New Patient Form | Internal Medicine and Pediatrics of Cullman, P.C.

New Patient

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Patient Information

Patient Name(Required)

First Last

Current Status(Required)

Sex

Date of Birth(Required)

Month

Day

Year

Race

Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone Number(Required)

Secondary Phone Number

Social Security Number

Email Address

Employer

Work Phone Number

Emergency Contact

Name

First Last

Phone

Identity Verification

Driver's License Upload(Required)

Max. file size: 50 MB.

To verify your identity, please upload a picture of the front of your driver’s license for review.

Responsible Party/Parents

Mother (Stepmother/Guardian) Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Phone Number(Required)

Social Security Number

Employer

Father (Stepfather/Guardian) Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Phone Number(Required)

Social Security Number

Employer

Spouse Information (If Applicable)

Spouse Name

First Last

Date of Birth

Month

Day

Year

Social Security Number

Insurance Information

Primary Insurance Company

Contract Number

Copay

Insured's Name

First Last

Date of Birth

MM slash DD slash YYYY

Secondary Insurance Company

Contract Number

Copay

Please Upload a Picture of the Front of Your Insurance Card

Max. file size: 50 MB.

Please Upload a Picture of the Back of Your Insurance Card

Max. file size: 50 MB.

New Patient Authorization

I authorize the doctor to release any information including the diagnosis and the records of any treatment or examination rendered during the period of such care to third party payors and/or other health practitioners. I authorize and request my insurance company to pay directly to the doctor or doctor's group insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I realize that failure to keep this account current may result in you being unable to provide additional services except for emergencies or where there is prepayment for additional services. In the case of default on payment of this account, I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this account or any future outstanding account balances. I also understand that unless a cancellation of an appointment is made 24 hours in advance of said appointment, I will be subject to charge for the time reserved.(Required)

I understand and agree to the New Patient Authorization statement.

INTERNAL MEDICINE & PEDIATRICS OF CULLMAN, P.C.

CONSENT FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
FOR PAYMENT, TREATMENT AND HEALTH CARE OPERATIONS

By signing below, you hereby consent for this Practice to use or disclose information about yourself (or another person for whom you have the authority to sign) that is protected under federal law, for the sole purposes of treatment, payment and health care operations. You may refuse to sign this consent form.

You should read the Notice of Privacy Practices for PHI attached to this form before signing the Consent. The terms of the Notice may change from time to time, and you may always get a revised copy of it by asking the Privacy Officer for this Practice.

You have the right to request that the Practice restrict how PHI is used or disclosed to carry out treatment, payment, or health care operations. The Practice is not required to agree to requested restrictions, however; if the Practice agrees to your requested restrictions, the restriction is binding on it.

Information about you is protected under federal law, and you have the right to revoke this Consent, unless we have taken action in reliance on your authorization (as determined by our Privacy Officer). By signing below, you recognize that the protected health information used or disclosed pursuant to this Consent may be subject to re-disclosure by the recipient and may no longer be protected under federal law.

Both parents must be listed on this form to accompany minor children as well as discuss conditions, and/or course of treatment of minor patients.

You may communicate with the following individuals regarding my condition or course of treatment:

You may communicate confidential information to me, or the following individuals:

Please provide the names and phone numbers of any individuals listed here.

By providing my information below, I confirm that I have read and understand and agree to the Consent for Use or Disclosure of Protected Health Information for Payment, Treatment and Health Care Operations.(Required)

Yes, I confirm

Patient's Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Mother (Stepmother/Guardian) Name(Required)

First Last

Father (Stepfather/Guardian) Name(Required)

First Last

CONSENT FORM FOR ePRESCRIBE PROGRAM

ePrescribe Program

ePrescribing is a way for doctors to send electronically an accurate, error free, and understandable prescription from the doctor’s office to the pharmacy. The ePrescribe Program also includes:

Fill status notification – Allows the health care provider to receive an electronic notice from the pharmacy telling them if your prescription has been picked up, not picked up, or partially filled.
Medication history transaction – Provides the health care provider with information about your current and past prescriptions. This allows health care providers to be better informed about potential medication issues and to use that information to improve safety and quality. Medication history data can indicate compliance with prescribed regimens; therapeutic interventions; drug-drug and drug-allergy interactions; adverse drug reactions; and duplicative therapy.

