family medicine

CHECK LIST

ARE COMPLETED, SIGNEDAND SS OPP ̂ '''''' '^O^^OWINGYOU! SENDING PAPERWORK TO US. THANK

__ Copy of Insurance Card(s)-co!or£OESi£referred— Copy of License or I.D. - colorcoBy^referred

— Page is £OMPLETFIY filled out and signedFinancial Policy

Authorization for release of Information

— P^^ctlces Acknowledgement FormPower of Attorney Information Sheet MUST BE FILI Pn nt it

_C.ns=n, for Tr.„„,e„ Vl™ur.„ce A^hortzaoon &Medical History Questionnaire Form

— Advance Beneficiary Notice

_ , Medicmon Ltt ^

in order to refill your medlcation{s)*-Chronic illnesses can include- Asthma Hooh- w-Hw. Bicd ,„d „e„u,

reschedule 'PPointmeu., please call our office ,o cancel or' '""P' "P »° « POPIP for prescripdon refills

TtVALPHA FAMILY MEDICINE

480 North Main Street, Suite 202, Alpharetta GA 30009

Phone: 678-619-1974 www.alphafammed.com

PATiENT iNFORMATION FORM

ALL PATIENTS OR RESPONSIBLE PARTIES MUST COMPLETE THIS FORM AND PROVIDE A PICTURE ID AND INSURANCE

CARD BEFORE SEEING A DOCTOR

LAST NAME.

ADDRESS__

STATE ZIP

E-Mail Address.

SSN

FIRST NAME M.I.

CITY

(HOME) PHONE. (WORK).

(CELL) PHONE.

BIRTHDATE SEX (M). (F).

RACE (Please circle): Asian African Am. Hispanic While Refuse Other

PREFERRED LANGUAGE ETHNIC

MARITAL STATUS: S M W D

ITY (Please Circle); Hispanic Not Hispanic Refuse

EMERGENCY CONTACT NAME PHONE

INSURANCE CARRIER.

INSURED'S NAME

RELATIONSHIP TO PATIENT.

INSURED'S EMPLOYER

INSURED'S SSN

INSURED'S BIRTHDATE

EMPLOYER'S ADDRESS

SECONDARY INSURANCE CARRIER.

INSURED'S NAME

Pharmcay phone # and address

INSURED'S SSN

INSURED'S BIRTH DATE

FATHER'S NAME

MOTHER'S NAME

IF PATIENT IS A MINOR. COMPLETE NEXT TWO LINES

PHONE

PHONE

IN ORDER TO IVIAINTAIN CONTINUITY OF CARE, I GIVE PERMISSION TO ALPHA FAMILY MEDICINE TO RELEASE MYMEDICAL RECORDS TO ANY SPECIALISTS, HOSPITALS OR MEDICAL FACILITIES ASSOCIATED WITH MY CARE PLAN. IUNDERSTANDTHAT ALPHA FAMILY MEDICINE ABIDES BY HIPAA REGULATIONS AND THAT ONLY THE RECORDS

PERTINENTTO THE VISIT WILL BE RELEASED.

SIGNED

Alpha Family Medicine, Inc.

480 N. Main Street, Suite 202, Alpharetta, GA. 30009Phone: 678-619-1974 Fax: 678-619-1966

WE FILE CLAIMS AS A COURTESY.

■ieirkieifk** FINANCIAL POLICY ********

We appreciate the opportunity to provide medical sen/ices to you this year. Our goal is to keep your financialarrangements as simple as possible by timely filing of ciaims and using the following guidelines:

1. You are ultimately responsible for payment of charges for services received at our office.

2. A fee of $30 will be added to your account for any check dishonored by your bank.

3. It is your responsibility to provide us with your current address, phone number and insurance information at eachvisit.

It is your responsibiiity to confirm with your insurance carrier that our doctor is your PCP prior to seeing thedoctor. If you choose to see a provider who is not on your plan you will be responsible for payment in fuil.

