NEW PATIENT PACKET INSTRUCTION - whitfieldfp.com

1 of 1 Whitfield Family Practice LLC 2828 Hwy 31 S, STE 111

Decatur, AL 35603 256‐686‐3456

NEW PATIENT PACKET INSTRUCTION:

1. Please fill out the following forms completely and accurately to the best of your ability. Accurate and up

to date personal health information is VITAL to providing effective, high quality medical care.

2. Forms may be completed electronically/digitally on the computer with Adobe Acrobat Reader DC or

equivalent software. Adobe Acrobat Reader DC is available by free download at the following address.

Click the link below or copy and paste the address into your web browser.

https://acrobat.adobe.com/us/en/acrobat/pdf‐reader.html#tt

a. Forms completed electronically may be returned to Whitfield Family Practice via the email

address below. Click the link below or copy and paste the address into your email client.

[email protected]

3. Alternatively, forms may be completed on the computer and printed for submission either by fax or in

person at the clinic.

4. Alternatively, forms may also be printed blank for completion by hand for submission either by fax or in

person at the clinic. If you choose to complete the forms by hand, please PRINT clearly and legibly to

avoid any processing delay.

a. Printed forms may be faxed to the following number: 256‐686‐3519

5. Form signatures may be the electronic, digital or handwritten type. Electronic, digital and handwritten

signature types will all be treated as equivalent.

6. If possible, we request all forms be submitted at least 24 hours prior to your appointment, in order to

more rapidly serve you in the clinic and minimize your wait time.

7. If prior submission is not possible, please bring all forms to your scheduled appointment.

8. If forms are submitted at least 24 hours prior, please arrive 15 minutes prior to your scheduled

appointment otherwise please arrive 30 minutes prior to your scheduled appointment.

9. Please bring all insurance cards along with your drivers license or other photo ID to your scheduled

appointment.

10. If you have any questions, please do not hesitate to call us at: 256‐686‐3456


Decatur, AL 35603 256‐686‐3456

NEW PATIENT REGISTRATION:

FIRST NAME: ______________________________LAST NAME___________________________________________

DOB: ________________________ Gender: M F Social Security: ________________________________

Address: ______________________________________________________________________________________

_____________________________________________________________________________________________ CITY STATE ZIP CODE

Primary Phone: ________________________________________Primary Phone Type: Home Cell Work

Alternate Phone: ______________________________________ Alternate Phone Type: Home Cell Work

Email: ________________________________________________________________________________________

Consent to Text: Yes No Text Message Phone Number: Primary Alternate

EMERGENCY CONTACT: _____________________________________ Relationship: _________________________

Emergency Contact Phone Number: ________________________________________________________________

Ethnicity: Not Hispanic/Latino Hispanic/Latino American Indian Other: ____________________

Race: White Black‐African American Asian Other: _____________________________________

Marital Status: Married Single Widowed Divorced Separated

Employment Status: Employed Retired Unemployed

ALLERGIES: ____________________________________________________________________

Pharmacy: __________________________________________

Pharmacy Location___________________________________

Pharmacy Phone: ____________________________________


Decatur, AL 35603 256‐686‐3456

SPECIALISTS YOU SEE:

Name Specialty

MEDICATION LIST:

Name/Dose Times/Day Reason


Decatur, AL 35603 256‐686‐3456

FAMILY HISTORY:

Family Member Medical Issues Mother

Father

Brother

Sister

Maternal Grandmother

Maternal Grandfather

Paternal Grandmother

Paternal Grandfather

Other:

PREVENTIVE CARE / SCREENING:

Screening Date of Last Screening Mammogram

Bone Density

Colonoscopy/Cologuard

Pap Smear

PSA Level Check


Decatur, AL 35603 256‐686‐3456

SURGICAL HISTORY:

Surgery Date/Year (Approximate)

IMMUNIZATION HISTORY:

Vaccine Date (approximate) Tdap / Td (Tetanus)

