New Patient Information

Last Name: ______________________________________First Name: ___________________________________ MI: __________

Date of Birth: _______________________________ Phone: __________________________________________

Address: ______________________________________________________ City: ___________________ Zip Code: ____________

Email Address: ________________________________________________________________________________________

Preferred Pharmacy: _______________________________________________________________________________________

Insurance Policy Holder Name and DOB: _______________________________________________________________________

In addition to providing primary care, we offer a variety of skin care and cosmetic procedures. Is this something you would be

interested in learning more about? Yes / No

Emergency Contact Information:

Full Name: _____________________________________________________________________________

Phone: _______________________________________ Relationship to Patient: _________________________________________

11/2018

PATIEN T HEALT H RECORD

Name: Date:

Medical History (This confidential information helps us determine proper treatment and medication):

Please indicate if you have ever had/or still have any of the following:AIDS/HIV infection Hepatitis/Jaundice

Anemia HerpesArtificial heart Valves High/low blood pressureArtificial joints/implants Hives/skin rashesAsthma Kidney diseaseBack or neck problems Liver diseaseBruise or bleed easily PacemakerBulimia or anorexia Psychiatric treatmentCancer/tumor Rheumatic feverChemical Dependency SeizuresChest pain Scarlet feverCortisone treatment Shortness of breathDiabetes Sickle cell anemiaEpilepsy/neurological problems Stomach ulcersFainting or dizzy spells StrokeGlaucoma PhlebitisHeart Disease Thyroid DiseaseMitral Valve Prolapse UlcersHeart murmur Other:Gout Other:

Are you allergic to: Penicillin Codeine Local Anesthetics Latex Other:

Have you been treated in the hospital in the past two years? Yes No

If yes, please write reason for admittance:

Please list all prescription drugs you are taking:

Has your Physician advised you to pre-medicate before dental Yes No Do you take vitamins regularly? Yes NoAre you taking hormones or birth control? Yes No Are you pregnant or nursing? Yes NoHave you ever had a blood test for hepatitis? Yes No Have you been vaccinated for Yes NoDo you use tobacco? Yes No Do you consume alcohol? Yes NoHave you had surgery? Yes No

If yes, please list type of surgery and year the procedure was done:

Please tick the box if any immediate family members have any of the following:

Arthritis Cancer Diabetes Heart Disease High Blood Pressure Kidney Disease Obesity

I HEREBY GIVE PERMISSION TO THE PROVIDER TO EXAMINE, DIAGNOSE AND TREAT ME AND ATTEST THAT THE ABOVE INFORMATION IS ACCURATE AND TRUE.

Patient Name (Printed): ___________________________________

Patient Signature: ________________________________________ Date: _______________

11/2018

REQUEST FOR ELECTRONIC ACCESS TO PROTECTED HEALTH INFORMATION (PATIENT PORTAL)

Name:

Date of Birth:

Our office provides an electronic patient portal free of charge to facilitate the distribution of lab results and otherinterpretative services. The patient portal is a one way system only from our office to the individual patient’s account. Through the portal you can:

- Receive lab and test results and referrals from the clinic- Receive invoices- Request an appointment (please note this appointment is not finalized until our office confirms it)- Fill out and make changes to your medical history- View and update your medication list- View and update your health summary information- View and update your demographic information- View and update your insurance information- View and update your portal account password and email

The system will send you an email when you initially create your portal account containing your automatically generated username and password. Please keep these in a safe place. The system will also send an email when a new message is sent to your account. The portal and its messages are encrypted in order to keep patient information private.

Unfortunately, our practice cannot guarantee that the portal will be accessible 24/7. The portal may be inaccessible due to routine maintenance without prior notification. Our practice may also suspend or terminate the Portal without advance notice to the patient. Our practice and its staff have no liability or responsibility to any authorized person who is unable to access the portal.

Please initial below:

I understand there are inherent risks in accessing my medical health record electronically, even though the data is encrypted.I understand the patient portal is an added service and it is the medical provider’s right to grant or deny me access to my electronic health record.If I have previously been granted access to the patient portal, I understand the practitioner may rescind my access to the patient portal at any time they feel necessary.I agree that the patient portal system is an interpretive service only and that all questions regarding my results or

any other message sent to me through the system must be directed to the office of Kelly Care, PC to receive a response.I understand that it is my responsibility to promptly log into the portal to view messages regarding my health that are sent to me from my provider.

