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1 DR. RICHARD P. TOWNSEND M.D. VERONICA DEAN FNP-C Family Nurse Practitioner LAURA GRUNDY FNP-BC Family Nurse Practitioner Dr. Richard Townsend is a third generation physician. He was educated in Canada and moved his practice to Dallas in He enjoys his practice and working with exceptional staff providing care for his many loyal patients. Dr. Townsend is a former team physician for Berkner High School. Dr. Townsend and his wife of 42 years enjoy travel, particularly trips to Mexico and their cottage in Ontario, Canada. In his spare time, Dr. Townsend enjoys golf, hockey, gardening and railroading. He is an avid history buff. Courtesy of D-Magazine 2006/2010 We are pleased that you have chosen us to be your primary care providers. To assist us in providing quality medical care, we request that you complete the forms attached. New Patient Registration Packet Medical History Questionnaire HIPAA Compliance Form HIE Health Information Exchange Authorization Medical Records Release Form The information gathered can be extremely important to your well-being which, of course, is our primary concern. Having the forms completed prior to the visit will allow you more time to discuss with the doctors or nurse practitioners any health issues you may have. We suggest that you bring your insurance card(s) and a photo ID so that we can make copies for our records. Please do not forget to bring your forms with you at the time of your visit as this will result in you having to do them again when you arrive at the office. Thank you for your cooperation E. Buckingham Road, Ste 110, Richardson, Texas Phone Fax

2 Richard Townsend, MD 1001 E. Buckingham Rd., Suite 110, Richardson, TX Phone: Fax: Please Note: So that we may maintain the most up to date and accurate information on our patients, in addition to the face sheet presented to you at every visit, we will request that you review and update this form at least once a year. Patient Information Name: First MI Last Address: City St Zip Phone: Home Work Cell Best Contact Number Birthdate Sex SS# Marital Status Married Single Divorced Widowed Occupation Address (Confidential Medical Information Will NOT Be ed) Ethnic Group: Caucasian African American Hispanic Other Preferred Language: English Spanish Other Do you have any communication difficulties? Hearing Loss Language Reading Difficulty Vision Other? Yes No If yes, please list: Spouse/Parent/Legal Guardian Information Name: First MI Last Relationship: Spouse Parent Guardian Other (Please Specify): Address: City St Zip Phone: Home Work Cell Address (Confidential Medical Information Will NOT Be ed) Preferred Language: English Spanish Other Do you have any communication difficulties? Hearing Loss Language Reading Difficulty Vision Other? Yes No If yes, please list: Emergency Notification [ ] Check box if same as spouse/legal guardian. If different, please complete information below. Name: Relationship to Patient: Address: City St Zip Phone: Home Work Cell Continue to the Back of this Page

3 Please provide a copy of all Insurance Cards and a Driver s License / Photo ID You will be asked to present your insurance card(s) at each visit so that we can confirm that all information in our files remains current. Insurance Information Medicare # Do You Have Insurance Primary to Medicare? Yes No If Yes, Please List: Medicare Supplement ID# Medicare Advantage Plan ID# Medicaid # Or Commercial Insurance Primary Insurance ID Gp: Policy Holder Relationship ( Circle One) Self Spouse Parent Other SS# Policy Holder s DOB Employer Employer s Phone Secondary Insurance ID: Gp Policy Holder Relationship (Circle One) Self Spouse Parent Other SS# Policy Holder s DOB Employer Employer s Phone Medication Refill Policy Please contact your pharmacy for medication refills. Your Pharmacy will fax us a medication refill request which the physician will review. Refill authorizations may require hours. Please allow sufficient time for us to process your refill request. Initial Privacy Practices Our office, physicians and staff, are committed to securing the privacy of your health information. We are making available to you a copy of our Notice of Privacy Practices. A copy of the Notice of Privacy Policies for Richard Townsend, MD has been made available to me. Signature Date Page 2 Continue to Next Page

4 [ ] Do Not Release Information Optional Authorization for Release of Medical Information I authorize Richard Townsend, MD to use the additional contact information listed below to discuss or disclose information regarding any matters relating to my appointments, insurance, test results or medical care. Name Relationship Phone [ ] Not Applicable (patient is an adult) Authorization to Treat a Minor (Ages 0-18 th Birthday) If there are circumstances when I am unable to bring my child to the office for his/her evaluation and treatment, I give my permission and authorization for the following persons (over the age of 18) to obtain medical care for my child. I also authorize the providers of Richard Townsend, MD to discuss or disclose information regarding any matters relating to my child s appointments, insurance, test results or medical care to those listed below. This authorization will remain in effect until I provide written notification to Richard Townsend, MD of changes or updates. I authorize Richard Townsend, MD to use the additional contact information listed below to discuss or disclose information regarding any matters relating to my appointments, insurance, test results or medical care. Name Relationship Phone Name Relationship Phone Page 3 Continue to the Back of this Page

