new patient packet adult - new horizons...

Welcome to New Horizons Healthcare

Please read the entire packet, complete the applications, and bring all necessary documentation to your appointment with

our Eligibility Coordinator.

Your appointment will be rescheduled with the Eligibility

Coordinator if packet is incomplete or requested documentation

is not available.

New Patient Packet

ADULT REV. 11/10/2016

This Page Intentionally

Left Blank

newhorizonshealthcare.org

Find us on Facebook (540) 857-9700

Roanoke, VA 24016

1215 3rd St SW3716 Melrose Ave NW

Roanoke, VA 24017

(540) 362-0360

Applicant's Signature Date Spouse's Signature Date

Last Name: First Name: DOB:

Welcome to New Horizons Healthcare! Please read the entire packet, complete the applications, and bring all necessary documentation to your

appointment with our Eligibility Coordinator or your appointment will be rescheduled.

Do NOT expect any controlled substances at your first appointment.

ALL APPOINTMENTS

Because of the demand for our services, it is very important to keep your scheduled appointment.

If you must cancel or reschedule, please give us at least a 24 hours’ notice by calling our office at (540) 362-0360 option 1. Your

courtesy will allow us to schedule another patient.

NO SHOWS

Cancelling an appointment with less than 24 hours notification is considered a no show.

Recurrent “no-show” appointments will restrict your ability to make future appointments.

SLIDING FEE DISCOUNT PROGRAM

AVAILABLE FOR MEDICAL AND DENTAL OFFICE CHARGES AND FOR MEDICATION ASSISTANCE PROGRAM (MAP)

All patients may apply (insured and uninsured) for the Sliding Fee Discount Program. If you have insurance, you may qualify

for additional discounts on charges under our Sliding Fee Program based on your annual income and the size of your family.

This discount may be applied to your deductible or co-insurance. If you have insurance, but do not have coverage for drugs, you

may also qualify for help with your medications through the MAP.

The sliding fee discount is good for one year and you will need to reapply annually.

An application to apply for this program is enclosed. Eligibility cannot be determined until we receive all requested information from

you. If it is determined you are not eligible for a sliding fee and you have incurred charges, you will be expected to pay the

balance due.

ESTABLISHING ELIGIBILITY FOR THE SLIDING FEE DISCOUNT PROGRAM REQUIRES THE APPLICATION FOR FINANCIAL ASSISTANCE

AND THE DOCUMENTATION BELOW:

• Wages from employment (30 days)

• Copy of your MOST RECENT Federal Income Tax Return or a completed Federal Form 4506T (Verification of Non-Filing).

• Our office will provide this form, if needed.

• Check stubs or statements showing INCOME from Social Security; Disability; Retirement or Veteran’s Benefits; Temporary

Assistance to Needy Families; Rental Assistance; Child Support and/or Rental Income.

• If you do not have an income from any of the sources above, please complete the enclosed Housing and Support

Verification Form to help us verify your current living circumstances to establish eligibility.

INITIAL APPOINTMENT WITH ELIGIBILITY COORDINATOR

THE FOLLOWING INFORMATION IS REQUIRED FOR ALL PATIENTS WHO CHOOSE TO APPLY FOR SLIDING FEE DISCOUNTS:

• Your driver’s license or other photo ID. We need to make a copy of your license for our file.

• Your completed Patient Health History Form

• Your completed Sliding Fee Discount Application with requested documentation

• Your insurance card if you have insurance. If you are covered by insurance, complete the Insurance Declaration Page.

If you have questions about your Sliding Fee Guidelines or the Pharmacy Assistance Program, you may call our Eligibility

Coordinator at 540-283-2556.

MEDICAL RECORDS FROM ANOTHER PHYSICIAN

A form for you to sign to allow us to request your medical records from another doctor or clinic if needed will be provided at

your eligibility appointment.

