Pride Family Medicine & Aesthetics

Welcome to Pride Family Medicine and Aesthetics.

We are glad to have you as a patient. Please fill out this secure form to be included in your medical record. We are requesting this information to expedite your visit. When finished, please click the "NEXT" button to sign our HIPAA, Patient Bill of Rights and Payment policies. Click "SUBMIT" after signing the Payment Policy. If you prefer not to fill out the secure forms online, please arrive at least 20 minutes prior to your appointment to fill out the paperwork. Thanks!

Reason for your visit today: * How did you hear about us? *

Patient Demographics

First Name (legal) * First Name (preferred) Middle Name Last Name * Date of Birth * Gender Identity * Gender Assigned at Birth * Street Address * City * State * Zip/ Postal Code * Email * Home Phone * Cell Phone * Work Phone Contact Preference * Ok to leave lab results/ health-related messages? * Preferred pharmacy * Pharmacy address/ phone number * Employer Occupation Marital Status Emergency contact * Emergency phone * Relation to patient * Race Ethnicity Language preference

Insurance Information

Do you have insurance? (If no, please write "no") * Which insurance plan? Member ID/ Policy number Group number Provider/ customer service number on back of card Do you have secondary insurance? Which insurance plan? Member ID/ Policy number Group number

SKIN HEALTH- This section is required for Aesthetic services

Medical patients are welcome and encouraged to complete this section.

Skin disease history Other skin disease history Areas of concern Other areas of concern Treatments of interest Other treatments of interest When under sun, my skin: Have you had plastic surgery to face/neck? Have you had Botox or Xeomin before? Have you had dermal fillers before? Do you have tattooed makeup? Do you sunbathe/tan?

Medical History

Are you allergic to any medications? * Any eviromental allergies? * Are you taking any medications? * Please list prior surgeries Prior medical conditions (check all that apply) Any other conditions

Assigned Female at Birth Only

Are you pregnant? Number of pregnancies Number of miscarriages Number of abortions Number of living Last Pap Smear Last Mammogram Birth control method

Lifestyle Factors

Do you drink alcohol? If yes, how many drinks per week? Do you smoke? If yes, how many packs per day, and how long have you smoked? Do you use recreational drugs? If yes, please list drug type and frequency Are you sexually active? If yes, # of partners in the last year I have sex with: How many caffinated drinks a day? How many hours do you spend exercising per week?

FAMILY MEDICAL HISTORY

Father History Other Father health issues: Mother history Other Mother health issues: Sibling history Other Sibling health isses: Father's Father Other health issues: Father's Mother Other health issues: Mother's Father Other health issues: Mother's Mother Other health issues: Any other pertinent family health issues:

By typing my name below, I attest that the information provided in this Health History Form is true and correct. I understand that the information will be used solely for the purpose of providing individualized care and will comply with the HIPAA Privacy Policy at Pride Family Medicine and Aesthetics.

Full legal name: * Relation to patient * Guardian name (if applicable):

HIPAA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

Our Responsibilities: We are required by applicable federal and state law to maintain the privacy of your protected health information. "Protected health information" (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your PHI. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect January 1, 2017, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all PHI that we maintain, including PHI we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.

Uses and Disclosures of Protected Health Information:

Treatment: We may use or disclose your PHI to a physician or other health care provider providing treatment to you. We may use or disclose your PHI to a health care provider so that we can make prior authorization decisions under your benefit plan.

Payment: We may use and disclose your PHI to make benefit claims for the health care services provided to you. We may disclose your PHI to other entities subject to the federal Privacy Rules for payment purposes. Payment activities may include processing claims, determining eligibility or coverage for claims, issuing premium billings, reviewing services for medical necessity, and performing utilization review of claims.

Health Care Operations: We may use and disclose your PHI in connection with our health care operations. Health care operations include the business functions conducted by a health insurer. These activities may include providing customer services, responding to complaints and appeals from members, providing case management and care coordination, conducting medical review of claims and other quality assessment and improvement activities, establishing premium rates and underwriting rules. In certain instances, we may also provide PHI to the plan sponsor of a group health plan. We may also in our health care operations disclose PHI to business associates with whom we have written agreements containing terms to protect the privacy of your PHI. We may disclose your PHI to another entity that is subject to the Federal Privacy Rules and that has a relationship with you for its health care operations relating to quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, case management and care coordination, or detecting or preventing healthcare fraud and abuse.

Disaster Relief: We may use or disclose your PHI to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.