Signature: Date: ___________________

11/2018

Office Policies and Procedures:

We are an appointment-based practice. All patients must make an appointment to be medically evaluated and diagnosed in person. All telecommunications from our Nurse Practitioners are limited to INTERPRETATIVE services only.

Operating Hours:

Monday - 7:30 AM – 7:00 PMTuesday - 7:30 AM – 7:00 PM

Wednesday - 7:30 AM – 7:00 PMThursday - 7:30 AM – 7:00 PM

Friday - 7:30 AM – 4:30 PMSaturday – 9:00 AM – 3:00 PM

Sunday - CLOSED

1. After Hours: If it is a Medical Emergency, call 911 immediately. For all non-emergency medical issues, please call our office and follow the phone instructions, or visit an after-hours clinic approved by your insurer. Please save other inquiries for business hours.

2. Patient Conduct: By signing this form, the patient agrees to comport themselves in a professional and cordial manner with all our office staff. Rude, aggressive, or other offensive behavior towards any member of our office staff will result in immediate patient dismissal.

3. Patient Portal: All patients under the age of 65 must register for a portal account. The portal enables patients to receive their lab results, view reports, request refills, and communicate with the providers through a secure, HIPAA compliant website. Patients require an email address to use this system and will receive an email notification when they receive a new health update.

4. Service Expectations: Please allow at least 3 business days for our staff to complete prior-authorization requests, records requests, prescription refill requests, and form completions. This does not include the time needed for non-practice entities to complete requests.

5. Health Insurance: We currently accept United Healthcare, Cigna, Aetna, Tricare, Blue Cross Blue Shield, and Medicare. We do not accept any form of Medicaid, even if it is within one of the accepted plans. It is the patient’s responsibility to provide accurate health insurance information in the form of an insurance card at the time of the visit and to know what type of coverage their plan provides.

6. Financial Responsibility: By signing this form, the patient agrees to pay all co-pays, co-insurances, deductibles, outstanding balances or other fees at the time of their visit. Payment must be received before the appointment or we reserve the option to reschedule it. Our practice accepts cash, credit/debit cards, and personal checks as forms of payment. An outstanding balance that is not paid within 30 days of the patient receiving notice is considered PAST DUE and will be forwarded to a collection agency.

7. Cancellations and No Show: Please cancel an appointment NO LESS than 24 hours before the scheduled time. Repeated offenses to this policy will be tracked and could be subject for patient dismissal. Patients who do not show up to their scheduled appointment and do not call to cancel or reschedule outside of the 24-hour window will be charged a $100.00 no show fee. Patients who call to reschedule their appointments within 24 hours of their scheduled appointment will be subject to a $50.00 late cancellation/reschedule fee.

8. Prescription Refills: a. It is illegal to alter and/or tamper with any prescriptions written by a medical provider. Any prescription thought to

be tampered with after leaving our facility will result in IMMEDAITE dismissal from our practice. Our office will also be required to notify the DEA as well as local law enforcement.

b. All chronic (regularly taken) medications require regular follow-up visits at our office. Our Providers will let you know the appropriate interval between visits and schedule your next follow up appointment accordingly. If you are overdue for your visit, your provider may choose to provide you enough medication until your scheduled appointment (maximum 1 week) as a courtesy.

c. Medications for acute problems (cough, fever, etc.) will require an office visit to ensure a correct diagnosis and appropriate medication is prescribed.

d. If a patient needs a refill between office visits, please have your pharmacy send us an electronic refill request or send a request through the portal.

11/2018

9. Controlled Substances:a. Any patient who is prescribed controlled substances will be subject to random urine drug screening at the

providers discretion. Refusal to comply with random urine drug screening will result in immediate dismissal from our practice.

b. All patients who receive controlled substance prescriptions from our office must be receiving them from our office ONLY. If it is brought to our attention that patients are having controlled substance prescriptions filled by more than one provider, the patient will be dismissed from our practice and the other provider(s) filling the prescriptions will be notified.

10. Referrals: Many insurance companies now require referrals for a patient’s visit to specialists. An office visit is required for referrals.11. Membership Fee: Starting in 2015, the practice charges an annual membership fee. Please ask for the fee schedule. This fee

schedule is subject to change on an annual basis. It is required to be part of the practice and must be collected before being seen by a Provider, requesting prescription refills, or requesting phone consults with providers.