5 Advance Medical Directive/Power of Attorney Do you have an Advance Medical Directive (Living Will)? Yes No Do you have a medical Power of Attorney (POA)? Yes No If yes, who keeps a copy? Consent for Treatment, Release of Information, Authorization & Assignment of Benefits I consent to treatment necessary to my care I authorize the release of all medical records to specialists and/or consulting physicians if applicable to my care and condition. I authorize any holder of medical or other information about me to release to the Social Security Administration, Health Care Financing Administration, its intermediaries, its carriers, or any other insurance carrier any information needed for this or any other related claim to be processed. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits either to me or to the party who accepts assignment. I understand it is mandatory to notify the health care provider of any party who may be responsible for paying for my treatment. I further authorize and request that insurance payments be directed to Texas Health Physician Group, DBA Richard Townsend, MD I have read, fully understand and agree to the above consent for treatment, financial responsibility statement, release of medical information & insurance authorization, and medication refill policy. Date Patient Name Signature Financial and Payment Policies Notice: Our office does NOT file Auto Insurance claims for visits relating to motor vehicle accidents. Payment is due at the time of service. This includes all co-pays and deductibles. Insurance will be filed for services rendered. Any charges for services not covered by insurance will be the responsibility of the patient or his/her guardian. Patient or guardian is responsible for notifying our office of any changes to demographics or insurance and billing information. Out of Network services not paid by the health insurance company will be the responsibility of the patient or his/her guardian. Richard Townsend, MD will provide medical information to the insurance company as required for payment of claims for services rendered. I have read, fully understand, and agree to the above consent for treatment, financial responsibility statement, release of medical information and insurance authorization. Patient Name Signature Date Please Note: So that we may maintain the most up to date and accurate information on our patients, in addition to the face sheet presented to you at every visit, we will request that you review and update this form at least once a year. Page 4

6 Medical Release of Information Form Patient Name: Date of Birth: Social Security #:XXX-XX- Previous/Maiden Name: Home Phone: Other Phone: Address, City, State, Zip Phone Fax I request and authorize : RICHARD P. TOWNSEND, MD To release the medical record of the above named patient to (the place you want your medical records to be sent): Name of recipient: Address: City & State: Zip Code: Phone: Fax*: Reason for release(required field): Continue care *(No Fee to release last 3 office visit notes, imaging reports, lab results and shot records) Continue care: All records** Personal Copy** Legal/Insurance** Other **: (**Minimum fee may apply) This request and authorization applies to: (initial appropriate line) Health Care information relating to the following treatment condition or dates of treatment: Indicate dates range of treatment: to This information may contain x-ray reports, laboratory reports, EKG reports, other diagnostic reports, consults, etc. All Health Care information including information relating to HIV/AIDS testing Sexually Transmitted Diseases Psychiatric Disorders / Mental Health or Drug and/or Alcohol use. (Please check all that apply) All Health Care information excluding information relating to HIV/AIDS testing Sexually Transmitted Diseases Psychiatric Disorders / Mental Health or Drug and/or Alcohol use. (Please check all that apply) I understand that I have the right to revoke this authorization by providing a written request to do so to the above named physician or organization. I understand that the revocation will not apply to information that has already been released. Signature of patient or authorized representative Date Relationship or status if signed by anyone other than the patient (parent, legal guardian, personal representative, etc.) Unless otherwise revoked this Authorization will expire six months from the date signed. I understand that authorizing the disclosure of this health information is voluntary. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by confidentiality rules. Please be aware that there is a fee for copying and sending medical records. This follows HIPAA guidelines and The Texas State Board of Medical Examiners fee guidelines. This fee is $25.00 for the first 20 (twenty) pages and $.50 cents for each additional page thereafter plus postage. The fee covers the cost of labor and supplies. This fee must be paid prior to the release of records. For a list of FAQ's please visit: Medical record request are processed by: AADPM Record Management (p) (f) CF-193 MRIF

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