I acknowledge by my signature below, that I have read and agree with the provisions of the Sliding Fee Program. I acknowledge and

1

321 Tazewell Ave SE Roanoke, VA 24013 (540) 362-0360

3716 Melrose Ave NW 1215 3rd St SW

newhorizonshealthcare.org Roanoke, VA 24017 Roanoke, VA 24016

Find us on Facebook (540) 362-0360 (540) 857-9700

Date


Applicant's Signature Date Spouse's Signature

Instructions for Sliding Scale Application

1. Please fill in every blank field.

2. Fill out income information. If any individual in the household is over 18 and is considered a dependent (i.e. full time student or

disabled), proof of dependence is required. Independent individuals over 18 in the household must apply separately.

IMPORTANT:

Documentation/Proof of All Income is required

to process Sliding Scale application

The following types of documentation are required, as applicable, to document your income:

EMPLOYED:

If employed during total of previous tax year, then the prior year’s IRS 1040 Income Tax Return OR

One month’s worth of CURRENT pay stubs showing gross income OR

A letter from your employer stating one (1) month gross salary

SELF EMPLOYED: Prior year’s Federal Income Tax return (IRS 1040), along with Schedule C.

UNEMPLOYED – NO INCOME: Letter from family or a friend confirming your need of Financial Assistance, or a Housing and

Support Verification Form verifying your lack of income.

UNEMPLOYMENT/WORKER’S COMPENSATION: Forms verifying weekly benefit amount or Denial of benefits

SICK LEAVE:

Statement from your doctor stating dates you are unable to work

Statement from employer indicating paid sick leave

If you are on leave without pay, letter from employer providing your year-to-date gross income and your hire date.

GOVERNMENT BENEFITS: Social Security, SSI, VA, Disability, or other government benefits

Letter confirming or denying, OR

Photocopy of check(s), OR

Bank statement showing automatic deposit

The Current Benefit Statement may be obtained from Social Security by calling 800-772-1213

SOCIAL SERVICES:

“Notice of Action” : Food Stamps, General Relief, Aid to Dependent Children, TANF

Letter confirming receipt of housing

OTHER RESOURCES: Provide legal proof, bank statement, or official award letter

Retirement benefits

Trust fund allotments

Child Support and/or Alimony received (not paid).

HOMELESS: If homeless, a letter from current shelter is required.

OTHER: Copy of custody papers for “other” dependents in your home.

How did you hear about us?

Medicare – Do you have Medicare Part-D prescription drug coverage: Yes /No

Did you qualify for extra help to assist with the cost of your premium and co-pays: Yes / No

Would you like additional info about Medicare Part D prescription drug coverage: Yes / No

2


Sex at birth: M F M F Are you a United States Veteran? Yes / No

Prefix: MtF FtM Do you need an interpreter?

Other What is your preferred language?

Last Name: Email Address:

Preferred Name: Date of Birth: How many are in your family?

Do you receive public housing? Yes / No

County:

-- African-American Native American Hispanic

- Asian Pacific Islander Non-Hispanic

- Caucasian More than One

Name: Relation:Home Telephone Number: ( ) -- Work Telephone Number: ( ) --

Home Address:

Date Employment Began: How often are you paid? $

Employer Phone Number: Amount you are paid? $

If unemployed, date employment ended: If unemployed, has anyone applied for Disability? Yes / No

Does anyone receive unemployement wages?

If so, provide amount received: This includes you.

Medicaid? Yes / No Who? Child Support Received (not paid): Yes / No Amount: $

Food Stamps/SNAP? Yes / No Amount:

Receive Social Security Benefits? Yes / No Alimony Received (not paid): Yes / No Amount: $

Did you file income taxes for last year? Yes / No

Did you file as (circle one): Joint -or- Single Do you Receive rental income? Yes / No Amount: $

Do you or others in your family have health insurance?Yes / No

Name(s): Stocks, Bonds, CD's, IRA's: Yes / No Amount: $

Insurance? (please bring card)

(Initial here) ONLY if I choose NOT to apply for sliding fee at this time, and that I understand that I may apply at any time in the future, if I so choose.

Applicant's Signature Date Spouse's Signature Date

Income: $ S/S Status: Eff. Dates: Seasonal: Y / N Migrant: Y / N Date/Init:

Home Telephone Number:

Are you/your spouse or any of your children under the age of 18?

