New Patient Registration & Consent

New Patient Registration & Consent
Complete the form to register as a new patient. Once the form has been submitted, we will schedule an appointment and contact you based on your contact preference.

You must complete all sections before moving to the next page.
Name*

PrefixFirst NameMiddle NameLast Name
Location Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from location address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
Social Security Number*
This is needed to order labs, prescribe medications, referrals, and for insurance verification. All your information is protected.
Birthdate*
Needed for insurance processing and for medical record
Sex:*
Martial status:*
Occupation:
Race/Ethnicity:*
Preferred method of communication (select all that apply):*

CallTextE-mail

Insurance & Payment Information
How will you be paying for this visit and future visits?*

InsuranceCash (or credit card) Payment
If you are paying by insurance, please take a picture of your insurance card, upload a copy of your card, or enter the information. You will need to provide your card at your appointment for verification.
Take a picture of the FRONT of your insurance card
Take a picture of the BACK of your insurance card
Take a picture of your photo ID
Upload a picture of the FRONT of your insurance card

Cancelof
Upload a picture of the BACK of your insurance card

Cancelof
Upload a picture of your photo ID

Cancelof

Patient Information, Practice Policies, and Consent Forms

In order for NPS to disclose your Protected Health Information to another person you must complete and sign this form and return it to us. You can complete the form online or email it to contact@nursepractitionerservices.com. You have the right to receive a copy of this form.
Telehealth Consent

1. I hereby authorize Nurse Practitioner Services of Michiana to use the telehealth practice platform for telecommunication for evaluating, testing and diagnosing my medical condition.

2. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended.

3. I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.

4. I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover.

5. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.
Controlled Substance Policy

Initial visits: If the prescription can be verified as filled within the last 30 days through the Prescription Drug Monitoring Program (PDMP), then the prescription can be refilled based on the provider’s discretion.

Subsequent visits: Pt. will need to be seen monthly by the provider, this can be telehealth or in person visits based on the provider’s discretion.

Missed visit: The medication (s) will not be refilled until your next visit.

Stolen medications: A police report must be made and a copy brought to your appointment in order to receive a refill.

Lost/Damaged medications: These will not be refilled until the next scheduled refill date. It is the patient’s responsibility to keep the medications in a safe location.

Pill Counts: the provider may request your original prescription bottles at any time for a pill count, the patient must produce the original medications and prescription bottles when requested by the provider.

Drug Screens: Every 3 months and as thought necessary by the provider. A failed drug screen is either a substance that is illegal and shows up on the screen or if the medication you are taking does not show up in the screen. If a drug screen is failed, no further controlled substances will be filled by the practice.

General Policies

Pharmacy: One pharmacy will be used for both controlled substances and non-controlled substance medications.

Have all of your medications available at every visit for verification and medication reconciliation.

If you cannot attend a scheduled appointment, at least 24 hour notice is necessary to avoid being considered a “No Show.”

Three (3) “No Shows” will result in termination from the practice.

Consent to Treat:

I am consenting to treatment by the providers and staff at Nurse Practitioner Services of Michiana (NPS). I consent taken blood tests and performance of any procedures deemed necessary in the course of my workup and diagnosis, whether or not related to presently known conditions, if my medical attendants find these necessary or advisable during the course of evaluation or treatment in for management of any complications that arise or otherwise. I have fully and completely disclosed my medical history, including allergies, blood conditions, prior medications or drugs taken, and reactions I have had to anesthetics, medications or drugs. I consented the administration of such drugs, medications or anesthetics as may be necessary or advisable by in the providers at NPS. I understand that medications may not eliminate all of the symptoms and the medications or treatments given may cause severe reactions or even shock, and that no guarantees to the contrary have been made to me. I understand that medications or treatments in a small number of cases, may cause bodily reactions or complications, requiring additional measures and treatment, which I request and to which I consent. I realize there are inherent risk of minor or major complications and then the procedures including pain, infection, and worsening of symptoms. I understand that any questions I have will be answered by my provider and I will address such questions before they leave. I agree to make no claims against the staff or providers at NPS for complications which may occur, except in the event of gross negligence on their part. If I should make any unwarranted claims, I agree to be responsible for the payment of all cost and attorneys fees incurred by the staff and providers and to post bond in advance of such sums. I further understand that the medical practice of the providers is to be judged according to the standards reasonably acceptable to other similarly experience providers practicing in similar facilities in the United States. I will follow instructions given to me by the providers at NPS and will take responsibility for my outcomes that occurred due to my not following the instructions will hold NPS harmless for any poor outcome due to my not following the instructions and advice given by the providers.

I certify that I have read and fully understand the above and informed consent and that I agree in light of the consent to treatment at NPS.
I agree to the Consent to Treat.
I agree to the Notice of Privacy Practicies.
I agree to the Financial Policies & Disclosures.
I have received a copy and understand where to locate the Notice of Privacy Practice, Financial Policy Notice and the Release of Information on the practice website.
By providing my signature below, I understand and agree to the above policies.*

Clear
Date

MonthDayYear
Date

Authorization for the Release of Patient Information
Please select how you would like your health information sent to you:*

E-mailPhone
Would you like us to send your health information phone and email to any personal contacts in the event that this information needs to be shared for medical or personal reasons?*
Enter a person or entity and which information you authorizing to send. Please use Y Uyes) or N (no) to fill in which information should be authorized to each person.
NOTICE TO RECIPIENT OF PROTECTED HEALTH INFORMATION Prohibition Against Re-Disclosure: This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R., Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client. Drug abuse patient records are also protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. parts 160 and 164. These conditions apply to every page disclosed and a copy of this authorization will accompany every disclosure.
Signature*

Clear
Date*

MonthDayYear
Date
Pharmacy Name*
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Primary Care Provider (Doctor, NP, or PA)*
When is the soonest you would like to be seen:*

MonthDayYear
Date
Where did you hear about Nurse Practitioner Services?*
Should be Empty:

New Patient Registration & Consent

Complete the form to register as a new patient. Once the form has been submitted, we will schedule an appointment and contact you based on your contact preference.

Insurance & Payment Information

Patient Information, Practice Policies, and Consent Forms

Authorization for the Release of Patient Information