All co-pays are due at the time of sen/ice. Failure to pay your co-pay at the time of service wiil result in anadditional $25 fee added to your account.

6. If you miss your appointment a NO-SHOW fee of $25 may be added to your account.7. Laboratory services are provided by a contracted outside lab. Lab charges not covered by your insurance will be

billed to you by an independent lab billing service.

I acknowledge and agree with the terms of this financial policy. I authorize payment of benefits toAlpha Family Medicine, Inc. for services rendered under the terms of my insurance policy. I authorizeAlpha Family Medicine, Inc. to release any medical information necessary to process insuranceciaims.

Responsible PartySignature Date

ALPHA FAMILY MEDICINE INCEnhancing Life & Excelling in Care

AUTHORIZATION FOR RELEASE OF INFORMATION

authorize

Patient Name

release my Medical Records to

Hospital / Physician Name

Please release the following information for Date of Service:

Discharge Summary Consult Report ER Reports

History & Physical Lab Report Eye Exam Report

Operative Report Radiology Report Mammography Report

Other Reports:

Social Security Number: Date of Birth:

Please FAX the records to:

Please Mail the requested medical records to the address at the bottom of this page.

I understand this authorization includes release of medical records, which may include informationregarding Human Immunodeficiency Virus (HIV), psychiatric and/or drug/alcohol abuse. Venerealdisease, and or any other statutory protected disease. This authorization and consent will expire 180days following the date signed. I understand that I may revoke this authorization and consent in writingat any time except to the extent that action has been taken in reliance thereon. If I sign for my minorchild, I consent that I am the custodial guardian. Furthermore, I understand that these records are forthe purpose of continuity of care and cannot be further released or disclosed.

Patient/Guardian Signature

Date:

Relationship to Patient

Date:

Witness Signature

480 Main Street, Suite 202, Alpharetta, GA 30009Tel: 678-619-1974 ❖ Fax: 678-619-1975

www.alphafammed.com

ALPHA FAMILY MEDICINE INC.Enhancing Life & Excelling in Care

You have the right to request an accounting of the disclosures of your PHI, again, the request must be in

writing.

This represents a summary of our legal mandate, with the details to be found in the published Policy

Statement. You can be assured that we will make every attempt to honor your privacy, and to maintain

our record of confidentiality. You may contact our office relative to any questions you may haveregarding this new law. Alpha Family Medicine Inc, HIPAA Compliance Officer, 480 North Main Street,

Suite 202, Alpharetta, GA 30009, Ph: 678-619-1974

I authorize the following individuals to have full access to my health information:

Print Name Relationship Date

Print Name Relationship Date

1^ gjyg permission for you to leave anymedical/lab information for me at the following phone numbers:

Home: .

Mobile:

Work:

Receipt of Notice of Privacy Practices Written Acknowledgement Form

'' bave received a copy of Alpha Family Medicine Inc,Notice of Privacy Practices.

Signature of Patient or Guardian Date

480 Main Street, Suite 202, Alpharetta, GA 30009Tel: 678-619-1974 ❖ Fax: 678-619-1975

www.alphafammed.com

y # I ^®wer of Attorneymedical & healthcare decisions

Information Sheet

Name:

Addr» (wh.r.

Street

City, State, Zip

Telephone Number:

Alternate Number:» □ Ceil □ Home □ Work» □ Cell □ Home □ Work

OK to receive:

= o „ c,. 0 0.h.r

Patient's Name

Signature

Date Signed / /

COMMUNICATION DIRECTIVE, CONSENT FOR TREAMENT,INSURANCE AUTHORIZATON AND ASSIGNMENT: (Must be singed and dated before treatment.)

Name Date of Birth

Please check )0( how you would like us to send your confidential health care information. Check aH thatapply.

You may email* me at (address)PLEASE NOTE THAT THE CONFIDENTIALITY OF ELECTRONIC COMMUNICATIONS CANNOTBE GUARANTEED.

You may contact me through my patient portal account.You may phone me at (daytime)You may leave a phone message

on my answering machine atwith another person at

Please list all individuals that may obtain your information, including any and all legal guardians if aminor or unable to consent.

