New Patient Packet

Adult New Patient Packet
Personal Information
Patient Name*

First NameLast Name
(If applicable) Previous Name:

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age
Social Security #
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
May we text and/or leave a voice mail on the phone numbers provided?

YesNo
Gender
Gender

FemaleMale
Gender Identity (If different from birth gender):
Language
Marital Status
Race / Ethnicity
Financial Responsible Party Information
Responsible Party Name

First NameLast Name
Relationship to Patient
Date of Birth

MonthDayYear
Date
Age
Social Security
Insurance Information
Primary Insurance
Policy Number
Group Number
Policy Holder Name
Policy Holder Date of Birth

MonthDayYear
Date
Relationship to Patient
Secondary Insurance
Policy Number
Group Number
Policy Holder Name
Date of Birth

MonthDayYear
Date
Relationship to Patient
Emergency Contact
Emergency Contact Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Patient
Reason for Visit
Primary Reason for Visit
Date Symptoms Started

MonthDayYear
Date
Were you seen at the Hospital/Urgent Care?
If yes, where?
Other issues you'd like to discuss?
Social History
Caffeine

HeavyModerateOccasionalNone
Alcohol Use

HeavyModerateOccasionalNone
Previous History of Alcohol

YesNo
Tobacco Use

SmokingFormer SmokerNever Smoked
Type
Current Amount
Previous History of Tobacco Use
Past Amount
Medical History
Arthritis

SelfMotherFatherSonDaughterMaternal GrandmotherMaternal GrandfatherPaternal GrandfatherPaternal GrandmotherSisterBrother
Alzheimer's

SelfMotherFatherSonDaughterMaternal GrandmotherMaternal GrandfatherPaternal GrandfatherPaternal GrandmotherSisterBrother
Asthma

SelfMotherFatherSonDaughterMaternal GrandmotherMaternal GrandfatherPaternal GrandfatherPaternal GrandmotherSisterBrother
Bleeding DO's

SelfMotherFatherSonDaughterMaternal GrandmotherMaternal GrandfatherPaternal GrandfatherPaternal GrandmotherSisterBrother
Cancer

SelfMotherFatherSonDaughterMaternal GrandmotherMaternal GrandfatherPaternal GrandfatherPaternal GrandmotherSisterBrother
COPD

SelfMotherFatherSonDaughterMaternal GrandmotherMaternal GrandfatherPaternal GrandfatherPaternal GrandmotherSisterBrother
Depression

SelfMotherFatherSonDaughterMaternal GrandmotherMaternal GrandfatherPaternal GrandfatherPaternal GrandmotherSisterBrother
Diabetes

SelfMotherFatherSonDaughterMaternal GrandmotherMaternal GrandfatherPaternal GrandfatherPaternal GrandmotherSisterBrother
Epilepsy

SelfMotherFatherSonDaughterMaternal GrandmotherMaternal GrandfatherPaternal GrandfatherPaternal GrandmotherSisterBrother
Gen / Birth DO's

SelfMotherFatherSonDaughterMaternal GrandmotherMaternal GrandfatherPaternal GrandfatherPaternal GrandmotherSisterBrother
GI Disorder

SelfMotherFatherSonDaughterMaternal GrandmotherMaternal GrandfatherPaternal GrandfatherPaternal GrandmotherSisterBrother
Heart Attack

SelfMotherFatherSonDaughterMaternal GrandmotherMaternal GrandfatherPaternal GrandfatherPaternal GrandmotherSisterBrother
Hypertension

SelfMotherFatherSonDaughterMaternal GrandmotherMaternal GrandfatherPaternal GrandfatherPaternal GrandmotherSisterBrother
Kidney Disease

SelfMotherFatherSonDaughterMaternal GrandmotherMaternal GrandfatherPaternal GrandfatherPaternal GrandmotherSisterBrother
Migraine

SelfMotherFatherSonDaughterMaternal GrandmotherMaternal GrandfatherPaternal GrandfatherPaternal GrandmotherSisterBrother
Seizure

SelfMotherFatherSonDaughterMaternal GrandmotherMaternal GrandfatherPaternal GrandfatherPaternal GrandmotherSisterBrother
Stroke

SelfMotherFatherSonDaughterMaternal GrandmotherMaternal GrandfatherPaternal GrandfatherPaternal GrandmotherSisterBrother
Other:
Surgical History
Appendix Removal

YesNo
Date of Removal

MonthDayYear
Date
Hernia Repair

YesNo
Date of Repair

MonthDayYear
Date
Other:
Please list the date of your last colonoscopy:
Please list the date of your last flu shot:
Please list the date of your last Tdap vaccine:
Please list the date of your last Pneumonia shot:
Please list the date of your last shingles shot:
Women Health/ Pregnancy History
Are you currently pregnant?

YesNo
Have you ever been pregnant?