Pneumonia (Prevnar 13 or Pneumovax 23)

Influenza

Zoster (Shingles)

Hepatitis B

COVID 19


Decatur, AL 35603 256‐686‐3456

Past Medical History:

(Check All That Apply)

AIDS / HIV Atrial Fibrillation Hepatitis Allergies / Hay Fever Heart Disease High Cholesterol Anemia Headaches High Blood Pressure Anesthesia Complications Gout Infertility Anxiety Disorder GI Problems Kidney Disease Arthritis Fibromyalgia Kidney Stones Asthma Endometriosis Liver Disease Autism Spectrum Disorder Eczema Lung Disease Bedwetting Eating Disorder MRSA Exposure Birth Defects / Inherited

Disease

Ear or Hearing Problems Meniere’s Disease Bladder or Kidney Problems Diverticulitis Mental Disorder / Illness Blood Diseases Difficulty Swallowing Muscle, Joint, Bone Problems Blood Transfusion Diabetes Osteoporosis Breast Cancer Depression Polyps Breast Problem Coronary Artery Disease Pulmonary Embolism COPD Constipation Reflux / GERD Cancer Congestive Heart Failure (CHF) Seizures / Epilepsy Chicken Pox Chronic Ear Infections Thyroid Disease Skin Problems Stroke Vison/Eye Problems


Decatur, AL 35603 256‐686‐3456

SOCIAL HISTORY:

Have you been to an area known to be high risk for COVID‐19?

Yes No

In the 14 days before symptom onset, have you had close contact with a laboratory‐confirmed COVID‐19 while that case was ill?

Yes No

In the 14 days before symptom onset, have you had close contact with a person who is under investigation for COVID‐19 while that person was ill?

Yes No

Do you or have you ever smoked tobacco?

Never Smoked Former Smoker Current Regular Smoker Current Occasional Smoker

Do you or have you ever used any other forms of tobacco or nicotine?

Yes No

What was the date of your most recent tobacco screening?

____________________________________

What is your level of alcohol consumption?

None OccasionalModerate Heavy

Do you use any illicit or recreational drugs? Yes No

What is your level of caffeine consumption? None/ Occasional/ Moderate

None OccasionalModerate Heavy

By signing below, I attest that the information provided in this registration is true and accurate to the best of my knowledge. I understand that signatures for this document will be considered equivalent whether handwritten, electronic or digital in nature.

_______________________________________________ _______________________ Patient Signature Date

Whitfield Family Practice LLC Amber J. Whitfield MD

2828 Hwy 31 S, STE 111, Decatur, AL 35603 256-686-3456

[email protected] www.whitfieldfp.com

Reason for Visit?

Please provide a brief description of the reason for your visit today. Include any specific problems or issues you would like addressed in order to allow the physician to better prepare for your visit.

_____________________________________________________________________________

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____________________Date

______________________________________ Patient Signature

1 of 1 Whitfield Family Practice LLC 2828 HWY 31 S, Suite 111

Decatur, AL 35603 256‐686‐3456

AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

Patient Name __________________________________________________________________________

SS Number_________________ Date of Birth_______________________________________

Address ______________________________________________________________________________

Phone Number ________________________Date of Service____________________________________

I authorize the use or disclosure of the above‐named individual’s health information as described below:

1.) ________________________________________________________________ is authorized to make the

disclosure.

2.) The type and amount of information to be used or disclosed is as follows: (include dates where appropriate)

ENTIRE RECORD DISCHARGE SUMMARY LABORATORY RESULTS

CONSULTATION REPORT HISTORY AND PHYSICAL IMAGING RESULTS

EMERGENCY/DEPTRECORD OPERATIVE NOTE

3.) I understand that the information in my health record may include information relating to sexually transmitted

diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also

include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

4.) This information may be disclosed to, and used by, the following individual or organization:

Name: ____________________________________ Phone: ________________ Fax: __________________

Address: ______________________________________________________________________________

5.) For the purpose of: __________________________________________________________________

6.) I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this

authorization, I must do so in writing and present my written revocation to the Medical Record Department. I

understand that the revocation will not apply to information that has already been released in response to this

authorization. I understand that the revocation will not apply to my insurance company when the law provides my

insurer with the right to contest a claim under my policy.

