NEW PATIENT PACKET

1 NEW PATIENT PACKET PATIENT s Name: _____ Last Middle First Address: _____ City: _____ State: _____ Zip: _____ Home Phone: _____ Cell Phone: _____ Primary Contact: Home Phone Cell Phone Email Address: _____ Driver s License #: _____ DOB: _____ Gender: Male Female Social Security #: _____ Employer: _____ Work Phone: _____ Race: White Hispanic Black or African American Asian Decline to Report Other: _____ Ethnicity: Hispanic or Latino/a Not Hispanic or Latino/a Decline to Report Other: _____ Whom may we call in Case of Emergency? Name: _____ Relationship to PATIENT : _____ Primary Phone #: _____ PracticePolicy contractedwithtocollectcopayments, ,the ;however,itisyour signatureand$ refilled on the next business day.

2 All refills must be done before Friday at noon. Canceling/ReschedulingAppointments :Ifyouareunabletokeepyourappointment,ple asenotifyourofficeatleasttwenty fourhoursinadvance appointment time. patients will be charged $ for missed appointments unless the appointment was cancelled 24 or more hours in advance. Whatifmychildneedstoseeaprovider? Aparentorlegalguardianmustaccompanypatie ntswhoareminorsonthepatient accompanying adult is responsible for payment on the account. PATIENT s Initials: _____ Insurance Information Primary Insurance Company : _____ Insurance Phone: _____ Insured Name: _____ DOB: _____ SS#: _____ PATIENT Relationship to Insured: _____ Insurance ID#: _____ Group#: _____ Address of Insured: _____ Secondary Insurance Company : _____ Insurance Phone: _____ Insured Name: _____ DOB: _____ SS#: _____ PATIENT Relationship to Insured: _____ Insurance ID#: _____ Group#: _____ Address of Insured: _____ Lonestar Medical 952 Gruene Road, Ste.

3 150 New Braunfels, Texas 78130 Phone: (830) 626 9911 | Fax: (830) 626 9922 Consent for Purpose of Treatment, Payment, Health Care Operations and Notice of Privacy Practices Iconsenttotheuseordisclosureofmyprotecte dhealthinformationbyLonestarMedical,fort hepurposeofdiagnosingor providingtreatmenttome, , ,JanDubensky, ,orSueBrandt, upon my consent as evidence by my signature on this document. IunderstandIhavetherighttorequestarestri ctionastohowmyprotectedhealthinformation isusedordisclosedtocarry outtreatment, ,ifLonestarMedicalagreestoarestrictionth atIrequest,therestrictionisbinding between Lonestar Medical and _____. (Write PATIENT s name here) Ihavetherighttorevokethisconsent,inwriti ng,atanytime, , ,JanDubensky, , Sue Brandt, , or Lonestar Medical has taken action in reliance on the consent.

4 My ProtectedHealthInformation meanshealthinformation,includingmydemogr aphicinformation,collectedfromme andcreatedorreceivedbymyphysician,anothe rhealthcareprovider,ahealthplan,myemploy erorahealthcare ,present,orfuturephysicalormentalhealtho r condition and identifies me or there is a reasonable basis to believe the information may identify me. IunderstandIhavearighttoreviewLonestarMe dical myprotectedhealthinformationthatwilloccu rinmytreatment,paymentofmymedicalclaimso rintheperformanceof my protected health information. arevisedNoticeofPrivacyPracticesbycallin gtheofficeandrequestingarevisedcopybesen tinthemailoraskingforone at the time of my next appointment. _____ Signature of PATIENT or Personal Representative Name of PATIENT or Personal Representative _____ Date Description of Personal Representative s Authority I am giving authorization to Lonestar Medical to disclose my medical and insurance information to the below person(s).

5 _____ _____ Person(s) to whom information may be disclosed Person(s) to whom information may be disclosed _____ Signature of PATIENT or Personal Representative Date Lonestar Medical 952 Gruene Road, Ste. 150 New Braunfels, Texas 78130 Phone: (830) 626 9911 | Fax: (830) 626 9922 PATIENT intake form Name : _____ Date of Birth : _____ Date of Encounter : _____ Reason for visit / Current Problem : _____ _____ Allergies ? Yes or No If yes, what? _____ Asthma ? Yes or NoDiabetes ? Yes or No List of Medications : Past Medical History : _____ _____ Surgical Medical History : _____ _____ Family History : _____ _____ Social History : Smoker? Yes or No If yes, how long? _____ Quantity: _____ Alcohol? Yes or No If yes, how often?

