practice policies while under the care of Dr. Jill Kalcich. This includes but is not limited to policies on missed appointments, refills, narcotics, terms for termination of care, after hours care and more. Printed Name: Date: Patient/Guardian Signature:

6 Notice of Privacy Practices The Health Insurance Portability and Accountability Act (HIPAA) requires that medical practitioners provide all patients with a notice that describes how personal health information (PHI) may be used and disclosed as well as patient rights and medical provider duties regarding this information. Please review the following, which is provided in compliance with HIPAA. Treatment Your personal health information will be used as necessary to provide optimal medical care. Information may be disclosed to other physicians, nurses or members of the healthcare team Payment Your personal health information may be disclosed in order to bill and receive payment from your insurance carrier, and is sometimes required in advance to pre-certify payment by insurers. Business Operations While committed to the highest possible level of privacy, there may be times when your PHI is disclosed to facilitate quality improvement initiatives, or for the purposes of general business operations including billing. Whenever possible, this information will be deidentified. Appointment Reminders Your PHI may be minimally disclosed when messages are left reminding you of upcoming appointments. Release of Information to Family and Friends With your written or documented verbal permission, your personal health information may be shared with friends or family of your designation, including those who accompany you to the appointments or assist in your care. Legally Required Uses and Disclosures There are cases in which your PHI may be shared without your permission, including reportable diseases, reportable patterns of injury, abuse, or neglect, events such as births and deaths, reactions to medications, for audits, investigations, and licensure, for judicial proceedings, warrants, subpoenas, as well as to avert a serious threat to safety or health. You Have the Following Rights: 1. To request restrictions on certain uses and disclosures, which may or may not be granted 2. To receive confidential communications 3. To inspect and copy PHI, provided such inspection has not been deemed a danger to your health or the health of others 4. To request the amending of PHI should you find it to be incomplete or in error 5. To receive an accounting of disclosures of PHI 6. To obtain a paper copy of this notice from the practice upon request

7 Duties of the Practice: 1. To maintain the privacy of confidential information and to provide required notices pertaining to same 2. To abide by the terms of the current notice in effect 3. If terms are changed by practice, revised notice will be sent to you electronically or in paper format Complaints If you believe your privacy rights have been violated, you may file a complaint with the practice (and/or) Secretary of the Department of Health and Human Services by writing to: Secretary of DHHS 200 Independent Avenue SW Washington, DC Effective Date: October 2008 OR Dr. Jill E. Kalcich Calumet Ave. Calumet, MI I acknowledge I have read and understood Keweenaw Holistic Family Medicine's Notice of Privacy Practices. Patient Signature: Date:

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