New Patient Information Patient Information Last Name* First Name* Middle Initial Date of Birth SSN Select Gender —Please choose an option—MaleFemale Address City State Zip Code Phone # Alternative Phone # Email Address* Marraige Status —Please choose an option—MarriedSingleDivorcedSeperated Employer Name / Occupation Work Number May we contact you at work, if necessary? —Please choose an option—YesNo Emergency Contact Name Relationship to Patient Emergency Contact Phone # Alternative Phone Please tell us how you heard about us: GUARANTOR INFORMATION (Only complete is patient is a dependent): Relation of Guarantor to Patient: Last Name First Name Middle Initial Date of Birth SSN Select Gender —Please choose an option—MaleFemale Address City State Zip Code Phone # Alternative Phone # Employer Name / Occupation Work Number May we contact you at work, if necessary? —Please choose an option—YesNo Insurance Information Primary Insurance Plan Name: Policy/ID #: Group #: Effective Date: Primary Policy Holder Name: Primary Policy Holder SSN: Policy Holder Date of Birth: Relationship to Patient: —Please choose an option—SelfSpouseParentOther Secondary Insurance Plan Name (if applicable): Policy/ID #: Group #: Effective Date: Primary Policy Holder Name: Primary Policy Holder SSN: Policy Holder Date of Birth: Relationship to Patient: —Please choose an option—SelfSpouseParentOtherWE DO NOT ACCEPT PERSONAL CHECK'S / ALL CO-PAY'S / BALANCES ARE DUE NOW.ASSIGNMENT OF INSURANCE AND FINANCIAL RESPONSIBILITY PLEASE READ:I AUTHORIZE PAYMENT OF ALL INSURANCE BENEFITS, BASIC AND MAJOR MEDICAL, FOR THIS PERIOD OF MEDICAL, EMERGENCY AND OR DIAGNOSTIC TREATMENTS TO BE MADE DIRECTLY TO EAST ALABAMA PRIMARY CARE, DR. SARAT MEKA / DR. RUBY POWAR. | UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES NOT COVERED BY MY INSURANCE PLAN, INCLUDING BUT NOT LIMITED TO CO-PAYS, DEDUCTIBLE, NON-COVERED CHARGES, PROFESSIONAL FEES. | WILL BE RESPONSIBLE FOR ANY COLLECTION FEES, COURT COST AND / OR ATTORNEY FEES INCURRED BY E.A.P.C. /DR. SARAT MEKA, DR. RUBY POWAR,FOR PARTICIPATING IN MY CASE. WHILE COLLECTING ON MY ACCOUNT, PHOTOCOPIES OF THIS AUTHORIZATION ARE AS THE ORIGINAL. | AUTHORIZE E.A.G.M.S., IT'S EMPLOYEES AND AGENTS TO CONTACT ME AT ANY / ALL PHONE NUMBERS INCLUDING CELL PHONE NUMBER FOR THE PURPOSE OF TREATMENT, INSURANCE AND PAYMENTS ETC. BY SIGNING BELOW § UNDERSTAND MY RIGHTS AND RESPONSIBILITY AS A PATIENT OF E.A.P.C.Pharmacy & MedicationsPHARMACY INFORMATION (Please choose one even if you are not on any current medications): Name of Pharmacy Pharmacy Phone Pharmacy Address Secondary Pharmacy (if-applicable) Pharmacy Phone Pharmacy Address ALLERGIES (Please indicate NKDA if you have No Known Drug Allergies):Please list any medications to which you are allergic and the type of reaction.MEDICATIONS (Please list any current prescriptions or over the counter medications):Please list the medication along with dosage & frequency.**PLEASE NOTE THAT WE DO NOT FILL CONTROLLED MEDICATIONS – INCLUDING BUT NOT LIMITED TO: HYDROCODONE/OXYCODONE, XANAX, ADDERALL/VYVANCE, TRAMADOL. WE WILL REFER YOU TO A SPECIALIST.MEDICAL HISTORYPAST MEDICAL HISTORY (Please check any current or previous conditions):Acid RefluxADHDAnemiaAnxietyAsthmaAtrial FibrillationBipolar disorderBlood clotsBlood transfusionCancer (Please indicate type below)Colon PolypsCOPDCoronary Artery DiseaseDepressionType1 DiabetesType2 DiabetesDiverticulitisGoutHeadachesHeart AttackHeart FailureHepatitis AHepatitis BHepatitis CHigh Blood PressureHigh CholesterolHIV/AIDSHyperthyroidismHypothyroidismKidney DiseaseKidney StonesLiver DiseaseLow Blood PressureLupusOsteoarthritisOsteopeniaOsteoporosisRheumatoid ArthritisSeizuresStrokeOther (Please elaborate below)Elaborate, if necessary PAST SURGICAL HISTORY (Please list all surgeries, performing doctor, and surgery date):SOCIAL HISTORY (Please complete entirely): Tobacco/Nicotine Use —Please choose an