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Minor Patient Consent Form for Use and Disclosure of Protected Health InformationI, _______________________________ (Please Print Name) hereby give my consent as parent/legal guardian for Promenade Primary Care, LLC to use and disclose protected health information (PHI) about ______________________________ (Please Print Minor’s Name) to carry out treatment, payment and health care operations (TPO). The Notice of Privacy Practices provided by Promenade Primary Care describes such uses and disclosures more completely.I have the right to review the Notice of Privacy Practices prior to signing this consent. Promenade Primary Care reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the practice at Promenade Primary Care, 955 L’Enfant Plaza, PR#325, Washington DC 20024.With this consent, Promenade Primary Care, LLC may call my home or other alternative location that I have provided and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others. With this consent, Promenade Primary Care, LLC may mail to my home or other alternative location I have provided any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements.With this consent, Promenade Primary Care, LLC may e-mail to the address I have provided, or through the secure electronic patient portal any items that assist the practice in carrying out TPO, such as appointment reminders, patient statements and test results. I have the right to request that Promenade Primary Care, LLC restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I have read and understand the Notice of Privacy Practices and am consenting to allow Promenade Primary Care, LLC to use and disclose the above mentioned minor’s PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Promenade Primary Care, LLC may decline to provide treatment to me._______________________________________________________Print Patient’s NamePrint Guardian’s Name_____________________________________________________ ____________Print Guardian’s Relation to PatientGuardian Signature DateOffice Policies and ProceduresWe are an appointment-based practice with scheduled walk in hours. Outside of posted walk in hours, all patients must make an appointment to be medically evaluated and diagnosed in person. All telecommunications from our Nurse Practitioners are limited to INTERPRETATIVE services only.Operating Hours: Monday-Friday 7:30AM to 4:30PM, except Wednesday 7:30AM to NoonAfter Hours: If it is a Medical Emergency, call 911 immediately. For all non-emergency medical issues, please call our office and follow the phone instructions, or visit an after-hours clinic approved by your insurer. Please save other inquiries for business hours.Patient Conduct: By signing this form, the patient agrees to comport themselves in a professional and cordial manner with any of our office staff. Rude, aggressive, or other offensive behavior towards any member of our office will result in immediate patient dismissal.Patient Portal: All patients under the age of 65 must register for a portal account. The portal enables patients to receive their lab results, view reports, request refills, and communicate with the providers through a secure, HIPAA compliant website. Patients require an email address in order to use this system, and will receive an email notification when they receive a new health update.Service Expectations: Please allow at least 3 business days for our staff to complete pre-authorization requests, records requests, prescription refill requests, and form completions. This does not include the time needed for non-practice entities to complete requests.Health Insurance: We currently accept United Healthcare, Cigna, Aetna, Tricare, Blue Cross Blue Shield, and Medicare. We do not accept any form of Medicaid, even if it is within one of the accepted plans. It is the patient’s responsibility to provide accurate health insurance information in the form of an insurance card at the time of the visit and to know what type of coverage their plan provides.Financial Responsibility: By signing this form, the patient agrees to pay all co-pays, co-insurances, deductibles, outstanding balances or other fees at the time of their visit. Payment must be received before the appointment or we reserve the option to reschedule it. Our practice accepts cash, credit/debit cards, and personal checks as forms of payment. An outstanding balance that is not paid within 30 days of the patient receiving notice is considered PAST DUE, and will be forwarded to a collection agency.Cancellations: Please cancel an appointment NO LESS than 24 hours before the scheduled time. Repeated offenses to this policy will be tracked and could be subject for patient dismissal.Prescription Refills: All chronic (regularly taken) medications require regular follow-up visits at our office. Our Providers will let you know the appropriate interval between visits and schedule your next follow up appointment accordingly. If you are overdue for your visit, your provider may choose to provide you enough medication until your scheduled appointment (maximum 1 week) as a courtesy. Medications for acute problems (cough, fever, etc.) will require an office visit to ensure a correct diagnosis and appropriate medication is prescribed. If a patient needs a refill between office visits, please have your pharmacy send us an electronic refill request or send a request through the portal.Referrals: Many insurance companies now require referrals for a patient’s visit to specialists. An office visit is required for referrals.I hereby consent to all office policies and procedures listed in this form by signing below._____________________________________________Print