List of Family Members (include yourself) Social Security # Date of Birth Relation Monthly Income Employer Name Full-Time Student

Healthcare may need to determine whether I qualify for financial assistance through the Sliding Scale Program.

The information provided above is, to the best of my knowledge and belief, complete, accurate and true. I authorize the release of all information which New Horizons

DECLARATION

City, ST, Zip:

Mailing Address:

DOB:First Name:Last Name:

FAMILY MEMBER'S INFORMATION - *If someone can claim you as a dependent, then list all other family members.

First Name:

PERSONAL INFORMATIONGENERAL INFORMATION

STATISTICS

( )

Marital Status:

Cell Telephone Number:

Work Telephone Number:

(The IRS defines a family as yourself, your spouse & any dependents)

Race: Ethnicity:

( )

( )

PERSONAL INFORMATION

PERSONAL INFORMATION

Employment, Retirement, Social Security, Pension, V.A. Disability, Worker's Compensation, Unemployement, Child Support, and ALL others not listed.

STATISTICS

UNEMPLOYMENT INFORMATION DISABILITY INFORMATION

Is anyone in your family* planning on applying for Disability? Yes / No

ADDITIONAL INCOME INFORMATION

DOCUMENT & PROVIDE PROOF OF ALL INCOME RECEIVED - Application will be rejected due to failure to comply.

EMERGENCY CONTACT

GOVERNMENT ASSISTANCE INFORMATION

FEDERAL TAX RETURN INFORMATION

INSURANCE INFORMATION

EMPLOYMENT INFORMATION




APPLICATION FOR FINANCIAL ASSISTANCE SLIDING SCALE PROGRAM

Office Use Only (below this line)

Gender: Transgender:

No response

3


Do you receive any form of public assistance for housing or living expenses? Do you have anyone to vouch for your living arrangements? Other - Explain:

Initial Here

To New Horizons Healthcare:

.


All rental fees are subsidized by


I with food and shelter

.(Date)




I authorize any above named organization or person to release information for verification of housing and support (living expenses) as requested.

(Date)

(Applicant's Name)

DO YOU RECEIVE SUBSIDIZED HOUSING?

If yes, please have a representative of the Housing Authority fill out this section and sign. Thank you.

(Beginning Date) (End Date)

Check All That Apply:

DATEPATIENT OR PARENT/LEGAL GUARDIAN SIGNATURE

am providing

This individual has no other means of support to the best of my knowledge. I am providing this support until

ARE YOU HOMELESS OR LIVE IN A SAFETY SHELTER? (RAM, TRUST, SALVATION ARMY, ETC.)

AUTHORIZED RELEASE OF INFORMATION

(Signature)

has been a resident at

DOB:

(Applicant's Name) (Address)

(Signature) (Title) (Date)

(Phone Number for Verification)(Locality Name)

(Date)(Title)(Signature)

is a current resident at

(Phone Number for Verification)

IS YOUR FOOD AND SHELTER PROVIDED BY FRIENDS/FAMILY OR MEMBER/ORGANIZATION?

If yes, please have this section filled out and signed by the person providing assistance. Thank you.

(Print Name)

First Name:Last Name:

HOUSING AND SUPPORT VERIFICATION FORM

PATIENT STATEMENT

from to

(Applicant's Name)

If yes, please have a representative of the shelter fill out this section and sign. Thank you.

(Facility Name)

To determine eligibility for discounted services, please complete ONE of the following that apply to your situation as of the date of this form. We appreciate your cooperation and wish to assure you that any information provided will be considered confidential.

4


Company Name: Policy Holder's Name:Address: Policy Holder's DOB:

City, St, Zip: Policy Holder's Employer:Subscriber/Policy/Medicaid/Medicare #: Relationship to the Patient:Group #:

Company Name: Policy Holder's Name:Address: Policy Holder's DOB:City, St, Zip: Policy Holder's Employer:Subscriber/Policy/Medicaid/Medicare #: Relationship to the Patient:Group #:

Pharmacy Name:Address:

City, St, Zip:Phone #:

Yes / No If yes, which organization(s)?