The medication history information would include medications prescribed by your health care provider at Internal Medicine and Pediatrics of Cullman, P.C. as well as other health care providers involved in your care and may include sensitive information including, but not limited to, medications related to mental health conditions, venereal diseases/sexually transmitted diseases, abortion(s), rape/sexual assault, substance (drug and alcohol) abuse, genetic diseases, and HIV/ AIDS. As part of this Consent Form, you specifically consent to the release of this and other sensitive health information

Consent

By signing this consent form you are agreeing that your provider at Internal Medicine and Pediatrics of Cullman, P.C. may request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payors for treatment purposes.

You may decide not to sign this form. Your choice will not affect your ability to get medical care, payment for your medical care, or your medical care benefits. Your choice to give or to deny consent may not be the basis for denial of health services. You also have a right to receive a copy of this form after you have signed it.

This consent form will remain in effect until the day you revoke your consent. You may revoke this consent at any time in writing, but if you do, it will not have an effect on any actions taken prior to receiving the revocation.

Understanding all of the above, I hereby provide informed consent to Internal Medicine and Pediatrics of Cullman, P.C. to enroll me in the ePrescribe Program. I have had the chance to ask questions and all of my questions have been answered to my satisfaction.

Do You Consent to Being Enrolled in the ePrescribe Program?(Required)

Patient Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Personal Representative Name(Required)

First Last

Current Symptoms Assessment

Please select any of the symptoms the patient is currently experiencing.

Abdominal Pain

Anxious Feelings

Back Pain

Bedwetting

Bleeding Tendencies

Blood in Stool

Bruising Easily

Chest Pain

Chest Pain with Deep Breath

Chills

Cold Intolerance

Cold Sweats

Concerning Skin Lesions

Constipation

Dark Stools

Daytime Sleepiness

Decreased Appetite

Decreased Energy

Decreased Sexual Function

Decreased Sleep

Depression

Diaper Rash

Difficulty Breathing Lying Down

Difficulty Taking Liquids

Difficulty Swallowing

Difficulty Urinating

Diarrhea

Double Vision

Dizziness

Dizziness or Lightheadedness on Standing

Dry Eyes

Ear Drainage

Ear Pain

Eye Crusting

Eye Redness or Drainage

Fever

Forgetfulness

Frequent Urination

Hair Loss

Having to Get Up to Breathe at Night

Headaches

Hearing Loss

Heartburn

Heart Fluttering/Racing

Heat Intolerance

Itching

Joint Pain

Loss in Interest/Pleasure in Activities

Lymph Node Swelling

Morning Stiffness

Mouth Ulcers

Muscle Pain/Aches

Nasal Congestion

Nausea

Neck Pain

Neck Stiffness

Numbness

Painful Urination

Problems with Male Sexual Function

Rash

Runny Nose

Shortness of Breath

Shortness of Breath with Exercise

Sleep Problems

Slow Urine Stream

Snoring

Sore Throat

Spitting Up

Swelling

Thrush

Trouble Controlling Bladder

Vomiting

Weakness in Localized Area

Weight Loss, Unintentional

Wheezing

Please Explain Your Selected Symptoms in More Detail

Family History

Please check all family history conditions that apply.

Breast Cancer

Colon Cancer

Congestive Heart Failure

Coronary Artery Disease

Diabetes

High Blood Pressure

High Cholesterol

Heart Attacks

Heart Attack Under 50

Heart Attack at Age Under 50

Stroke

Please Explain Your Selections in More Detail

New Patient

Patient Information

Emergency Contact

Identity Verification

Responsible Party/Parents

Spouse Information (If Applicable)

Insurance Information

New Patient Authorization

INTERNAL MEDICINE & PEDIATRICS OF CULLMAN, P.C.

CONSENT FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR PAYMENT, TREATMENT AND HEALTH CARE OPERATIONS

CONSENT FORM FOR ePRESCRIBE PROGRAM

ePrescribe Program

Consent

Current Symptoms Assessment

Family History

CONSENT FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
FOR PAYMENT, TREATMENT AND HEALTH CARE OPERATIONS