Patient Intake Form

New Patient Information form:

Partida Corona Medical Center
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2 /Unit no.

CityState

Zip CodeCountry
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Gender
Social Security #
XXX-XX-XXXX
Home Phone Number
Format: (000) 000-0000.
Cell Number
Format: (000) 000-0000.
Please upload photo of I.D or passport

Cancelof
You will be provided with login password to your medical records. Please provide below your E-mail address for password:
Any change to the email address will need to be done in person.

Emergency Contact
Name

First NameMiddle NameLast Name
Phone Number
Format: (000) 000-0000.
Relation to you?

Financial Agreement
Thank you for choosing Partida Corona Medical Center as your healthcare provider. Please carefully read and initial by each statement and sign below. This policy has been put in place to ensure that financial payments are recovered to allow us to continue to provide quality medical care for our patients. It is important that we work together to assure that payment for services is as simple and straightforward as possible. Our practice manager or billing department will be glad to discuss these policies with you.
I understand that if I do not have my insurance card, referral, and/or copayment that my appointment may be rescheduled until such time that I can provide the required documents or payments.
I understand that Partida Corona Medical Center Will collect all copayments at the time of visit and any procedure deductibles and coinsurance up to an amount equal to payment in full for the planned procedure code. Payment in full and expected coinsurance payment responsibility are determined by the anticipated billing codes, details of your insurance policy, and agreement between your insurance company and Partida Corona Medical Center. Any overpayment to your account will be refunded to you at your request after payment and/or remittance has been received from your insurance company
I understand that a $25 service fee will be added added for any checks returned for any reason and I will be responsible for payment payment of the fee and the amount of the returned check. NSF checks must before deemed with certified funds (cashier's check, money order, or cash).
I understand that if I am unable to make a scheduled appointment I need to contact Partida Corona Medical Center at least 24 hours before my scheduled appointment time. Due to high demand for appointments, missed appointments prevent us from scheduling appropriately and keep others in need of urgent care from being seen. A $25FEE WILL BE ASSESSED FOR ALL MISSED APPOINTMENTS AND $200 FOR MISSED PROCEDURES NOT CANCELED OR RESCHEDULED WITH AT LEAST 24-HOUR ADVANCED NOTICE.
I understand that if my account is not paid in full within 90 days of a statement date, a 35% collection agency processing fee will be added to the outstanding balance and will be turned over to collections for further processing. No additional appointments will be made for delinquent accounts until they are brought current.
Partida Corona Medical Center will allow 60 day from the date of fling for my insurance company to process or pay a claim. State law allows insurance companies operating in the state no more than 60 days to processclaims. It is my responsibility to provide my insurance company with requested information needed to process a claim for services. It is also my responsibility to notify Partida Corona Medical Center if there is any change in my insurance coverage, residence, or phone number. I understand that my insurance policy is an agreement between my insurance company and me. It is my responsibility to know what is covered under my plan. ULTIMATELY, IT IS UP TO ME TO KNOW MY INSURANCE BENEFITS.
The cost for "special forms" or"letters" is $40.00 on expedited service (24-48 hours). Payment issue at the time form(s) are dropped off. These forms include:Unemployment/Disability, Workers' Compensation, FMLA, and letters for insurance/employer purposes.
We Require patients to complete assignment of benefits authorizing insurance to remit payment to physician's office. I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled, private insurance,and any other plans to: Partida Corona Medical Center. This assignment will remain in effect until revoked by me in writing. A photocopy of this agreement is to be considered as valid as the original. I understand that I am financially responsible for all charges whether or not paid by said insurance.I hereby authorize said assignee to release all medical information necessary to secure payment.
Privacy Policy Act We are committed to protecting your health information. A record is created on your visit in order for us to provide you with quality care and to comply with certain legal requirements. A more in depth description of the Privacy Policy Actually may be obtained by our front office staff. In simple terms, your personal and medical information is important to us
Signature

I have read and agree to all the provisions of the above financial policy. I understand that I am ultimately responsible for all professional fees incurred for professional services performed by the attending physician.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Hippa Privacy Authorization Form

Authorization for Use of Disclosure of Protected Health Information (Required by the Health Insurance and Portability and Accountability Act, 45 C.F.R Parts 160 & 164)
I authorize Partida Corona Medical Center to use and disclose the protected health information described below to: (whom you would like us to share your information with)
Effective Period:

Option 1
This authorization for release of information covers the period of healthcare from the the following dates. MM-DD-YYYY - TOblanks

OR

Option 2
All Past,Present,and Future periods. Please type in the text to confirm all past present and future periods.
Extent of Authorization

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.
Should be Empty:

Rows	YES	NO	Comments
Ischemic heart disease/ Previous Heart attack
Atrial Fibrillation
Diabetes
Hypertension
COPD
Asthma
CVA/ Stroke / TIA or mini-stroke
Thyroid Problems
Arthritis
Depression
Anxiety
Other Psychiatric condition
Gerd

New Patient Information form:

Emergency Contact

INSURANCE INFORMATION

Financial Agreement

Hippa Privacy Authorization Form