1215 3rd St SW



3716 Melrose Ave NW

DECLARATION

Does any other agency/organization pay for your services? (Ex. Every Woman's Life, PACT through BRBH, DARS, VDH, etc.?

DATE

The information provided above is, to the best of my knowledge and belief, complete, accurate and true. I authorize the release of all information which New Horizons Healthcare may need to determine whether I qualify for financial assistance through the Sliding Scale Program.

PATIENT OR PARENT/LEGAL GUARDIAN SIGNATURE DATE

PREFERRED PHARMACY INFORMATION

INSURANCE DECLARATION PAGEPlease present ALL insurance cards to Eligibility Coordinator at time of appointment.

NO INSURANCE COVERAGE

Medicaid), employment, or a private company. When I receive insurance coverage or pharmacy prescription coverage, I will notify I currently do not have any medical insurance or pharmacy prescription coverage, whether through the government (Medicare or

New Horizons Healthcare within 30 days of the start date of the new insurance and will provide a copy of my card.

Initial here:

WITNESS SIGNATURE

Does your primary insurance offer prescription drug coverage? Y / N

SECONDARY INSURANCE COVERAGEINSURANCE COMPANY INFORMATION SUBSCRIBER INFORMATION

PRIMARY INSURANCE COVERAGEINSURANCE COMPANY INFORMATION SUBSCRIBER INFORMATION

Does your secondary insurance offer prescription drug coverage? Y / N


5


Yes / No If yes, circle one: 81mg -or- 325 mg

Asthma Eczema Liver Disease Other Cancer Emphysema/COPD Neck/Back Problems Cataracts/Glaucoma Gastrointestinal Disorders Skin Disorders Provider: Depression/Anxiety Heart Disease Seizures Provider: Diabetes/Sugar High Blood Pressure Stroke Provider: Blood Clots/ High Cholesterol Thyroid Disorder Provider: Bleeding Disorder HIV/STD Tuberculosis Provider: Colorectal Cancer Ischemic Vascular Disease Urinary Tract Infections Provider:

Appendectomy Gall Bladder Removal Joint Replacement Back Surgery Hernia Repair Major Car Accident Coronary Artery Bypass Hysterectomy Tonsillectomy Tubal Ligation C-Section Other:

If deceased, give age:

Asthma

Bleeding Disorders

Cancer & Type Type: Type: Type: Type: Type: Type:

COPD

Depression

Diabetes/Sugar

Drug/Alcohol Abuse

High Blood Pressure

High Cholesterol

Strokes




Heart Attack


CONDITION

List All Medication Allergies:

Coronary Artery Disease

ALIVE / DECEASED ALIVE / DECEASEDALIVE / DECEASED

MEDICAL ILLNESSES OR CONDITIONSHave you been diagnosed with any of the following conditions? If so, do you, or have you seen a specialist? Please provide provider names below.

Other

Seizures

SURGICAL HISTORY

ALIVE / DECEASED

FAMILY MEDICAL HISTORY: (BLOOD RELATIVES)

Screen.

ALIVE / DECEASED

MOTHER SONS: # DAUGHTERS: #

LIST ANY HOSPITALIZATIONS IN THE LAST 10 YEARS BELOW: (DATE, HOSPITAL, NAME, & REASON)

SURGERY YEAR

FATHER

Kidney StonesArthritis

BROTHERS: # SISTERS: #

ALIVE / DECEASED

SURGERY YEARSURGERY YEAR

First Name: DOB:Last Name:

MEDICAL HISTORYCURRENT MEDICATIONS (INCLUDE NON-PRESCRIPTION PRODUCTS)

MEDICATION/STRENGTH DOSAGEMEDICATION/STRENGTH DOSAGE

6


Date of last Pap Smear: Date of last mammogram:Location of last Pap Smear: Location of last mammogram:History of Abnormal Pap? Yes / No Do you conduct monthly breast exams? Yes / No

Age began menstruating: How long are your periods?Date of last menstrual period: Are they irregular?

Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No

N / C N / C N / C N / C N / C N / C N / C

M / S / A M / S / A M / S / A M / S / A M / S / A M / S / A M / S / A

Flu Shot Date: Whooping Cough Date: Colonoscopy Date: Tetanus/TDAP Date: Shingles Date: EGD Upper Endoscopy Date: Pneumonia Date: Hep Date: Cardio Stress Test Date: Varicella Date: HPV Date: EKG Date: Meningitis Date: MMR Date: Diabetic Eye Exam Date:

Yes / No Do you drink alcohol? Yes / No Do you exercise regularly?Yes / NoYes / No # of drinks per day/week? How many times per week?

Do you use e-cigarettes? Yes / No

Amount per day? Explain:For how long?




#6#5

Natural or Cesarean?

SOCIAL HISTORY

VACCINES/DIAGNOSTIC TESTS

MEN ONLY PSA Testing: Yes / No Prostate Exam: Yes / No


ADDITIONAL COMMENTS

GYNECOLOGY HISTORYMEDICAL HISTORY (CONT.)

MAMMOGRAMPAP SMEAR

MENSTRUAL CYCLE

OB HISTORY

EXERCISEALCOHOL/DRUG USETOBACCO USE

PREGNANCY

Full-term Delivery

Living?

Miscarriage/Stillborn/AbortionBirth Weight over 9 lbs?Gestational Diabetes?

Do you smoke?Do you use smokeless tobacco?

VACCINES

Other recreational drug use? Yes / No Describe:

Date: .

DIAGNOSTIC TESTS

#4#3#2#1 #7


7



Left Blank

8

Street City State Zip






ABOUT YOU

EMERGENCY CONTACT

Person Responsible for Account if Other than Yourself

Employer Address:

When is the best time to reach you? How did you hear about us?

Other family members seen by us?

Employer: How long? Occupation:

Name: Relation:

)0

Home Phone: (

Name: Relation:

Home Phone: ( Social Security #:

0Work Phone:

Home Address:

(

I prefer to be called: q Male q FemaleDOB: Age:

( ))0 0

Home Phone: Cell Phone: ( ) Work Phone:

Home Address:

Name: DOB: Social Security #:

Ext:

Driver's Lic. #:

Billing Address:

Employer: Work Phone: ( )

q

Driver's Lic. #:

q q No

Employer: Work Phone: ( )

INSURANCE INFORMATION

)

Insured's SSN:

Insurance Co.Address:

Insured's Name: Insured's SSN:

Insurance Co. Name: Phone #:

Dental Coverage? Yes Medical Coverage?

Dental Coverage? Medical Coverage?

Employer's Address:

Secondary Insurance q q Yes q No

Group # (Plan, Local or Policy #)

Insurance Co.Address:

( )

Insured's Name:

Insured's Employer:

NoOrthodontic Coverage?Yes q

Insured's Employer: Employer's Address:

q Yes q No

Insurance Co. Name: Phone #: ( ) Group # (Plan, Local or Policy #)

Orthodontic Coverage?

________________________________________________ _______________________________________________

DOB:

NoPrimary Insurance

Yes q No

DOB: Relation:

Relation:

q Yes q

( )

This page is ONLY for those who wish to become patients in our dental clinic.

Today's Date: Email Address:


0

Find us on Facebook

newhorizonshealthcare.org

3716 Melrose Ave NW 1215 3rd St SW 321 Tazewell Ave SE

Roanoke, VA 24017 Roanoke, VA 24016 Roanoke, VA 24013

(540) 362-0360 (540) 857-9700 (540) 362-0360

9

Are you currently in pain? qYes qNo

any previous dental work? Do you still have wisdom teeth? qYes qNo

discomfort in your jaw joint (TMJ/TMD)?

Type of bristles on your toothbrush? qHard qMed q

Do you use anything in addition a brush and floss? qYes qNo Are you happy with the way your smile looks?

