Clay Primary & Family Care, LLC

Adult Patient Information

Last Name: * First Name: * Middle Name: Date of Birth * Social Security Number: * Street Address: * City * State: * Zip Code: * Sex: * Email Address: Cell Phone Number: Home Phone Number: Employer: Work Number:

Emergency Contact Information:

Last Name: First Name: Date of Birth: Relationship to Patient: Home Phone Number: Cell Phone Number: Work Phone: Patient Signature: *

Insurance Information:

Name of Insurance: ID Number: Group Number: Effective Date: Patient's Relationship to Subscriber: Subscriber's Name: Subscriber's Date of Birth:

Financial Policy and Assignment of Benefits

Payment is due at the time services are rendered. We collect payment for services prior to your visit, and any remaining balance due will be collected at checkout. If you wish for us to file claims with your medical insurance, you must provide a current and valid copy of your insurance card and any other required information.

While we make every reasonable effort to verify insurance benefits and eligibility, verification of benefits is not a guarantee of payment. You are ultimately responsible for understanding your insurance coverage, including but not limited to: Covered and non-covered services, Deductibles, Co-payments, Co-insurance, Referral or authorization requirements. If we are unable to verify your insurance coverage or benefits at the time of service, you may be required to pay the estimated amount due at the time services are rendered.

If your insurance company denies, reduces, or does not pay all or part of your claim, you are responsible for any remaining balance determined to be patient responsibility after claim processing.

Any amount collected at checkout is an estimate based on the information available at the time of service. Additional balances may remain after your insurance company has processed your claim, and you agree that Clay Primary & Family Care, LLC may bill you for any remaining patient responsibility.

WORKER'S COMPENSATION:

For Worker?s Compensation claims, if the patient is not self-employed, the patient is generally not personally responsible for balances determined to be covered under applicable Worker?s Compensation laws.

MISSED APPOINTMENTS AND CANCELLATION POLICY:

To help ensure appointment availability for all patients, Clay Primary & Family Care, LLC requests at least 24 hours? notice for appointment cancellations or rescheduling. Patients who fail to appear for a scheduled appointment without notice (?no-show?) or who cancel less than 24 hours before the appointment time may be charged:

$25.00 for regular office visits.

$50.00 for extended appointments, including physicals and procedures.

Outstanding no-show balances may be required to be resolved prior to scheduling future routine appointments. We understand emergencies may occur and reserve the right to waive fees at the discretion of the practice.

ASSIGNMENT OF BENEFITS & AUTHORIZATION:

By electronically signing below, I authorize the release of medical and other information necessary to process claims for medical services rendered. I authorize payment of medical benefits directly to Clay Primary & Family Care, LLC for services rendered, medical equipment provided, and products used in my care and treatment. I request payment of authorized government or insurance benefits either to myself or to the party who accepts assignment.

COLLECTIONS POLICY:

I understand that unpaid balances may be subject to collection activity. If my account becomes delinquent, I understand that my account and limited personal information necessary for collection efforts may be forwarded to a collections agency or other third party acting on behalf of Clay Primary & Family Care, LLC for the purpose of collecting the outstanding balance.

ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY:

By electronically signing below, I acknowledge that I have read, understand, and agree to the terms above. I understand that I am financially responsible for charges determined to be my responsibility by my insurance carrier or otherwise owed by me.

Patient Signature: *

Past Medical History

Personal Medical History: If cancer was selected, provide details: List any other Medical Conditions: Current Medications / Dose/ Frequency: Preferred Pharmacy: Preferred Pharmacy Number: Drug Allergies / Reaction: Environmental allergies: Other Allergies: Past Surgery:

Social History

Select which one best describes your relationship with tobacco: Marital Status Occupation: Do you drink alcohol: Type of alcohol: How many drinks per day: Do you use recreation marijuana? Do you use other recreational drugs? List other recreational drugs used: Have you ever used needles to inject drugs? Have you ever taken someone else's drugs?

Family Medical History

Family History: If cancer was selected what type: Any other family history: For any condition selected above, please provide details:

HIPAA Acknowledgment and Communication Consent

I understand that a copy of the Notice of Privacy Practices of Clay Primary & Family Care, LLC is posted within the office, available to me upon request, and that I have been offered access to it.

I understand that my protected health information (PHI) may be used and disclosed for purposes of treatment, payment, and healthcare operations (TPO) as permitted by federal and state law.

I understand that I have the right to request restrictions on certain uses and disclosures of my PHI. The practice is not required to agree to my request, but if it does, it will comply with the agreed restriction, except as otherwise required or permitted by law.

I authorize Clay Primary & Family Care, LLC to contact me regarding my care and account using the following methods: Telephone (including voicemail messages), Mail, Electronic communications (including text messages and patient portal). These communications may include appointment reminders, billing information, insurance matters, and clinical information. I understand that electronic communications may not be fully secure and accept the associated risks.

I understand that I may revoke my consent for communication in writing at any time, except to the extent that action has already been taken in reliance on it, and except where communication is required or permitted by law.

By signing below, I acknowledge that I understand the information above and consent to the communication methods described.

Patient Signature: *