New Pt Intake Packet New Patient Intake Form FILL AND SUBMIT PRINT AND FILL FILL AND SUBMIT "*" indicates required fields Date* DD slash MM slash YYYY PERSONAL INFORMATIONPatient Name* First Middle Last Date of Birth* DD slash MM slash YYYY Gender* Male Female Marital Status Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code HomeWorkCell*e-Mail (For Patient Portal Set-up)* Occupation* Employer* Primary Care Physician PhoneReferring Physician PhonePharmacy Name PhonePharmacy Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code INSURANCE INFORMATIONPrimary Insurance* Phone*ID* Group #* Medical Group* Subscriber Name* DOB* DD slash MM slash YYYY Relation* Secondary Insurance PhoneID Group # Medical Group Subscriber Name DOB DD slash MM slash YYYY Relation EMERGENCY CONTACTName* Phone*Relation* These questions are included to comply with new Federal Health guidelines – we are required to ask for this informationEthnicity (check one)* Hispanic or Latino Not Hispanic or Latino Declined or Unspecified Race (check one)* American Indian/Alaskan Native Asian Native Hawaiian/Other Pacific Island Black/African American White Declined or Unspecified Preferred Language (check one)* English Other Declined or Unspecified Name of Patient DOB DD slash MM slash YYYY (Initial Each Line) #1 I request that payment of all authorized Medicare/Insurance benefits be made to Diablo Digestive Care, Inc., for any medical or surgical services furnished to me by my physician or supplier.(Initial Each Line) #2 I hereby authorize the release of any and all medical information about me acquired during the course of my examination/treatment needed to make these benefits payable by the Health Care Financing Administration (Insurance Companies) and its agents.(Initial Each Line) #3 I understand that my signature requests that payment be made, and authorizes release of medical information necessary to pay the claim(s). If item 9 of the HCFA-1500 claim form is complete, my signature authorizes releasing of the information to the insurer or agency shown.(Initial Each Line) #4 I understand that my insurance company is being billed as a courtesy to me.(Initial Each Line) #5 I also understand that I am personally responsible for all charges incurred during the course of my examination/treatment, including any co-payments/co-insurance deemed my responsibility by my insurance.(Initial Each Line) #6 I am aware that any office visit co-payments set by my insurance, are due and payable to my physician or supplier at the time that services are rendered to me.(Initial Each Line) #7 I understand that any missed or no-show appointments for office visits or procedures can be billed to me.(Initial Each Line) #8 In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge; and I (the patient) am responsible only for the deductible, co-insurance, and non-covered services. Co-insurance and the deductible are based upon the charge determination of the Medicare carrier(Initial Each Line) #9* Procedure/Clinic Visit Cancellation and Reschedule Policy At Diablo Digestive Care, Inc., our goal is to provide quality care in a timely manner. In regards to procedures, we request notification via phone at least 48 hours in advance if you are unable to keep your appointment. In regards to clinic appointments, we request notification via phone at least 24 hours in advance if you are unable to keep your appointment. If you fail to appear for your scheduled appointment/procedure, or if you do not notify us by phone of your inability to keep your scheduled visit, the time that has been allotted for your visit may not be utilized by another patient and will result in a loss of time and resources. Our Cancellation/Rescheduling Policy We request that you please give our office a 48 hour notice in the event that you need to cancel or reschedule your procedure and a 24-hour notice in the event that you need to cancel or reschedule your clinic visit. This will allow us to make the appointment time available to someone else. Our office number is (925) 363-0069 If you miss your procedure or do not contact us with at least 48 hour prior notice, we will consider this to be a missed procedural appointment and a $200 fee will be assessed to you. If you miss your clinic visit or do not contact us within 24 hour prior notice, we will consider this to be a missed clinical appointment and a $50 fee will be assessed to you. This will NOT be billed to your insurance.Signature of Patient*Date DD slash MM slash YYYY For use and/or disclosure of Protected Health Information (PHI) to carry out treatment, payment, and healthcare operations.(Patient)* , hereby states that by signing this consent, agrees and acknowledges: The Diablo Digestive Care, Inc., Privacy Notice has been offered to me to review prior to my signing this consent. The Privacy Notice includes a description of the uses and/or disclosures of my Protected Health Information (PHI) which is necessary for the facility to provide treatment to me, and also necessary for the facility to obtain payment for treatment and to carry out normal operations. I understand that the Privacy Notice will be available to me in the future upon request. The facility has further explained that it is my right to obtain a copy of the Privacy Notice prior to signing this consent, and has encouraged me to read the Privacy Notice carefully prior to my signing this consent. The facility reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with applicable law. I understand that, and consent to, the following appointment reminders that will be used by the facility: A postcard or letter mailed to me at the address provided by me; and/or Telephoning my home and leaving a message on my answering machine or with the individual who answers the phone. Email to the email address I have listed in my account. Email address* I understand that, and consent to, a detailed message regarding test results/treatment plan being left on a voicemail system: Yes No Phone Number*A message will be left requesting you call the office.Consent* I consent to the following persons (e.g. spouse, family member) receiving detailed information regarding my diagnosis and treatment, including test results (e.g. laboratory, x-ray, procedure, and biopsy results):*Name* Relationship* Phone*The facility may use and/or disclose my PHI (which includes information about my health or condition, and the treatment provided to me) in order for the facility to treat me and obtain payment for that treatment, and as necessary for the facility to conduct its specific health care operations. I understand that I have a right to request that the facility restrict how my PHI is used and/or disclose to carry out treatment, payment and/or health care operations. However, the facility is not required to agree to any restrictions that I have requested. If the facility agrees to a requested restriction, then the restriction is binding on them. I understand that this consent is valid for one (1) year. I further understand that I have the right to revoke this consent, in writing, at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent that the facility has already taken action in reliance on this consent. I understand that if I revoke this consent at any time, the practice has the right to refuse to treat me. I understand that if I do not sign this consent evidencing my consent to the uses and disclosures described to me above and contained in the Privacy Notice, then the Practice cannot treat me. I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way that I can understand.Name of Individual (Printed)* Signature*Date* DD slash MM slash YYYY Name of Legal Representative/Relationship* Signature of Legal Representative*Date* DD slash MM slash YYYY Name of Witness* Signature of Witness*Date* DD slash MM slash YYYY CAPTCHAUntitled PRINT AND FILL Downlaod Form