Health Related Services: We may use your PHI to contact you with information about health-related benefits and services or about treatment alternatives that may be of interest to you. We may disclose your PHI to a business associate to assist us in these activities. We may use or disclose your PHI to encourage you to purchase or use a product or service by face-to-face communication or to provide you with educational material or medicine samples.

Public Benefit: We may use or disclose your PHI as authorized by law for the following purposes deemed to be in the public interest or benefit: as required by law; for public health activities, including disease and vital statistic reporting, child abuse reporting, certain Food and Drug Administration (FDA) oversight purposes with respect to an FDA-regulated product or activity, and to employers regarding work-related illness or injury required under the Occupational Safety and Health Act (OSHA) or other similar laws; to report adult abuse, neglect, or domestic violence; to health oversight agencies; in response to court and administrative orders and other lawful processes; to law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims, suspicious deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of identifying or locating a suspect or other person; to avert a serious threat to health or safety; to the military and to federal officials for lawful intelligence, counterintelligence, and national security activities; to correctional institutions regarding inmates; and as authorized by and to the extent necessary to comply with state worker's compensation laws. We will make disclosures for the following public interest purposes, only if you provide us with a written authorization or when disclosure is required by law: to coroners, medical examiners, and funeral directors; to an organ procurement organization; and in connection with certain research activities.

On Your Authorization: You may give us written authorization to use your PHI or to disclose it to another person and for the purpose you designate. If you give us an authorization, you may withdraw it in writing at any time. Your withdrawal will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your PHI for any reason except those described in this notice. We will make disclosures of any psychotherapy notes we may have only if you provide us with a specific written authorization or when disclosure is required by law.

Personal Representatives: We will disclose your PHI to your personal representative when the personal representative has been properly designated by you and the existence of your personal representative is documented to us in writing through a written authorization.

Use and Disclosure of Certain Types of Medical Information. For certain types of PHI we may be required to protect your privacy in ways more strict than we have discussed in this notice. We must abide by the following rules for our use or disclosure of certain types of your PHI:

- Communicable Disease Test Results. We may not disclose the result of any communicable disease test, unless the disclosure is required by law or the disclosure is to you, your personal representative, a physician or other person who ordered the test, or a health care worker who has a legitimate need to know the results of the test for safety purposes, or pursuant to an authorization signed by you.

- Genetic Information. We may not disclose genetic information unless the disclosure is authorized under state or federal criminal law and the disclosure relates to identifying an individual in the course of a criminal or judicial proceeding; is required under specific order of a state or federal court; is authorized under state or federal law to establish paternity; is made to a blood relative of a decedent for purposes of medical diagnosis; or is made to identify a decedent.

- Status as Victim of Family Violence. We may not disclose your status as a victim of family violence unless the disclosure is to you; to a physician or health care provider for the provision of health care services; to a licensed physician designated by you; as required by law or pursuant to an order of the Texas Insurance Commissioner or a court order; to our attorneys; or when necessary for our payment and healthcare operations, a party to a sale of all or part of our business or to medical and claims personnel we contract with, providing we cannot without undue hardship first segregate the medical information in a way that does not disclose your status as a victim of family violence.

- Mental Health Information. We may not disclose your mental health information except for the same purposes for which we received the information or as may be required by law.

- Confidential Communications from a Physician. We may not disclose confidential information about you that we receive from a physician for any purpose other than for which we received the information or as may be required by law.

- Medical Information Maintained by Medicare, Medicaid or third-party insurance. Your medical information that is maintained by our office may only be disclosed for payment and health care operations purposes or as allowed by Texas law pertaining to insurance billing operations.

- Medical Information We Receive While Performing Utilization Review. If we collect or receive your medical information while performing utilization review activities, we may not disclose that information unless the disclosure is required by law or to an individual or entity that we have contracted with to aid us in performing utilization review.

- Research: We may use data collected for ongoing research. We may collect or study existing data, documents, records, pathological specimens, or diagnostic specimens, if these sources are available or if the information is recorded by the investigator in such a manner that subjects cannot be identified, directly or through identifiers linked to our patients. In any regard, you will receive additional information and/or consent forms if your data will be used for research; and you will be given the chance to examine the purpose or intent of the study before your data is used.

Individual Rights: You may contact us using the information at the end of this notice to obtain the forms described here, explanations on how to submit a request, or other additional information.

Access: You have the right, with limited exceptions, to look at or get copies of your PHI contained in a designated record set. A "designated record set" contains records we maintain such as enrollment, diagnoses, treatments, and case management records. You must make a request in writing to obtain access to your PHI. If we deny your request, we will provide you a written explanation and will tell you if the reasons for the denial can be reviewed and how to ask for such a review or if the denial cannot be reviewed.

