Please, enter your first name followed by last name
Please, give the name of your Preferred pharmacy and its phone number
Please, enter your cell phone
If this cell phone is the best way to reach you, please check this box. If not, provide an alternate phone
Please, provide your email
Please, re-enter your email
Please, enter your complete address including your street address, city, state and zip code.
Individual to contact, in case of emergency
Indicate your relationship to emergency contact
Best phone to reach the Emergency Contact
Please, indicate if you have a HSA or a FSA account?
NOTE: You may use your HSA or FSA account for any of the Lifestyle Programs at Lifestyle Docs.
Please, indicate if you currently have medical insurance
Enter name of your Primary insurance company
Please, enter the name of the Insured person and their Social security number
Please, enter your relationship with the insured person
Enter Primary Insurance's Group no.
Enter Primary Insurance's ID number
If applicable, enter name of Secondary Insurance
Enter name of person with secondary insurance followed by their Social security number
Enter your relationship with the insured person
Enter the Group no. for Secondary insurance
Enter the ID number for the Secondary insurance
Consent to Treatment
I hereby authorize all medical personnel associated with Embee Lifestyle Docs to perform treatment that may be deemed necessary or advisable for my condition. I understand that I'm liable for payments of bill incurred.
NOTE: Typing your name in the signature line below will be equivalent to signing on a paper document.
Typing your name in this field will indicate giving consent to treatment as described above
I understand that this will divulge my medical condition and other personal medical information to other group member(s). I agree to keep all information that is shared in the group by other member(s) confidential and to not discuss such information outside of the group. I understand that I don?t have to share any personal information with the group or health care providers unless I choose to do so.
Only if you selected yes on the above field then typing your name in this field will be equivalent to signing your name on a paper document and will indicate your consent to participate in group visits/sessions.
Release of Information
I hereby authorize all medical personnel at Embee Lifestyle Docs to release my PHI(personal health information), that is information pertaining to my health care, test results, billing and/or accounting information to primary insurance company and secondary insurance company, if any. In addition, I authorize release of my PHI to the following individuals.
Please, include first and last name, followed by relationship to you. If you do not wish to give access to any other person, please, write None
Typing your name in this field will be equivalent to signing your name on a paper document and will indicate your consent to release of your health information to the individuals listed above
Insurance & Medicare Authorization
I hereby authorize release of information necessary to file a claim with my insurance company and assign benefits to Embee Lifestyle Docs and/or the doctor indicated on the claim. I understand I am financially responsible for any balance not covered by my Insurance carrier.
Typing your name here indicates your consent to assign benefits to Embee Lifestyle Docs from your insurance carrier. NOTE: Typing your name on the signature line below will be equivalent to signing a paper document.
I hereby authorize payment of Medicare benefits to be made on my behalf to Embee Lifestyle Docs for any services furnished to me. I hereby authorize release of medical information to Centers of Medicare and Medicaid and its agents any information needed to determine any benefits or benefits payable for payable related services. I understand I am financially responsible for any balance not covered by Medicare.
Typing your name here indicates your consent to assign benefits to Embee Lifestyle Docs from Medicare. NOTE: Typing your name on the signature line will be equivalent to signing a paper document
Financial Policy and other General Policies
I hereby acknowledge that I have reviewed and agree with the Financial Policy and other General Policies of this practice available on the website at lifestyledocs.com. I authorize Embee Lifestyle Docs, PLLC to charge my credit card for the various services as outlined on the Financial Policy.
Typing your name in this field will be equivalent to signing your name on a paper document. Please, sign in this field only after reviewing the Financial Policy and other General Policies document.