New Patient Information

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 

 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
I hereby authorize East Main Family Medical Clinic to release any information concerning my illness/accident and treatment to Insurance Carriers. I hereby assign East Main Family Medical Clinic, L LC payments for Medical services rendered to my dependents or myself. I understand that 1 am financially responsible for all charges whether or not covered by insurance. You will be responsible for any returned check fees.
 
 
 
MEDICAL HISTORY
 
 
 
 
 
 
Past Surgical History
Have you or a family member had problems with anesthesia?
 
 
 
 
 
 
 
 
Have you or a family member had problems with bleeding?
 
 
 
 
 
 
 
 
Do you have a sensitivity or allergy to Latex?
 
 
 
 
 
 
 
 
Past Medical Illness (check all that apply)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Drug Allergies
 
 
 
 
 
 
 
 
What Medication are you taking now?
 
 
 
 
 
 
 
 
 
Social History
Are you
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Are you currently pregnant?
 
 
 
 
 
 
 
 
 
 
 
Noise exposure: Mild, Moderate, Severe
Do/did you smoke or chew tobacco?
 
 
 
 
 
 
 
 
 
 
 
 

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
I authorize
 
 
to disclosure the information from my records to the East Main Family Medical Clinic, Inc
I authorize the East Main Family Medical Clinic, Inc. to disclose the information from my records to:
 
I authorize the disclosure of:
The Purpose of the disclosure:
I understand that the information in my health record may include information relating to sexually transmitted disease;acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

I understand that I have a right to revoke this authorization at any time. I understand that the revocation will not apply to information that has already been used or disclosed under this authorization. I understand that revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. If this authorization has not been revoked, it will terminate on the following date in the event or condition:. If I fail to specify an expiration date, event or condition, this authorization has not been revoked, it will terminate on the following date in the event or condition:
If I fail to specify an expiration date, event or condition, this authorization will automatically expire in six (6) months.
I understand that I can refuse to sign the authorization, I need not sign this form to obtain treatment, payment, or health pan enrollment or eligibility. I understand that any disclosure of information carries with it the potential for redisclosure by the recipient and that the information may then be no longer protected by federal confidentiality rules.
 
 
 
 
 
 
PATIENT CONSENT FOR TREATMENT ASSIGNMENTOF INSURANCE BENEFITS AUTHROIZATION TORELEASE INFORMATION
CONSENT FOR MEDICAL TREATMENT
(This is good for my lifetime)
My permission is given today for any medical treatment, including but not limited to, examination injections, diagnostic testing, and medical procedure, as may be deemed advisable by members of the staff of East Main Family Medical Clinic.

AUTHORIZATION TO RELEASE INFORMATION
(This is good for my lifetime)
I authorize East Main Family Medical Clinic to release any medical information necessary to process this claim(Medicaid, Medicare, Insurance). I authorize any holder of medical or the fiscal agent for Medicare or Medicaid, any information needed to determine these benefits or the benefits payable for related serviced.

ASSIGNMENT OF BENEFITS
(This is good for my lifetime)
I request and authorize payment of medical benefits to the East Main Family Medical Clinic for services provided. I request that payment of authorization Medicare and Medicaid (for any other insurance company that will pay benefits on my behalf) benefits be made on my behalf to East Main Family Medical Clinic.

NOTICE OF PRIVACY PRACTICES
I have received the Notice of Privacy Practices and 1 have been provided an opportunity to review it.