Name Relationship ^Phone #

Name Relationship, Phone #

Name Relationship Phone #

Name Relationship Phone #

1. CONSENT TO DIAGNOSTIC TESTS, PROCEDURES AND TREATMENT:I consent to care involving routine diagnostic tests, procedures and treatment as performed or orderedby the clinicians at Alpha Family Medicine Inc, including their assistants or designees. No guaranteehas been given to me as to the results that may be obtained from my care.

2. CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION:I consent to Alpha Family Medicine Inc (AFM), using or disclosing my protected health information forthe purpose of providing treatment to me, obtaining payment for health care services rendered to me orto carry out the Practice's health care operations. I also consent to AFM using or disclosing myprotected health information for treatment activities provided by another health care provider as well aspayment activities conducted by another health care provider or entity. I further consent to thedisclosure of my protected health information in order for another provider or health care entity toconduct health care operations including quality assessment and reviewing the competence of healthcare professionals.

3. NOTICE OF PRIVACY PRACTICES:By my signature below, I acknowledge that I have read and/or received and agree to the terms of theNotice of Privacy Practices from Alpha Family Medicine Inc.

4. FINANCIAL AGREEMENT AND ASSIGNMENT OF BENEFITS:I authorize direct payment of benefits provided under any health care plan or medical expenses policydue to me or payable on my behalf to Alpha Family Medicine Inc. I acknowledge that any or all of theexpenses not paid by my third party payor are my responsibility. I also understand that any unpaidaccount may be assigned to a collection agency or attorney for collection purposes.

I agree that a copy of this consent, release and assignment of benefits may be used in place of theoriginal. I understand that I am entitled to a copy of same if I make such a request and that thisconsent, release and assignment are valid until rescinded in writing or replaced by one of a later date.

Patient Signature Today's Date

The undersigned certifies that if the patient is a minor or unable to consent and the undersigned certifies thathe/she has read and agrees to the above as the responsible party of the patient.

Responsible Party Signature. Today's Date

Patient Name: DOB:How did you hear about us?Pharmacy Address & Number:Ailergies: Do you have any aliergic or adverse reaction to any medication or substance? [] Yes [] NoIf yes please list: What kind of Reaction and severity

Weight: Height: BP / HR SP02 TEMP

Teii us why you're here today:

Medications: Please list any medications you are taking (including alternative, herbal and over-the-counter.)

Please list names dosage and how often you are taking medication:

Past Medical History: Please list any medical conditions you have been diagnosed with in the past or arecurrently being treated for:1.2 .3 .

4 .

Past Surgical History: Please list any surgeries you have had in the past1 .2 .

3.4 .

Have you ever had a colonoscopy? If yes, when?Are you a smoker? If yes, how much do you smoke (per day/week)?Do you drink any alcohol? If yes, how much do you drink (per day/week)? ̂Do you drink caffeine? If yes, how much do you drink (per day/week)? _Do you exercise? If yes, how many hours (per day/week)?Stress Level? (High) (Low) (Med)

Gynecological Health

LMP date: How many days did it last?Does it come every month ? Circle One: Yes No How is the flow?At what age did you start your menstrual cycle?Date of last pap smear? Were the results normal or abnormal? _Do you use any form of birth control?Are you post-menopausal? Date of last mammogram?Most recent bone density scans?

Your Patient Name:

Tell us about your family history any medicai problems.

Mother Problem:

Onset age Died of age_

Father Problem:Onset age Died of age^

Brother Problem:Onset age Died of age_

Sister Problem:Onset age Died of age_

Maternal Grandmother Problem: _Onset age Died of age_

Maternal Grandfather Problem:Onset age Died of age^

Paternal Grandmother Problem:

Paternal Grandfather Problem:

A. Notifier:

B. Patient Name: C. Identification Number:

Advance Beneficiary Notice of Noncoverage (ABN)NOTE: If Medicare doesn't pay for D below, you may have to pay.

