HTFM Patient Portal - Publicforms

Available Forms

*1 New Patients: Consent for Treatment & Payment & Acknowledgements *2 New Patients: Cancellation & No Show Agreement *3 New Patients: Text Messaging *4 New Patients: Patient Financial Responsibility *5 New Patients: Updox Patient Portal *6 New Patients: Telehealth (VideoChat)Consent form *7 New Patients: Alternate Phone/Person *8 New Patients: Address and Insurance form *9 New Patients: Medical Records Request To Us 10) New Patients: Please Read! Thank you! 24) Patients Rights & Responsibilities 27) Telehealth (VideoChat) Consent form 31) Address and Insurance Update form 34) Consent for Payment Plan 35) Medical Records Request From Care Management Request for Medicare CCM Staff Log Patient Satisfaction Survey Prescription Refill Request

*1 New Patients: Consent for Treatment & Payment & Acknowledgements

Consent to Medical Care

The undersigned consents to any laboratory, imaging, anesthetic, medical, surgical or emergency treatment and / or clinic services rendered the patient under the instruction of the Provider. The patient understands that no guarantee or assurance has been made as to the results that may be obtained during treatment. The patient also consents to observation of the patient during administration of medical treatment, surgical or diagnostic procedures of the purpose of education of students whose presence is deemed appropriate by the attending Provider.

Release of Patient Information

The undersigned hereby consents that Home Towne Family Medicine may release to the guarantor?s insurance company, or any third party payer, pertinent information related to the medical treatment including: HIV testing and treatment, sexually transmitted disease testing and treatment, psychiatric, alcohol and drug treatment records in order to secure contractual payments of services rendered (unless a restriction has been requested, the see restriction agreement).

Assignment of Insurance Benefits

In the event the patient is entitled to medical benefits of any type whatsoever arising out of any policy of insurance insuring the patient or any other party liable to the patient, such benefits are hereby assigned to Home Towne Family Medicine for application to patient?s bill. The patient my be responsible for 100 % of charges not covered by this assignment. Patients eligible for Medicare hereby authorize Home Towne Family Medicine to bill and collect from Medical directly. Any charges not covered by Medicare or any supplementary insurance may be the responsibility of the patient.

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By checking this box, I acknowledge the opportunity to review the ?Notice of Privacy Practices?.

this item can be found http://hometownedoc.com/Privacy.html

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By checking this box, I acknowledge the opportunity to review the ?Patient Rights & Responsibility? notice.

This item can be found within the forms window

Check here if you wish to have a copy of the Notice of Privacy practices and Rights and Responsibilities emailed to you.

That he / she has read the foregoing, and is the patient, or is duly authorized by the patient as his / her legal representative to execute the about and accept its terms. If competent, the patient should sign in space indicated. If a minor, or incapable of signing, responsible representative should sign in the space indicated.

The Undersigned Certifies

Patient Name *

Date of Birth *

Today's Date *

Permission to Treat Minors

I, the undersigned, give permission to the Home Towne Family Medicine providers to treat for any medical or surgical problem that may arise during my absence.

Full Name of Parent or Gurdian

Complete only if applicable

Relationship to patient

Complete only if applicable

* Required field