Tricity Family Medicine & Urgent Care

Patient Demographic Form

Patient's First Name * Patient's Last Name * Patient's Date of Birth * Office Preference SSN # Sex * Preferred Pronoun Street Address * City * State * Zipcode * Preferred Contact Method * Cell Phone * Work Phone Email * Phone/text Message Permission * EMERGENCY Contact Name * Emergency Contact's Relationship to the Patient * Emergency Contact Phone # * Race * Ethnicity * Marital Status * Language * Any Communication Barrier: Provider Preference * Are we your Family Physician/ Primary Care Doctor?: * If not, then your Primary Care Physician Name & Contact Info Preferred Pharmacy Name & Address * How did you hear about us: *

Permission to Release Medical Information

I authorize Tricity Family Medicine & Urgent Care, PLLC, to give Clinical, Personal & Financial information, in person or by telephone, in regards to my treatment to:

Share my health information with: Name, Relationship & Phone# Share my health information with: Name, Relationship & Phone#

I understand, at any time, I need to revoke or change this consent, I must submit in writing to Tricity Family Medicine & Urgent Care Clinic, PLLC. You may visit our website www.tricityfamily.com or ask staff to recieve a copy of detailed HIPPA policy - Notice of Privacy Practices.

Responsible Party Information (Please fill out if patient is a minor)

Parent/ Guardian Name Relationship to the Patient Parent/ Guardian SSN # Parent/ Guardian Phone Parent/ Guardian Employer Parent/ Guardian Occupation Do you have an Existing Advance Directive/ Living Will/ Health Power of Attorney *

Primary Insurance Information

Type of Insurance * Other Insurance Company Policy Holder/ Subscriber's Full Name * Policy Holder/ Subscriber's Birthdate * Patient's Member ID # * Group # * Patient's Relationship to the Subscriber * Policy Holder's Employer Insurance Company Phone# Insurance Company Claim Address Do you have Secondary Insurance Secondary Insurance Name/ Member ID

Policies

RELEASE OF MEDICAL INFORMATION - I authorize Tri-City Family Medicine & Urgent Care Clinic, PLLC, to release the medical records concerning my son/ daughter/self to any physician, hospital, or agency involved in the care of the patient listed.

ASSIGNMENT OF MEDICAL BENEFITS - I authorize my insurance carrier to assign all surgical and or medical benefits, if applicable, to Tri-City Family Medicine and Urgent Care Clinic, PLLC. I also authorize release of medical information necessary to process all medical insurance claims.

PAYMENT POLICY - Co-payments are to be collected at the time services are received. We accept cash, checks, Visa and Master Card. All medical services provided are directly charged to the patient or responsible party. If our physician is contracted with your insurance carrier, we will accept their negotiated rate for the charges billed. However, you will be responsible for any balance deemed patient responsibility/non-payable/non-covered by your insurance and billed accordingly. Payment is expected in full upon receipt of statement or payment arrangements must be made with our billing office.

CANCELLATION POLICY - Our office requests that if an appointment needs to be canceled, we receive notice no later than 24 hours prior to the appointment. We charge $35.00 for a no-show appointment, to be collected on or before your next appointment. Three or more reschedules/ cancellations will require a credit card on file and a $50.00 deposit prior to scheduling future appointments.

REFERRAL POLICY - I understand that it is my responsibility to obtain a referral through my primary care physician's office if required by my insurance company. Failure to do so will result in charges being billed directly to myself.

Patient/ Responsible Party's Full Name * E-SIGNATURE *