12. Saturday Walk-In Clinic: On Saturdays, our office sees patients from 9:00AM to 12:45PM. Saturday hours are walk-in only. Saturday services include: prescription refills, cold/flu/sinus symptoms, UTI’s, immunizations/vaccinations, sprains, minor laceration repair. Services we do not provide on Saturdays include: adult physicals, wellness exams, hypertension, chest pain, lab work, and issues best addressed by an Emergency Room.

I HEREBY CONSENT TO ALL OFFICE POLICIES AND PROCEDURES LISTED IN THIS FORM BY SIGNING BELOW.

____________________________________________ Patient Name (Printed)

____________________________________________ ______________________________Patient Signature Date

11/2018

Adult Patient Consent Form for Use and Disclosure of Protected Health Information

I, _______________________________ (Please Print Name) hereby give my consent for Kelly Care, PC to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). The Notice of Privacy Practices provided by Kelly Care, PC describes such uses and disclosures more completely.

I have the right to review the Notice of Privacy Practices prior to signing this consent.

Kelly Care, PC reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the practice at 6100 Day Long Lane Suite #105 Clarksville, MD 21029.

With this consent, Kelly Care, PC may call my home or other alternative location that I have provided and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.

With this consent, Kelly Care, PC may mail to my home or other alternative location I have provided any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements.

With this consent, Kelly Care, PC may e-mail to the address I have provided, or through the secure electronic patient portal any items that assist the practice in carrying out TPO, such as appointment reminders, patient statements and test results. I have the right to request that Kelly Care, PC restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I have read and understand the Notice of Privacy Practices and am consenting to allow Kelly Care, PC to use and disclose my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Kelly Care, PC may decline to provide treatment to me.

_______________________________

Print Patient’s Name

_______________________________ ______________________Signature of Patient Date

11/2018

Medical Information Release Form for Individuals (HIPAA Release Form)

I, _________________________________, direct my health care and medical services providers and payers to disclose and release my protected health information described below to:

Full Name: ______________________________________ Relationship: ______________________________

Contact information: _______________________________________________________________________

Full Name: ______________________________________ Relationship: ______________________________

Contact information: _______________________________________________________________________

Health Information to be disclosed upon the request of the person named above (Check either A or B): A. ______ Disclose my complete health record (including but not limited to diagnoses, lab tests, prognosis, treatment, and

billing, for all conditions) OR B. ______Disclose my health record, as above, BUT do not disclose the following (check as appropriate):

o Mental health records o Communicable diseases (including HIV and AIDS) o Alcohol/drug abuse treatment o Other (please specify): ___________________________________________________

Form of Disclosure (unless another format is mutually agreed upon between my provider and designee): A. _______An electronic record or access through an online portal B. _______Hard copy

This authorization shall be effective until (Check one): A. _______ All past, present, and future periods, OR B. _______ Date or event: __________________________________________________

(NOTE: You may revoke this authorization in writing at any time by notifying your

health care providers, preferably in writing.)

_____________________________________________ __________________Name of the Individual Giving this Authorization Date of Birth

_____________________________________________ __________________Signature of the Individual Giving this Authorization Date

11/2018

HIPAA Privacy Authorization Form for Medical Office

1. Authorization:

________ I authorize Kelly Care, PC (healthcare provider) to receive, use, and disclose the protected health information described below for:

Physician/Office Name: _________________________________________ Contact Number: _______________________

2. Effective period and types of records to be disclosed:

This authorization for release of information covers the period of healthcare from:

_________ A. Beginning Date: __________________ End Date: ___________________.

_________ B. ALL past, present, and future medical records (or until informed otherwise in writing).

_______ Visit notes_______ Test Results_______ Insurance information_______ Lab results_______ Reports of other health care providers_______ Other: _____________________________________________

3. Extent of Authorization:

__________ A. I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse).

__________ B. I authorize the release of my complete health record except for the following information:

_______ Mental health records_______ Communicable diseases (including HIV and AIDS)_______ Alcohol/drug abuse_______ Other: __________________________________

4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.5. This authorization shall be in force and effect until (date specified), at which time this authorization expires.6. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.7. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.8. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

____________________________________ _______________________________ ________________Printed Name of Patient OR Guardian Signature of Patient OR Guardian Date of Birth

11/2018