Disclosure Accounting: You have the right to receive a list of instances since April 14, 2003 in which we or our business associates disclosed your PHI for purposes, other than treatment, payment, health care operations, or as authorized by you, and for certain other activities. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. We will provide you with more information on our fee structure at your request.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your PHI. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Any agreement we may make to a request for additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf. We will not be bound unless our agreement is in writing.

Confidential Communication: You have the right to request that we communicate with you about your PHI by alternative means or to alternative locations. You must make your request in writing. This right only applies if the information could endanger you if it is not communicated by the alternative means or to the alternative location you want. You do not have to explain the basis for your request, but you must state that the information could endanger you if the communication means or location is not changed. We must accommodate your request if it is reasonable, specifies the alternative means or location, and provides satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right, with limited exceptions, to request that we amend your PHI. Your request must be in writing, and it must explain why the information should be amended. We may deny your request if we did not create the information you want amended and the originator remains available or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement to be attached to the information you wanted to be amended. If we accept your request to amend the information, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.

Right to Receive a Copy of the Notice: Although you are provided a copy of this notice on the day of your first visit, you may request a copy of our notice at any time.

Questions and Complaints: If you want more information about our privacy practices or if you have questions or concerns, please contact: Practice Coordinator, Pride Family Medicine and Aesthetics, 1201 North Lakeline Blvd., Suite 400, Cedar Park, TX 78613. If you are concerned that we may have violated your privacy rights, you may complain to us using the contact information listed above. You also may submit a written complaint to the U.S. Department of Health and Human Services; see information at its website: www.hhs.gov. If you request, we will provide you with the address to file your complaint with the U.S. Department of Health and Human Services. We support your right to the privacy of your PHI. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Communication Preference: You may indicate your communication preference in our separate PATIENT INTAKE FORM. If you did not fill the form, your default communication preference will be by telephone at the number you gave on file and we will leave general messages only if necessary.

By typing my name below, I am attesting that I have reviewed and understand the HIPAA privacy policy at Pride Family Medicine and Aesthetics.

Full legal name: * Relation to patient * Guardian name (if applicable):

PATIENT?S BILL OF RIGHTS STATEMENT AND TREATMENT CONTRACT

Patients at Pride Family Medicine and Aesthetics have certain rights and responsibilities. We recognize that a respectful relationship between the healthcare provider and the patient is the foundation of proper medical care.

PATIENTS HAVE THE RIGHT TO:

- Receive humane care and treatment with respect and consideration

- Privacy and confidentiality when seeking or receiving care except for life-threatening conditions

- Confidentiality of your health records

- Be informed of and to exercise the option to refuse participation in any research aspect of your care without compromising access to medical care and treatment

- Receive accurate information regarding diagnosis, treatment, risks involved, and prognosis of illness or health related condition

- Ask about reasonable alternatives to care

- A second professional opinion regarding one?s health care and treatment

- Participate actively in decision regarding ones treatment

- Accessible information regarding the scope and availability of services

- Be informed about any legal reporting requirements regarding any aspect of screening or care

PATIENTS HAVE THE RESPONSIBILITY TO:

- Provide complete information about one?s illness or problem to enable proper evaluation and treatment

- Ask questions so that an understanding of the condition or problem is ensured

- Show respect to health personnel and other patients

- Reschedule/cancel an appointment so that another person may be given that time slot

- Pay bills and/or file health claims in a timely manner

- Use prescription and medical devices for oneself only

- Inform the provider if one?s condition worsens or an unexpected reaction occurs from a medication

MISSED APPOINTMENT FEES

To ensure the above, patients must call the clinic at least 24 hours in advance in order to cancel an appointment. Failure to call the office within 24 hours of canceling or missing an appointment will result in a missed appointment fee.

To ensure adequate time spent with patients, Pride Family Medicine and Aesthetics accepts patients by appointments only. Patients who come to the clinic on a walk-in basis may have to wait a longer period of time to see the provider. Consequently, there is no guarantee that walk-in patients may be seen unless there is a cancellation.

Patients will be charged a fee in the amount of $25.00 for failure to keep office visits and $50.00 for procedure visits scheduled at an hour or more of the providers time without 24-hour notice. Three missed appointments without 24-hour notice may result in dismissal as a patient.

RESCHEDULING APPOINTMENTS

Patients may call the office up to 24 hours before the scheduled time to reschedule an appointment. If a patient calls to reschedule an appointment that is scheduled within the next 24 hours, it will be considered a missed appointment. Additionally, we cannot reschedule an appointment that has already been rescheduled. For this instance, it will be considered a missed appointment as well.

