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:

Please Read Carefully and Sign

Payment is due at time of service. We collect payment for services before your visit. Any remaining balance due will be collected upon checkout. After submitting the claim to insurance, if any remaining patient responsibility exists, you will receive a bill.

If you wish for us to file your medical insurance, you must provide us with a current copy of your insurance card.

If we are unable to obtain verification of your benefits from your insurance company, you will be required to pay the full amount due, at the time of service.

If your insurance denies your claim, you will be responsible for any remaining balance.

While we will do our best to obtain your benefits from your insurance company, you are ultimately responsible for knowing your insurance coverage information. For example, what your plan does and does not cover; any deductibles, co-insurance, or co-pays you are responsible for.

If we cannot fully verify your health plan coverage or benefits from your insurance company, we reserve the right to bill you for any additional amount your insurance company informs us is assigned to patient responsibility after processing your claim.

If you do not possess health insurance and are "self pay", you are responsible for the full amount due at the time of service.

Worker's Compensation: If the patient is not self employed, they are not subject to any financial responsibility for unpaid balances.

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

By electronically signing below, I am agreeing to all the terms above and that I understand that I am responsible for payment at the time when services will be rendered. I also understand that my total when checking out is an estimate of my financial responsibility, and give Clay Primary & Family Care, LLC the right to bill me for any remaining balance that may result after the insurance company has processed my claim. Finally, I understand that any unpaid balance may result in my personal information being sent to a collections company, for the purpose of collecting my past due debt.

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 Patient Consent for Use and Disclosure of Protected Health Information

I hereby give my consent for Clay Primary & Family Care, LLC to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by Clay Primary & Family Care, LLC describes such uses and disclosures more completely.)

I have the right to review the Notice of Privacy Practices prior to signing this consent. Clay Primary & Family Care, LLC 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, "Attn: Compliance Officer at 865 Blanding Blvd., Orange Park, Fl 32065".

With this consent, Clay Primary & Family Care, LLC may call my home or other alternative location 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, Clay Primary & Family Care, LLC may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards, patient statements, and medical records.

With this consent, Clay Primary & Family Care, LLC may electronically (text, patient portal, etc) send any items that assist the practice in carrying out TPO, such as appointment reminders, and patient statements, and medical records. I have the right to request that Clay Primary & Family 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.

With this consent, Clay Primary & Family Care, LLC and all its agents may report or otherwise cooperate with any law enforcement officials or regulatory agencies in any investigation which may arise as a result of, or related to, my receiving controlled substances as a patient of Clay Primary & Family Care, LLC, or if Clay Primary & Family Care, LLC or its agents suspect illegal activity.

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, Clay Primary & Family Care, LLC may decline to provide treatment to me.

By signing this form, I am consenting to allow Clay Primary & Family Care, LLC to use and disclose my PHI to carry out TPO.

Patient Signature: *