Concierge New Patient Packet

New Patient Information

This questionnaire will take about 10-20 minutes to complete.
Legal Name (First Middle Last)*
Name you like to be called
Birth Date*

MonthDayYear
Date
Social Security Number
Preferred Language
Age
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Address (only complete if different from Mailing Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender
Preferred Pronouns
Legal Gender
Sex assigned at birth
Ethnicity (required by Vaccine program, Medicare, and insurance)

American IndianHispanic/LatinoAsianAfrican AmericanNon-Hispanic/LatinoNative Hawaiian or Pacific IslanderWhiteDecline to specify
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
initial here GPC may leave detailed voice messages at my home phone
initial here GPC may leave detailed voice messages at my cell phone
initial here GPC may text message me at my cell phone
initial here GPC may use Spruce to message and text with me
Email address
example@example.com
Choose one initial Allow email: GPC may send my personal health information via email. I understand that email may be unencrypted and that this carries risk of a third party gaining access. I also understand that emails may be part of my permanent medical record. I also give permission for GPC to communicate via email with my specialists and other outside providers as indicated through my release of information form.
-OR-
initialDo not allow email: I do not wish to have email initiated from GPC. I understand that if I email GPC they may respond to my request via email.
Emergency Contact

NameRelationship
Emergency Contact Address (if different from yours)
Home/Cell Phone Number of Emergency contact
Please enter a valid phone number.
Work Phone Number of Emergency contact
Please enter a valid phone number.
Guardianship - If applicable please list who has legal guardianship and their phone number:
Preferred Pharmacy
Cross streets
initial GPC may speak to the person indicated below about my medical condition. This may include information related to mental/behavioral health, substance abuse, sexually transmitted disease, HIV status and reproductive medicine unless specified below field.
Name/Relationship: Name/Relationship
Phone #: Area Code Phone Number
With my signature below, I acknowledge and understand that this information will be kept in my medical record according to and the instructions above will be honored until revoked by me in writing. It is my responsibility to notify GPC should I change one or more of the telephone numbers listed above.

Clear
Today's date

MonthDayYear
Date
If you are signing as the guardian please enter your name here:

First NameLast Name
CONSENT TO BE TREATED: I give permission and authorize the providers and staff of Greenlake Primary Care to examine and treat me. Iftreatment is for a minor, I hereby give permission for the patient to receive treatment. In the rare even that I cannot be reached, I authorize GPC to institute any necessary care for the patient, including hospitalization.This authorization is in effect until rescinded in writing.

Clear

Greenlake Primary Care Financial Policy (updated 3/2021)

Greenlake Primary Care (GPC) contracts with Medicare for Part B and Molina AppleHealth; we will bill for covered services on your behalf. We do not bill third party for motor vehicle accidents. We do not take EPO plans or HMO plans, or any other insurance plans.

Know your insurance plan. Before your visit, call the toll free number on the back of your insurance card.

• Ask your insurance representative if you have out of network benefits.

• Make sure that you do not have an EPO or HMO plan that prohibits out of network providers

• You may also ask whether you need a written referral to specialists, how often this needs to be renewed, and review your coverage, deductible, co-payment, and benefit limits.

Greenlake Primary Care will submit your bill to Medicare and Molina AppleHealth. For all other insurance products, we are out of network and you are responsible for paying at the time of service. We make no guarantee regarding out of network insurance reimbursement or payments.

Questions about your account can be answered by Tess Moore, MD at 206 524 5656

For your convenience we accept both Visa and Master Card, and ACH payments (through HINT only) Checks returned for insufficient funds will result in an immediate charge of $35.00 against your account.