Medicare does not pay for everything, even some care that you or your health care provider havegood reason to think you need. We expect Medicare may not pay for the D below.D. E. Reason Medicare May Nojt Pay: F. Estimated

Cost

WHAT YOU NEED TO DO NOW:

• Read this notice, so you can make an informed decision about your care.• Ask us any questions that you may have after you finish reading.• Choose an option below about whether to receive the D. listed above.

Note: If you choose Option 1 or 2, we may help you to use any other insurancethat you might have, but Medicare cannot require us to do this.

G. Options: Check only one box. We cannot choose a boxffqr; you.

□ OPTION 1. I want the D. listed above. You may ask to be paid now, but Ialso want Medicare billed for an official decision on payment, which is sent to me on a MedicareSummary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible forpayment, but I can appeal to Medicare by following the directions on the MSN. If Medicaredoes pay, you will refund any payments I made to you, less co-pays or deductibles.□ OPTION 2. I want the D listed above, but do not bill Medicare. You mayask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.□ OPTION 3. 1 don't want the D listed above. I understand with this choice Iam not responsible for payment, and I cannot appeal to see if Medicare would pay.H. Additional Information:

This notice gives our opinion, not an official Medicare decision. If you have other questions onthis notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).Signing below means that you have received and understand this notice. You also receive a copy

i. Signature: J. Date:

Accordi ng to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 0MB control number.The valid 0MB control number for this information collection is 0938-0566. The time required to complete this infonnation collection is estimated to average 7minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the informationcollection. If you have comments conceming the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 SecurityBoulevard. Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-R-131 (03/11) Form Approved 0MB No. 0938-0566

ALPHA FAMILY MEDICINE INC.

%ijjil F Enhancing Life & Excelling In Care

HIPAA

Health Insurance Portability and Accountability Act

On April 14# 2001# the Health Insurance Portability and Accountability Act became law, with an effectivedate of April 14,2003. This law Impacts on many aspects of the healthcare Industry, and expands yourrights as a patient to the protection of your Individually Identifiable Health Information (IIHI). We haveposted a detailed policy letter on our web site (aiphafammed.com), which you are encouraged to readand download. Copies will be available, upon request, at your next visit.

Our resDonsibilltv:

Our practice Is dedicated to maintaining the privacy of your IIHI. In conducting our business, we willcreate electronic medical records regarding you and the treatment and services we provide to you. Weare required by law to provide you with this Important Information concerning our procedures relativeto the use of your IIHI and your rights as a patient to know as to how we will use or disclose your IIHI,your privacy rights In your IIHI, and our obligations concerning the use and disclosure of your IIHI.

We may use and disclose your Personal Healthcare Information (PHI) In the day-to-day operations of ouroffices as pertains to Treatment, Payment and Operations (TPO). This relates to the continuum of carebetween primary care givers and consulting physicians, as well as healthcare workers on our staff. Wemay be required to share your PHI with your Insurance carrier as related to healthcare Issues orpayment events. Or we may use your PHI within our practice to evaluate our quality of care or conductcost- management or business planning activities.

Further, we may use your IIHI to contact you for medical purposes, or for appointment reminders; toInform you of certain treatment options or alternatives; or as may be requested or directed by you torelease said information to family or care giving personnel.

We may, from time to time, be required to release your PHI as a result of federal or state mandate, orby competent legal directive.

Your rights!

You have a right to request that we communicate with you In a certain manner or location, for example,appointment reminders at work or at home.

You have the right to request a restriction to use or disclose of your IIHI to certain Individuals or entitles.

You have the right to Inspect or obtain a copy of the IIHI, less psychotherapy notes. This request must bemade In writing.

You may ask to amend health Information, If you believe that it is incorrect or Incomplete, and you mayask for amendment of your PHI, subject to restrictions as established by the HIPAA law.

480 Main Street, Suite 202, Alpharetta, GA 30009Tel: 678-619-1974 ❖ Fax: 678-619-1975

www.alphafammed.com