option—CurrentFormerNever Type & How Often Duration of Use If you quit, how long ago? Alcohol Use —Please choose an option—DailySociallyRarelyNone Frequency (in a month) Recreational Drug Use —Please choose an option—CurrentFormerNever Type & For How Long Family History of Substance Abuse Exercise —Please choose an option—YesNo Type & How Often Diet (indicate type if other than regular) Caffine —Please choose an option—YesNo Average Amount (indicate per day, week or month) Caffine Type Other liquid intake during the day: Who are you living with: How often do you feel stressed: —Please choose an option—NoneA littleTo some extentRather muchVery much Any Pets at Home? —Please choose an option—YesNo Do you have smoke and carbon monoxide detectors in your home? —Please choose an option—YesNo Are you passively exposed to smoke? —Please choose an option—YesNo Do you use sunscreen routinely? —Please choose an option—YesNo Are you able to care for yourself? —Please choose an option—YesNo Are you blind or have difficulty seeing? —Please choose an option—YesNo Are you deaf or have serious difficulty hearing? —Please choose an option—YesNo Do you have difficulty concentrating, remembering, or making decisions? —Please choose an option—YesNo Do you have difficulty walking or climbing stairs? —Please choose an option—YesNo Do you have difficulty dressing or bathing? —Please choose an option—YesNo Do you have difficulty doing errands alone? —Please choose an option—YesNo Are you able to walk? Without restrictions? —Please choose an option—Without RestrictionsWith an Assistive DeviceNo Are you sexually active? —Please choose an option—YesNo How many children do you have? Do you have an advanced directive? —Please choose an option—YesNo What is the highest grade or level of school you have completed? HEALTH MAINTENANCE (Please indicate performing doctor, date, and results) Last Tetanus/TDAP vaccine Last Flu Vaccine Last Colonoscopy Performing Doctor/Clinic Performing ColoGuard Last Vision Exam Performing Doctor/Clinic Last Dental Exam Performing Doctor/Clinic Women Only OBGYN Doctor/Clinic Last Pap Smear Mammogram DEXA FAMILY HISTORY (Please list any of the following or any other family medical history):Anemia Anxiety Asthma Atrial Fibrillation Bipolar Disorder Blood Clots Cancer (indicate type)COPD Coronary Artery Disease Depression Diabetes Heart Attack Heart Failure High Blood Pressure High CholesterolHIV/AIDS Hyperthyroidism Hypothyroidism Lupus Seizures Stroke Sudden Cardiac Death Brother Daughter Father Paternal Grandfather Paternal Grandmother Mother Maternal Grandfather Maternal Grandmother Sister Son MEDICAL INFORMATION RELEASEI give the physicians and staff at East AL Primary Care permission to release information to the following Family Members, regarding my medical condition (s), test results, appointment, drug and (or) alcohol abuse and financial status.Release Option #1 Name: Relationship to Patient: Phone #: Release Option #2 Name: Relationship to Patient: Phone #: I, the undersigned, allow the facsimile as E-Mail process of prescription request, medical records, orders, and appointment listing to referred facilities to expedite your healthcare. Patient Name Patient Signature If signing for a dependent, please indicate relationship. Patient ConsentI understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can, and will be used to:Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly or indirectly.Obtain payment from third party payersConduct normal healthcare operations such as quality assessment and physicians’ certifications.I have been informed by you of your Notice of Privacy Practices containing a more complete description of uses and disclosures of my health information. I have been given the right to review such Notices of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact East Alabama Primary Care at any time at the address above to obtain a current copy of the Notices of Privacy