7.) Unless otherwise revoked, the authorization will expire on the following date, event, or condition:

_______________________________________________________________________________________

Patient Signature: Date: Time:

Witness Signature: Date: Time:

1 of 1 Whitfield Family Practice LLC 2828 HWY 31 S, STE 111

Decatur, AL 35603

HIPAA Privacy Authorization Form

Authorization for Use or Disclosure of Protected Health Information

Patient Name:__________________________________________________________________

Date of Birth:__________________ E‐mail Address:____________________________________

I authorize access and disclosure of my Protected Health Information (PHI), including but not limited to billing,

condition, treatment and prognosis, to the following:

Name: ____________________________________________ Relationship:________________

Name: ____________________________________________ Relationship:________________

I request the following restrictions to releasing my PHI:

I understand I have the right to revoke this authorization in writing at any time. I understand that a revocation is

not effective to the extent that any person or entity has already acted in reliance on my authorization, or if my

authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to

contest a claim. Unless otherwise revoked this authorization shall be in force and effect one year from today’s date

at which time this authorization expires. I understand that signatures for this document will be considered

equivalent whether handwritten, electronic or digital in nature.


Witness Signature: Date: Time:

AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

Patient Name

SS Number________________ Date of Birth_________ Phone Number

Address

1. I authorize the use or disclosure of the above‐named individual’s health information to:

Whitfield Family Practice LLC 2828 Hwy 31 S, STE 111, Decatur, AL 35603 Phone: 256-686-3456 Fax: 256-686-3519

2. Disclosure is authorized for provision of medical care for the above-named individual:

3. Unless otherwise revoked, the authorization will expire on the following date, event, or

condition:________________________________________________________________

4. I understand that the information in my health record may include information relating tosexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or humanimmunodeficiency virus (HIV). It may also include information about behavioral or mentalhealth services, and treatment for alcohol and drug abuse.

5. I understand that I have a right to revoke this authorization at any time. I understand that if Irevoke this authorization, I must do so in writing and present my written revocation to theMedical Record Department. I understand that the revocation will not apply to information thathas already been released in response to this authorization. I understand that the revocationwill not apply to my insurance company when the law provides my insurer with the right tocontest a claim under my policy.

6. I understand that for the purposes of this document signatures will be considered equivalentwhether hand written, electronic or digital in nature.


Witness Signature:______________________________Date:_______________Time: ________

FOR CLINIC USE

1. ____________________________________________________is authorized to disclose health

information for the following dates of service:_________________________________________

2. The type and amount of information to be used or disclosed is as follows:

ENTIRE RECORD DISCHARGE SUMMARY LABORATORY RESULTS CONSULTATION REPORT HISTORY AND PHYSICAL IMAGING RESULTS EMERGENCY DEPT RECORD OPERATIVE NOTE

3. Notes_________________________________________________________________________

1 of 1 Whitfield Family Practice LLC 2828 HWY 31 S, Suite 111

Decatur, AL 35603 256‐686‐3456

Whitfield Family Practice LLC Amber J. Whitfield MD



ASSIGNMENT OF BENEFITS, AUTHORIZATION TO SETTLE CLAIM AND DIRECTION TO PAY MEDICAL PROVIDER DIRECTLY

By my signature below, for good and valuable consideration (including but not limited to the extension of credit to me), I hereby assign, transfer and convey to Whitfield Family Practice LLC and/or its contracted healthcare providers (hereinafter the Provider) all of my rights, title and interest in and to medical expense reimbursement in whatever form, including but not limited to any automobile liability medical expense payments or other health benefits indemnification and/or agreement otherwise payable to me. This pay-ment shall not exceed my indebtedness to the above-named assignee and I acknowledge that I will timely pay any indebtedness owed by me to the assignee that is not otherwise satisfied by the above-mentioned assigned proceeds. I also acknowledge that any medical expenses not covered under my insurance pol-icy will be my responsibility.