Name_____________________________________________Date_________________________SignatureADULT PATIENT REGISTRATION FORMPLEASE PRINTToday’s Date:PCP:PATIENT INFORMATIONLast NameFirst NameM.I.DOB://Age:Sex: MFMarital Status:MarriedSingleDivorcedWidowedSocial Security #:Email Address:Street Address:City:State:Zip:Home #:Cell #:Work #:Employer Name & Address:Employer Phone Number:INSURANCE INFORMATIONPlease give your insurance card to the receptionist.Name Of Policy Holder:DOB://Address of Policy Holder:Relationship to Patient:SelfSpouseParentOther: Insurance Company:AetnaBlue CrossCignaMedicareTricareUnited Health CareOther: Group Number:Policy ID Number:SECONDARY INSURANCE INFORMATIONName Of Policy Holder:DOB://Address of Policy Holder:Relationship to Patient:SelfSpouseParentOther: Insurance Company:AetnaBlue CrossCignaMedicareTricareUnited Health CareOther: Group Number:Policy ID Number:EMERGENCY CONTACTName:Relationship:Phone:I attest that the above information is true to the best of my knowledge. I authorize Kelly Goodman, NP & Associates PC to charge my insurance based on the information I provided for services rendered. I acknowledge that I am responsible for all fees that are not covered by my insurance.685800107950052584351079500SignatureDatePATIENT HEALTH RECORDName: Date: What is your present problem(s): How long have you been bothered by the above? What have you done for your problem? Medical History (This confidential information helps us determine proper treatment and medication):Please indicate if you have ever had/or still have any of the following:AIDS/HIV infectionHepatitis/JaundiceAnemiaHerpesArtificial heart ValvesHigh/low blood pressureArtificial joints/implantsHives/skin rashesAsthmaKidney diseaseBack or neck problemsLiver diseaseBruise or bleed easilyPacemakerBulimia or anorexiaPsychiatric treatmentCancer/tumorRheumatic feverChemical DependencySeizuresChest painScarlet feverCortisone treatmentShortness of breathDiabetesSickle cell anemiaEpilepsy/neurological problemsStomach ulcersFainting or dizzy spellsStrokeGlaucomaPhlebitisHeart DiseaseThyroid DiseaseMitral Valve ProlapseUlcersHeart murmurOther:GoutOther:Are you allergic to:? Penicillin? Codeine? Local Anesthetics? Latex?Other: Have you been treated in the hospital in the past two years?? Yes? NoIf yes, please write reason for admittance: Please list all prescription drugs you are taking:Has your Physician advised you to pre-medicate before dental treatment?? Yes? NoDo you take vitamins regularly?? Yes? NoAre you taking hormones or birth control?? Yes? NoAre you pregnant or nursing?? Yes? NoHave you ever had a blood test for hepatitis?? Yes? NoHave you been vaccinated for hepatitis?? Yes? NoDo you use tobacco?? Yes? NoDo you consume alcohol?? Yes? NoHave you had surgery?? Yes? NoIf yes, please list type of surgery and year the procedure was done:Please tick the box if any immediate family members have any of the following:? Arthritis? Cancer? Diabetes? Heart Disease? High Blood Pressure? Kidney Disease? ObesityI HEREBY GIVE PERMISSION TO THE PROVIDER TO EXAMINE, DIAGNOSE AND TREAT ME AND ATTEST THAT THE ABOVE INFORMATION IS ACCURATE AND TRUE:Patient Signature: Date: REQUEST FOR ELECTRONIC ACCESS TO PROTECTED HEALTH INFORMATION (PATIENT PORTAL)Name: Date of Birth: Email Address: Our office provides an electronic patient portal free of charge to facilitate the distribution of lab results and otherinterpretative services. The patient portal is a one way system only from our office to the individual patient’s account. Through the portal you can:-Receive lab and test results and referrals from the clinic-Receive invoices-Request an appointment (please note this appointment is not finalized until our office confirms it)-Fill out and make changes to your medical history-View and update your medication list-View and update your health summary information-View and update your demographic information-View and update your insurance information-View and update your portal account password and emailThe system will send you an email when you initially create your portal account containing your automatically generated username and password. Please keep these in a safe place. The system will also send an email when a new message is sent to your account. The portal and its messages are encrypted in order to keep patient information private.Unfortunately, our practice cannot guarantee that the portal will be accessible 24/7. The portal may be inaccessible due to routine maintenance without prior notification. Our practice may also suspend or terminate the Portal without advance notice to the patient. Our practice and its staff have no liability or responsibility to any authorized person who is unable to access the portal.Please initial below:68580019685000I understand there are inherent risks in accessing my medical health record electronically, even though the data is encrypted.68580019685000I understand the patient portal is an added service and it is the medical provider’s right to grant or deny me access to my electronic health record.68580019685000If I have previously been granted access to the patient portal, I understand the practitioner may rescind my access to the patient portal at any time they feel necessary.I agree that the patient portal system is an interpretive service only and that all questions regarding my results or any other message sent to me through the system must be directed to the office of Kelly Goodman NP & Associates PC to receive a response.68580019494500I understand that it is my responsibility to promptly log into the portal to view messages regarding my health that are sent to me from my provider.Signature: Date: ................
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