Would you like fresher breath? qYes qNo

qYes qNo

Please list additional drugs/materials that cause allergic reactions:

Have you been told that you snore or hold your breath

Have you ever taken Fosamax, or any other

Acetaminophen Blood Thinners Insulin/Diabetes Drugs Thyroid MedicationAntibiotics Blood Pressure Medication Nitroglycerin TranquilizersAntihistamines Cold Remedies Recreational DrugsAspirin Digitalis/Heart Medication Steroids/Cortisone

Abnormal Bleeding Colitis Headaches Liver Disease SeizuresAlcohol Abuse Congenital Heart Defect Heart Attack Low Blood Pressure ShinglesAnemia Diabetes Heart Murmur Lupus Sickle Cell DiseaseArthritis Difficulty Breathing Heart Surgery Mitral Valve Prolapse Sinus ProblemsArtificial Bones/Joints Drug Abuse Hemophilia Osteoporosis Steroid TherapyArtificial Valves Emphysema Hepatitis Pacemaker StrokeAsthma Epilepsy Herpes Persistent Cough Thyroid ProblemsBlood Transfusion Fainting Spells High Blood Pressure Psychiatric Treatment TonsilitisCancer Fever Blisters HIV+/AIDS Radiation Treatment Tuberculosis (TB)Chemotherapy Glaucoma Hospitalization Rheumatic Fever UlcersChicken Pox Hay Fever Kidney Problems Scarlet Fever Venerial Disease

Signature Date

Signature Date

the CDC and the ADA.

I affirm that the information I have given is correct to the best of my

knowledge. It will be held in the strictest confidence and it is my

responsobility to inform this office of any changes in my medical status. I

authorize the dental staff to perform the necessary dental services I may need.

My method of payment will be .

AUTHORIZATIONS

qNo

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

Yes No Yes No Yes No

I certify that I am covered by _____________________ Insurance Co. and I assign

directly to Dr. ______________________. All insurance benefits, otherwise payable

to me. I understand that I am responsible for payment of services rendered and also

responsible for paying any co-payment and deductible that my insurance does not

cover. I hereby authorize the dentist to release all information necessary to secure the

payment of benefits. I authorize the use of this signature on all my insurance

submissions, whether manual or electronic.

MEDICAL HISTORY

DENTAL HISTORY

Have you ever had periodontal disease?

Are you taking birth control pills?_______

Do you floss daily?

Do you require antibiotics before dental treatment? qq NoYes

Do you now or have you ever experienced pain/

Have you experienced problems associated with

_____________________________________________________

Your current dental health is: PoorqFair

For Women:

No

qNo

Are you allergic to any of the following?

__________________________________________________

qq NoYes

Sulfa Drugs

Other

Sedatives

_______________________

qYesq

qYes

Soft

NoqYesq

qYes qNo

NoYes

Do you have mobility in your teeth? qYes

If not, what would you change? _____________________

_______________

_________________________________________________________

Why did you leave your previous dentist?

How long do you use a toothbrush before replacing it? _________

If yes, what? ______________________________________

qqqq Brush daily?NoYes

m m

m m

Do you or have you experienced any of the following?

m m

m m

Yes No Yes No

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

Yes No

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

Yes Nom m

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

m m

PAYMENT IS DUE AT TIME OF SERVICEOur office is HIPAA compliant and is committed to meeting or

exceeding the standards of infection control mandated by OSHA,


Do your gums ever bleed?

Are your teeth sensitive to heat, cold, or anything else?

Last Seen:Previous/Present Dentist:

If yes, why?

__________

qNo

qYes qNo

Phone:Address:

Physician's Name:

qGoodq

m m

m m

Y - N Y - N

Erythromycinm m

m m

qYes q

Would you like whiter teeth?

What did you like most & least about any dentist you have seen?

_________________________________________________________

q

_____________________________

Do you have a personal physician?

qGood q

Penicillin

Latex

Please explain:

Your current physical health is:

Aspirin

No

Y - N

m m

m m

m m

m m

Jewelry/MetalsBarbituates

m m

m m

m m

m m

qYesq

Bisphosphonate?

Fair qPoor

qYes qNo

qYes qNo

q

while sleeping or wake up gasping for breath?

Do you smoke or use tobacco in any other form?

Yes q

Week #: Yes

Are you taking any of the following?

m m

Yes No

Are you currently under the care of a physician?