6 _____ Marital Status : Married Single Divorced Widowed Exercise? Yes or No If yes, how often? _____ Recreational Drug Use? Yes or No If yes, how often? _____ Staff Initials and Date: _____ Lonestar Medical 952 Gruene Road, Ste. 150 New Braunfels, Texas 78130 Phone: (830) 626 9911 | Fax: (830) 626 9922 OFFICE AND COLLECTION POLICIES Office Visits you the highest quality of care. atleastthreehours priorthe scheduledappointmenttimemaybesubjecttoac ancellationfeeof$ $ $ require more than a signature and for writing letters each time these services are provided. Always bring a current list of all your medications with the exact dosages to each office visit.

7 Office Hours Monday Thursday: 8:30am 5:00pm and Friday: 8:30am 3:00pm (closed for lunch most days 12:30pm 1:30pm) Allergy shot patients must come in no later than 30 minutes prior to closing. Telephone Calls hourandweekend calls resulting in telephone treatment, may be billed a telephone consultation fee from $ to $ Non Urgent Pharmacy Request hourvoicemailbox forourpatientstoleavenon weekdays. Our policy is to complete your request by calling your pharmacy within 24 hours of the message being left. Any prescription requested after 12pm on Friday will be refilled the following business day. After Hours Calls ,aphysicianfromourcallgroupcanbe ,alwaysgotoanemergencyroomwhereyouwillre ceive ,callourofficefirstbeforegoingtotheemerg enceroom;manyproblemscanbehandledoverthe telephone.

8 Lonestar Medical 952 Gruene Road, Ste. 150 New Braunfels, Texas 78130 Phone: (830) 626 9911 | Fax: (830) 626 9922 Privacy and Security LonestarMedicalholdsallinformationpertai ningtothecareandtreatmentofourpatientsin thestrictestconfidence. Allinformationinthepatient smedicalrecordismaintainedwiththeutmostc areandrespecttopreserveprivacyand smandatedHIPAA requirementsfor ,youwillbeaskedtoreviewand acknowledgereceiptofourNoticeofHIPAAP rivacyPracticethatoutlinesthecircumstanc eforwhichwecandisclose necessaryforLonestarMedicaltodisclosepro tectedhealthinformationforinstancesnotre latedtoyourongoing treatment and/or payment of claims. A PATIENT may request to view a copy of their medical record in the office. Collection Policy obligationtotheinsurancecompaniestheyare contractedwithtocollectcopayments,deduct ibles,andcoinsurance.

9 Onceabalancereaches90daysold,regardlesso fpaymentreceived,itmaybetransferredtoath irdpartyforfurther collections or other actions. I have read and understand the office and collection policies of Lonestar Medical. Signature Printed Name Date Lonestar Medical 952 Gruene Road, Ste. 150 New Braunfels, Texas 78130 Phone: (830) 626 9911 | Fax: (830) 626 9922 ADVANCE PRACTICE NURSE CONSENT FOR TREATMENT Lonestar Medical has on staff an advance practice nurse to assist in family medical care. practicenursecandiagnose,treat,andmonito rcommonacuteandchronicdiseasesaswellas ,theadvancepracticenursemaytreatminor lacerations and other minor injuries. Ihavereadtheabove,andherebyconsenttothes ervicesofanadvancepracticenurseformy health care needs.

10 IunderstandthatatanytimeIcanrefusetoseet headvancepracticenurseandrequesttosee a physician. _____ Signature of PATIENT /Legal RepresentativeDate _____ Name of PATIENT /Legal Representative Lonestar Medical 952 Gruene Road, Ste. 150 New Braunfels, Texas 78130 Phone: (830) 626 9911 | Fax: (830) 626 9922 PATIENT PORTAL USER AGREEMENT LonestarMedicalispleasedtoprovideaPatien tPortalinpartnershipwithourelectronicmed icalrecordsprovider, physician communication. All users must be established by a previous office visit. records, ,byusingthePatientPortal,theuseragreesto providefactual and correct information. The PATIENT Portal provides access to the following services; which may or may not be utilized at this time: Request prescription refills Receive educational material View current and past statements Send messages to clinical staff Receive health maintenance reminders ThePatientPortalis apply: PATIENT is SEEN by a medical provider in our office.