YesNo
Please list the date of your last mammogram:

MonthDayYear
Please list the date of your last pap smear:

MonthDayYear
Allergies
Select applicable options

No known food/pet allergyNo known medication/drug allergy
Please list any food/pet allergies.
Please list any medication/drug allergies.
Current Medications
Medication, Dosage, & Frequency
Preferred Pharmacy Information
Pharmacy Name
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mail Order Pharmacy
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Statement of Patient Financial Responsibility
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Mercy Grace Private Practice appreciates the confidence you have shown in choosing us to provide for your health care needs. The service you have elected to participate in implies a financial responsibility on your part. The responsibility obligates you to ensure payment in full of our fees. As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. However, you are ultimately responsible for payment of your bill.

You are responsible for payment of any deductible and co-payments/co-insurance as determined by your contract with your insurance carrier. We expect these payments at time of service. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amounts not covered by your insurer. If your insurance denies any part of your claim, or if you or your physician elects to continue past your approved period, you will be responsible for your balance in full.

Should your account fall into a default status due to non-payment, your balance may be eligible for collections. Collections balances should be taken care of immediately to avoid disruption in services. Balance will need to be paid in full in order to schedule appointments. Any account in collections status may be eligible for discharge.
Initial*
I have read the above policy regarding my financial responsibility to Mercy Grace Private Practice for providing rehabilitative services to me or the above names patient. I certify that the information is, to the best of my knowledge, true and accurate. I authorize my insurer to pay any benefits directly to Mercy Grace Private Practice the full and entire amount of my bill incurred by me or above named patient; or, if applicable any amount due after payment has been made by my insurance carrier.
DISCLAIMER: By signing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Patient Signature*

Clear
Date*

MonthDayYear
Date
Guarantor Signature

Clear
Date

MonthDayYear
Date
Co-Pay Policy Some health insurance carriers require the patient to pay a co-pay for services rendered. It is expected and appreciated at the time the service is rendered for the patient at EACH VISIT. Mercy Grace Private Practice does NOT bill for co-pays. Thank you for your cooperation in this manner.
Signature*

Clear
Authorization to Bill/Pay: I hereby authorize Mercy Grace Private Practice and its affiliates to release any information required in the course of my examination or treatment which include HIV, communicable disease or drug abuse information. I also hereby authorize payment directly to the business of Mercy Grace Private Practice and its affiliates for the surgical and/or medical benefits, if any, otherwise payable to me for the services rendered. I understand that I am financially responsible for all charges not coved by my insurance. Further, I understand that I am responsible for all charges incurred in the collection of my account(s) and will pay all fees involved should my account(s) e placed with a collections service. I DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Signature*

Clear
Date*

MonthDayYear
Date
Self-Pay I agree to pay Mercy Grace Private Practice the full and entire amount for the treatment provided to me.
Initial
Consent for Treatment and Authorization to Release Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
I hereby authorize Mercy Grace Private Practice through its appropriate personnel, to perform or have performed upon me, or the above-named patient, appropriate assessment and treatment procedures.

I further authorize Mercy Grace Private Practice and its affiliates, to release appropriate agencies, any information acquired in the course of my, or the above named patient’s, examination and treatment including Healthcurrent (HIE) and AZ immunizations program (ASIIS).

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Patient/Guarantor Signature*

Clear
Date*

MonthDayYear
Date
Cancellation / No Show Policy

We understand there may be times when you miss an appointment due to emergencies or obligations to work or family. However, we urge you to call 24 hours prior to your appointment to cancel. Please initial the following:
If it is necessary to cancel an appointment, a 24 hour notice is requiredIf you miss an appointment or fail to provide 24 hours advanced notice, there will be a charge of $50.00. This charge will not and cannot be billed to your insurance companyI understand if I no show for two consecutive appointments, no show for three appointments or cancel for a total of 4 appointments, I may be discharged from care.I understand that if I arrive past my appointment time, the appointment will be rescheduled for another day if no other appointment slot is available on that day.
Our office will notify you in writing, via mail, if you are discharged from care.

I have read and understand the above information and I agree to the terms described:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Patient/Guarantor Signature*

Clear
Date*

MonthDayYear
Date
HIPPA NOTICE OF PRIVACY PRACTICES I hereby acknowledge that I have been presented with Mercy Grace Private Practice’s HIPAA Notice of Privacy Practices. My signature below is indicative of my acknowledgment and understanding. I am aware that I can obtain a copy of this in the office or on www.mgppaz.com. All of my questions have been answered accordingly. DISCLAIMER: By signing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Signature*

Clear
Date*

MonthDayYear
Date
Release of Information
I Name hereby authorize MGPP to release or discuss any and all information pertaining to myself or my child with Name Relationship to Patient
I authorize MGPP to contact me at HOME WORK CELL

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
May we leave a message on your machine?*

YesNo
Signature*

Clear
Should be Empty:

Adult New Patient Packet

Personal Information

Financial Responsible Party Information

Insurance Information

Emergency Contact

Reason for Visit

Social History

Medical History

Surgical History

Women Health/ Pregnancy History

Allergies

Current Medications

Preferred Pharmacy Information

Statement of Patient Financial Responsibility

Self-Pay I agree to pay Mercy Grace Private Practice the full and entire amount for the treatment provided to me.

Consent for Treatment and Authorization to Release Information

Cancellation / No Show Policy

Release of Information