Practices.I understand that I may request in writing that you restrict how my confidential information is used or disclosed to conduct treatment, payment, or healthcare operations. I also understand that you are not required to agree to my requested restriction, but if you do agree then you are bound to abide by such restrictions.I understand that I may revoke this consent in writing at any time, except to the extent that you have acted relying on this consent.I Understand Patient Name Patient Signature If signing for a dependent, please indicate relationship. Notice of Privacy PracticesTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND ABOUT HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE CLICK HERE AND REVIEW IT CAREFULLY.I acknowledge that I received the Notice of Privacy Practices upon registration as a patient for East AL Primary Care, LLC and I acknowledge that I was offered a copy of the Notice of Privacy Practices upon registration as a patient for East AL Primary Care, LLC but declined receipt. Patient Name Patient Signature If signing for a dependent, please indicate relationship. OFFICE AND FINANCIAL POLICIESCELLPHONE USE: Please do not use your cellphone when you are brought back to see your provider. Please put your cellphone on silent or turn it off while with your provider.FINANCIAL POLICY: All payment due is required at the time of service. Co-Payments, Deductibles and Balance Due will be COLLECTED during Check-In. No checks are accepted currently but we accept debit cards and all major credit cards.RESCHEDULE/CANCELLING/NO SHOW: We understand that circumstances arise that you may need to cancel or reschedule your appointment. If you must reschedule or cancel, please contact the office 24 hours in advance. On weekends, leave a Voice Mail. We do contact you via text, email and by phone to remind you of your appointment.IF YOU DO NOT SHOW UP FOR YOUR APPOINTMENT (NO SHOW), YOU WILL BE CHARGED A $25 NO SHOW FEE THAT WILL BE COLLECTED PRIOR TO YOUR NEXTAPPOINTMENT.REQURIED FORM COMPLETION: Forms are time consuming but are necessary at times to be completed by your care team. We will complete your form (s) upon request, but we charge a normal fee for the completion of varied forms. Please inquire as to the charges associated with your form.PRIOR AUTHORIZATIONS FOR MEDICATIONS: There is a $10 fee for a prior authorization on a medication. Completion of a prior authorization does not guarantee your insurance company will approve your medication. The $10 fee will be enforced regardless of approval for your medication.MEDICATION REFILLS: Patients are required to be seen at least EVERY 6 Months to receive medication refills. Please contact your PHARMACY for refills on the following medications: Acid Reflux, Arthritis, Blood Pressure/Blood Sugar/Diabetic, Cholesterol and Stomach Medications. Patient Name Patient Signature If signing for a dependent, please indicate relationship. Non-Covered WaiverUnder your health plan, you are financially responsible for co-payments, co-insurance, and deductibles for covered services, as well as those services that exceed benefit limits. You are also financially responsible for all non-covered services as defined by your health plan contract. For example, this may include services such as flu vaccinations, EKG’s etc. The services or products may or may not be covered according to your health plan. Your acknowledgement below indicates that you have been advised of this information and that you agree to pay for any services not covered under your plan.I Agree**AT THIS TIME, PLEASE MAKE SURE YOU HAVE FILLED OUT THIS ENTIRE FORM TO THE BEST OF YOUR CAPABILITY. USE “N/A” OR “NEVER” IF NOT APPLICABLE TO YOU. WE ARE UNABLE TO SCHEDULE YOU UNTIL WE HAVE THIS FORM IN ITS ENTIRETY. THANK YOU FOR YOUR COOPERATION. WE LOOK FORWARD TO WORKING WITH YOU** Patient Name Patient Signature If signing for a dependent, please indicate relationship.