We require at least 24-hour notice if you are unable to keep your appointment. Missing an appointment without notice and/or late cancel is considered a no show. Repeated no shows may result in a charge of up to $50.00. A third no show within 12 months may result in dismissal from the practice.
For Medicare and Molina AppleHealth Release of Insurance Benefit: As a Medicare/Molina AppleHealth participant, I authorize Greenlake Primary Care to request and directly collect, on my behalf, all covered benefits due for products and services provided by Greenlake Primary Care. I authorize Medicare/Molina AppleHealth insurance benefits to be paid directly to my provideror to Greenlake Primary Care. If these insurance benefits are paid directly to me and owed to GPC, I will endorse these checks for such payments to Greenlake Primary Care.
Initial to indicate consent
Financial Responsibility: For Medicare/Molina AppleHealth beneficiaries, I am financially responsible for any co-payments, deductibles, balances due, and charges for services not covered by Medicare/Molina AppleHealth. For all other direct pay patients, I understand that payment is due at the time of service. As a courtesy, GPC will provide me with an invoice and receipt of payment that I can submit to my insurance company, this is not a guarantee of reimbursement.
Initial to indicate consent
Release of Health Information applies to Medicare, Molina AppleHealth, and those submitting claims to their insurance for reimbursement: I authorize Greenlake Primary Care, to release any health care information necessary to facilitate the processing of claims and audit of payments, for the services provided to me or my child by Greenlake Primary Care. This authorization is in effect until rescinded in writing.
Initial to indicate consent
I have read and understand this policy. A copy will be kept in my chart and a copy may be furnished to me at my request. Your signature below means that you have read, understand, and agree to all of the terms contained in this Financial Policy, and insurance release. All authorizations are in place until rescinded in writing. If you are signing for patients other than yourself, your signature means that you have the authority to act on their behalf and you are financially responsible for services they receive under this Policy.

Clear
Today's date

MonthDayYear
Date
Credit Card Authorization:
I authorize Greenlake Primary Care to charge my credit on file for both my monthly Concierge fee as well as any incidental charges. These include charges collected for labs, medications, late fees as above, and other incidentals that will be explained to me prior to any payments being rendered. Credit card numbers and ACH will be entered directly by me or staff into the secure payment system HINT or directly into our online credit card terminal through Transaction Express. No card numbers or bank information is stored in my chart or in the office and the card number, cannot be accessed once entered.
●     I can ask and receive a statement of my account which the practice will provide within 5-7 business days
●     Start date of authorization is pursuant to start date of my signed membership agreement.
●     The authorization is in effect until rescinded in writing.

I have read and understand this policy. A copy will be kept in my chart and a copy may be furnished to me at my request.
Signature

Clear

Medical History
Briefly state your main concerns with your health
Please list your medical problems and the month/year it began
condition month/year began
condition    month/year began
condition    month/year began
condition    month/year began
condition    month/year began
condition    month/year began
condition    month/year began
condition    month/year began
condition month/year began
Please list any surgeries, injuries, and hospitalizations with approximate date
surgery/hospitalization date
surgery/hospitalization      date
surgery/hospitalization      date
surgery/hospitalization      date
surgery/hospitalization      date
surgery/hospitalization      date
Medication/Supplement - Dose - Frequency or Number
medication-dose-frequency
medication-dose-frequency
medication-dose-frequency
medication-dose-frequency
medication-dose-frequency
medication-dose-frequency
medication-dose-frequency
medication-dose-frequency
medication-dose-frequency
medication-dose-frequency
Allergies to Medications/Food
medication/food and reaction
medication/food and reaction
medication/food and reaction
medication/food and reaction
medication/food and reaction
medication/food and reaction
Family History for genetic (first-degree) relatives
Father living (Y/N) - age or age at death health problems list medical problems
Mother   living (Y/N) - age or age at death   health problems   list medical problems
Brother   living (Y/N) - age or age at death health problems   list medical problems
Brother   living (Y/N) - age or age at death   health problems   list medical problems
Sister   living (Y/N) - age or age at death   health problems   list medical problems
Sister   living (Y/N) - age or age at death   health problems   list medical problems
Preventive Care
enter dates for any you have had
mammogram date
pap smear date
bone density (DEXA)   date
abdom aneurysm test   date
EKG   date
heart stress test  date
heart catheterization   date
eye exam   date
Preventive Care
continued
colonoscopy date
stool colon cancer test date
endoscopy   date
chest X-Ray   date
chest CT   date
Tb test  date
Hepatitis C test   date
HIV test  date
Vaccines - enter dates for any you have received
Flu date
Pneumococcus date
Tetanus   date
Hepatitis B   date
Shingles   date
HPV   date
COVID #1   date
COVID #2   date
If applicable
number of pregnancies/births #/#
Problems with periods
days of flow
age of start of periods   #
age at menopause (if applicable)   age
Hot flashes   Abnormal pap

New Patient Information