I further authorize the Provider to negotiate, collect and settle any claim with any insurance carrier or other third-party payor with regard to these services, which authorization shall include authority to:

(1) request and receive from any insurer or any other party any and all documentation and rec-ords that I am empowered to request regarding this claim, including, without limitation, a state-ment of coverage, policy declarations page and insurance policy. In addition, the provider has the authority to request and receive any Independent Medical Examination Reports, notices sent to me regarding appointments for Independent Medical Examinations and Examinations Under Oath (including proof of mail), Records Review Reports, coverage denial letters, Explanations of Bene-fits, and Benefit Payment Sheets or Logs (P.I.P. Payout Sheets), without regard as to whether such documentation has already been provided to me and,

(2) to endorse in my name any check issued for payment where benefits were assigned. By wayof this assignment and notice, I further instruct you, the insurer, to furnish to Provider copies of all future notices affecting Provider’s interest in this claim, including, without limitation, any notices of requested medical examinations or statements.

The Provider hereby objects to any reductions or partial payments. Any partial or reduced payment, re-gardless of the accompanying language, issued by the insurer and deposited by the provider shall be done so under protest, at the risk of the insurer, and the deposit shall not be deemed a waiver, accord, satisfaction, discharge, settlement, or agreement by the provider to accept a reduced amount as payment in full.

I further direct my insurer to direct all payments for services rendered by the Provider directly to Provider at the billing address contained on Provider’s medical bills.

THIS IS A DIRECT AND IRREVOCABLE ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER MY POLICY OF INSURANCE AND ALABAMA CODE 27-1-19.

A photocopy of this form shall be considered as effective and valid as the original. Signatures for this document will be considered equivalent whether handwritten, electronic or digital in nature.

I have read the foregoing and understand and agree to each of the above provisions:

___________________________ _________________________ ______________ Patient Signature Patient Name Date


Decatur, AL 35603 256‐686‐3456

NO SHOW/CANCELLATION POLICY

As a courtesy, please call Whitfield Family Practice at 256‐686‐3456 as

soon as you know that you will be unable to make your scheduled

appointment. We will be happy to reschedule your appointment for

you.

I understand that if I miss an appointment and/or fail to give Whitfield

Family Practice a minimum of 24 hours notice for rescheduling, I will be

required to pay a “No Show” fee of $25.00 prior to my next

appointment. I understand that signatures for this document will be

considered equivalent whether handwritten, electronic or digital in

nature.

Patient Signature: Date:

Witness Signature: Date:

of 1 Whitfield Family Practice LLC Amber J. Whitfield MD



Laboratory Services Disclosure

For patient convenience, Whitfield Family Practice makes available clinical staff for drawing blood, collecting nasal swabs and other samples for laboratory diag-nostic tests. Should you choose to utilize the in-clinic staff for laboratory sample collection, testing may be completed by Whitfield Family Practice or an external lab facility depending upon the testing required by the provider. You are not required to use the in-clinic staff for diagnostic testing. If you do not wish to use the in-clinic staff, please let the physician and/or nurse know. We will be happy to provide testing orders for the lab facility of your choice.

I understand that I am not required to use the clinical staff for blood or other samples. I understand that I will be provided with testing orders to a lab of my choice upon request. I understand that for the purposes of this document signatures will be considered equivalent whether hand written, electronic or digital in nature. _______________________________________ _______________ Patient Name Date _______________________________________ Patient Signature




Patient Responsibilities

1. Introduction

This document outlines the responsibilities of patients (The Patient) cared for by Whitfield FamilyPractice LLC (The Practice). Failure to meet any of these responsibilities may result in dismissalof The Patient from The Practice, especially if failure is repeated or continual.