Are you pregnant? Are you nursing? NoqYes

Dental Anesthetics

Codeine Tetracycline

No

m m

m m

m m

m m

m m

m m

Yes Nom m

qNo


newhorizonshealthcare.org Roanoke, VA 24017 Roanoke, VA 24016 Roanoke, VA 24013

Find us on Facebook (540) 362-0360 (540) 857-9700 (540) 362-0360

10

DENTAL CARE GENERAL RISKS CONSENT FORM

GENERAL RISKS:

Included (but not limited to) are complications resulting from the use of dental instruments, drugs, sedation, medications,

analgesics (pain killers), anesthetics, and injections. These complications may include: swelling, sensitivity, bleeding,

pain, infection, numbness and tingling sensation in lip, tongue, chin, gums, cheeks, and teeth which is temporary, but on

infrequent occasions may be permanent. Additional complications may include reactions to injections, changes in occlusion

(bite), jaw and muscle cramps and spasms, temporomandibular (jaw) joint difficulty, loosening of teeth, referred pain to the

ear, neck, head, vomiting, allergic reaction, delayed healing, sinus perforations, and possible treatment failure.

MEDICATIONS:

Prescribed medications and drugs may cause drowsiness and lack of awareness and coordination; these reactions may be

influenced by the use of alcohol, tranquilizers, sedatives, or other drugs. It is not advisable to operate any vehicle or

hazardous device until recovered their effects.

ALTERNATIVE TREATMENTS:

These treatments include: no treatment, waiting for more definitive development of symptoms, and tooth

extractions. Risks involved in these choices may include: pain, infection, swelling, loss of teeth, and infection in

other areas.

CONSENT:

I, the undersigned, being the patient (parent or guardian of minor patient), consent to the performance procedures

decided upon to be necessary or advisable in the opinion of the doctor.

DATESIGNATURE OF WITNESS

DATEPRINTED NAME OF PATIENT OR PARENT/LEGAL GUARDIAN


DOB:Last Name: First Name:


newhorizonshealthcare.org Roanoke, VA 24017 Roanoke, VA 24016 Roanoke, VA 24013

Find us on Facebook (540) 362-0360 (540) 857-9700 (540) 362-0360

11


Left Blank

12






_____ CONSENT FOR TREATMENT: I authorize the employees, agents and staff of New Horizons Healthcare to perform and

hereby consent to such medical treatment and examinations, including diagnostic procedures or behavioral health evaluations and

treatment, as may in the opinion of the patient’s physician be necessary.

_____ NO GUARANTEE: I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees

have been made as to the result of any procedures, treatments or examinations.

_____ FINANCIAL RESPONSIBILITY: I understand that I am financially responsible for all charges, whether or not paid by

insurance. New Horizons Healthcare does not participate in every insurance plan. I understand that I am responsible for verifying

that my NHH provider is a participating provider in my insurance plan. Payment is expected at time of service.

_____ RELEASE OF INFORMATION: I authorize the clinic to release my and all of my patient medical and billing information

to any physician involved in my treatment; to any health care facility to which I/ the patient is discharged or transferred for

treatment, billing, quality assurance, collection, or defense of litigation or anticipated litigation; and to any insurance company,

review organization or other entity, which is directly or indirectly responsible for payment or review of services provided by New

Horizons Healthcare. I consent to use and disclosure of my protected health information to carry out treatment, payment or health

care operations by New Horizons Healthcare.

_____ DEEMED CONSENT FOR BLOOD TESTING: I understand that under Virginia Law, if a health care provider, a person

employed by, under the direction of, or control of a healthcare provider, Is directly exposed to bodily fluids of a patient, which may

transmit viruses causing HIV or Hepatitis B or C, the patients will be deemed to have consented to testing for HIV or Hepatitis B or

C, and the release of such test results to the person who was exposed. (Exposure could occur due to an accidental needle stick.) A

patient who tests positive will be afforded the opportunity for individual face-to-face disclosure of test results and appropriate

counseling.