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2. Information

Accurate information to include health and family history is essential to providing effective, highquality health care. Inaccurate information may result in treatment decisions that are detrimentalto the health of The Patient up to and including disability or death. It is The Patient’sresponsibility to provide accurate information, to the best of their ability, at registration and toinform The Practice at each appointment of any changes to their information.

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3. Honesty

Open and honest communication is essential to providing effective, high quality health care.Intentionally dishonest or misleading communications undermine the quality and safety of patientcare along with the overall working relationship between The Practice and The Patient. It is ThePatient’s responsibility to be honest with the The Practice at all times, including when providinganswers or information that may entail emotional or psychological discomfort.

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4. Compliance

Patient compliance with the agreed upon treatment plan is essential to providing effective, highquality health care. Noncompliance wastes time, money and other resources of both The Patientand The Practice, which could be better spent elsewhere. It is the responsibility of The Patient tomake every effort to comply with the agreed upon treatment plan. It is the The Patient’sresponsibility to notify The Practice as soon as practicable of any problems or issues, such asadverse drug reactions or injuries, that hinder compliance in order to allow revision of the treat-ment plan.

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5. Controlled Substances

Controlled substances are essential tools for providing effective management of pain, anxiety, depression and many other health problems. It is the policy of The Practice to prescribe con-trolled substances as medically necessary for responsible use by patients. Drug screening may be required to ensure patient safety and compliance. It is The Patient’s responsibility to use prescribed controlled substances only in the manner directed by The Practice, to secure con-trolled substances from unauthorized individuals and to properly dispose of controlled substances when removed from the treatment plan.

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6. Patient Appointments

Maintaining scheduled appointments is essential to providing effective, high quality health care.Scheduled appointments are an opportunity for The Practice to monitor the progress of care andrevise as necessary support The Patient. Missed appointments are detrimental to providing pa-tient care and waste resources of The Practice. Late arrival for appointments impacts the care ofother patients. It is The Patient’s responsibility to make every reasonable effort to attend andarrive on time for scheduled appointments. If The Patient is unable to attend a scheduled ap-pointment, it is The Patient’s responsibility to contact The Practice and reschedule or cancel atleast 24 hours prior to the scheduled appointment. Failure to do so will subject The Patient to the“No Show Policy” and associated fees.

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7. Financial

Financial reimbursement for services is essential for the continued ability of the practice to provide high quality effective care. The Practice must pay for staffing, facilities, utilities, medical equipment and supplies, among other items, all of which are costly. The Practice will make every effort to bill and collect from The Patient’s insurance prior to requiring any payment from The Patient, apart from insurance co-payments. The Practice is contractually obligated to collect co-payments at the time of service by the insurance company. Co-payments cannot be billed to The Patient after services are provided. It is The Patient’s responsibility to satisfy all bills from and debts to The Practice in a timely manner regardless of whether the insurance company pays or how much the insurance company pays. The Practice will make every effort to accommodate patients suffering financial hardship via application of reasonable payment plans or other methods.

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8. Kindness and Respect

Kindness and respect is essential for maintaining the relationship between The Practice and ThePatient. The Practice strives to operate in the spirit of our motto and treat every patient as if theywere family, with kindness, support, understanding and respect in order to promote their healthand overall well-being. It is The Patient’s responsibility to always provide the same level ofkindness and respect to the The Practice staff.

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9. Agreement

I understand and agree to abide by the patient responsibilities listed above.I understand that failure to abide by the patient responsibilities may lead todismissal from the practice, especially if done continually or repeatedly. Iunderstand that for the purposes of this document signatures will beconsidered equivalent whether hand-written, electronic or digital in nature.

_______________________________________ _______________ Patient Name Date

_______________________________________ Patient Signature

NEW PATIENT PACKET INSTRUCTION - whitfieldfp.com

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