_____ SLIDING FEE SCALE: Qualifying for our sliding fee scale based on your family income and family size may result in

lower charges. You are required to report any income and family size changes to us as this may impact the amount you are expected

to pay. We will review and update your information annually. Eligibility cannot be determined until we receive all requested

information from you. If it is determined you are not eligible for a sliding fee and you have incurred charges, you will be expected

to pay the balance due. We will assist you by arranging a payment plan if needed. You will be asked to pay a minimum fee for you

first visit until the sliding fee eligibility process is complete. The remaining cost of the first and subsequent visits will be based on

the outcome of the determination. If you do not pay for the services at the time they are rendered, your balance must be paid in full

within sixty (60) days.

_____ MEDICARE LIFE-TIME/MEDICAID SIGNATURE AUTHORIZATION AND ASSIGNMENT: I request that

payment of authorized Medicare/Medicaid benefits be made on my/the patients behalf for any services furnished by or in the clinic;

including physician services. I authorize any holder of medical or other information about me, to release to New Horizons

Healthcare for Medicare and Medicaid Services, the Virginia Department of Medical Assistance Services and their agents, any

information needed to determine these benefits or benefits for related services. I assign the benefits payable for physician and other

medical services to the physician or organization furnishing the services and authorize such physician or organization to submit

claim to Medicare and/or Medicaid for payment. I understand that I/the patient am responsible for any deductibles, co-payments and

any applicable percentage of remaining charges.

_____ CERTIFICATION AND ACKNOWLEDGMENT: I certify that all foregoing information and all information supplied by

me, as part of the registration process is correct. I also acknowledge that I have reviewed and understand the New Horizons

Healthcare’s Notice of Privacy Practices (HIPAA).

_____ PATIENT RIGHTS AND RESPONSIBILITIES: I hereby acknowledge that I have been given the opportunity to review

and/or receive a copy of New Horizons Healthcare's posted Patient Rights and Responsibilities.

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Home

Phone

Cell

Phone

Text

MessageEmail


SIGN UP FOR OUR NEW HEALTH

REMINDER SERVICE!

TO ENSURE YOU STAY HEALTHY, WE’VE IMPLEMENTED AN EASY TO USE AUTOMATED APPOINTMENT REMINDER

SERVICE. TO SIGN UP, SIMPLY TELL US HOW YOU WOULD LIKE TO BE NOTIFIED; BY PHONE, EMAIL, OR TEXT

MESSAGE.

HOW IT WORKS: Two days before your appointment, we will send you a friendly reminder message. You will

then be able to confirm or cancel the appointment.

SIMPLY FILL OUT THE BOTTOM OF THIS CARD TO SIGN UP!

Please provide your contact information:

Patient Name (Last, First):

Patient birth date (month, day, year):

Home phone: ( ) -

Cell phone: (________)__________-________________

Email Address:

Initial here if you do not wish to be web enabled:

You have options!

Circle the best method of contact:

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3716 Melrose Ave NW Phone: (540) 362-0360

Fax: (540) 366-5590

1215 3rd St SWPhone: (540) 857-970 Fax: (540) 857-9704

Acknowledgement of Receipt of Notice of Privacy Practices

By law, we are required to provide you with our Notice of Privacy Practices (NPP). This Notice describes how your

medical information may be used and disclosed by us. It also tells you how you can obtain access to this information.

Effective Date

of this Notice November 1, 2013

Privacy Officer

Kimberly Robertson, COO

[email protected]

(540) 362-0360

I hereby acknowledge that I have been given the opportunity to review and/or receive a copy of New Horizons

Healthcare’s NOTICE OF PRIVACY PRACTICES. I understand that if I have questions or complaints regarding

my privacy rights that I may contact the person listed above. I further understand that the practice will offer me

updates to this NOTICE OF PRIVACY PRACTICES should it be amended, modified, or changed in any way.

Printed Name of Patient or Patient’s Representative

Relationship of Patient’s Representative to Patient

Signature of Patient or Patient’s Representative Date

Evidence of the authority of the patient’s representative (attach evidence to last page of this acknowledgement):

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321 Tazewell Ave SE Phone: (540) 362-0360

Fax: (540) 366-5590

mailto:[email protected]

new patient packet adult - new horizons...

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