MEDICATION REFILLS

Standards of Care set forth by medical certifying bodies in conjunction with clinic procedures dictate how often patients should be seen between medical visits and issuance of medication refills. Some medications and conditions require patients to be seen in the clinic before refills are made ? usually every three months for most chronic conditions. The office routinely checks and verifies prior patient prescriptions through the Texas Prescription Authority, the patient's pharmacy and patient's insurance company.

CONTROLLED SUBSTANCE MEDICATIONS

Pride Family Medicine and Aesthetics does not provide ongoing pain management and psychiatric services. No refills of certain medications for the above conditions are given on a routine basis. Patients are referred to a specialist at the discretion of the care provider when the above medications are required for long-term treatment. Additionally, all patients requesting controlled substance medications, will be subject to monitoring via the Prescription Access in Texas online database.

UNINSURED HOSPITAL ADMISSIONS

SELF-PAY patients will be provided outpatient care only. No providers from Pride Family Medicine will admit self-pay patients in any hospital. Self-pay patients who are admitted in a hospital will be assigned to an admitting physician per the hospital?s program for non-insured patients.

MID-LEVEL PROVIDERS

Pride Family Medicine uses Nurse Practitioners for the care and treatment of medical patients. All Nurse Practitioners are licensed with the state of Texas and operate under the supervision of Dr. Michael Martin, MD. A Nurse Practitioner is not a medical doctor, but is a registered nurse who has completed advanced nursing education (generally a master's degree or doctoral degree) and training and can diagnose, treat and monitor common acute and chronic diseases as well as provide health maintenance care. In addition, NPs can treat minor lacerations and other minor injuries. Pride patients will always be scheduled with a Nurse Practitioner, and patients have the right to request to been seen by an MD at another facility.

By typing my name below, I am attesting that I have read, understand and agree to the above statements. Furthermore, I had a chance to ask questions from a representative at Pride Family Medicine and Aesthetics and those questions were adequately answered to my satisfaction.

Full legal name * Relation to patient * Guardian name (if applicable):

PAYMENT POLICY

Pride Family Medicine and Aesthetics appreciates the confidence you have shown us in choosing us to provide for your health and skincare needs. The services you have elected constitute a financial responsibility on your part that obligates you to ensure payment in full of our fees. Please keep in mind that medical insurance generally only covers medical visits and rarely Aesthetics procedures. Your medical insurance is a contract between you and your insurance company. As a courtesy we will verify your coverage and bill your insurance carrier on your behalf. However, you are ultimately responsible for full payment of your bill and our office cannot guarantee that your carrier will pay your claim.

You are responsible for payment of any deductible and co-payment/co-insurance as determined by your contract with your insurance carrier. Payment is due at the time service is rendered. This includes co-pays. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amounts not covered by your insurer. If your insurance carrier denies any part of your claim, you will be responsible for your balance in full. Our office will not enter into a dispute with the insurance carrier over a claim, although we will be happy to assist wherever possible. If an insurance payment is mistakenly sent to the patient, instead of the office for service rendered, the patient is expected to provide payment with 10 days of receipt along with the Explanation of Medical Benefit statement provided by your insurance.

LATE CANCELLATION AND NO SHOW POLICY:

Patients must call the clinic at least 48 hours in advance in order to cancel an appointment or reschedule to a later date. Failure to call the office within 48 hours of canceling/rescheduling or missing an appointment will result in a missed appointment fee. Patients will be charged a fee in the amount of $50.00 for failure to keep medical office visits and consultations and $75 for procedure visits without 48-hour notice.

PAYMENT METHODS:

Pride Family Medicine and Aesthetics accept the following payment methods: cash, credit card, debit card, Health-Savings account (HSA) cards and CareCredit. In addition, Pride Aesthetics offers in-house financing for some multiple-treatment skincare packages. We do not accept personal checks.

I have read the above policies regarding my financial responsibilities to Pride Family Medicine and Aesthetics for providing a medical and/or medical spa service to me. If I do not have health insurance or am having an Aesthetics procedure, I agree to pay the practice the full and entire amount of treatment given to me at each visit. I authorize my insurer to pay any benefits directly to Pride Family Medicine and Aesthetics, and that I will pay the full and entire amount of any bill incurred by me and if applicable any amount due after payment has been made by my insurance carrier.

I agree to pay any costs incurred by Pride Family Medicine and Aesthetics in collecting any amount due including, without limitations collection agency fees and attorney?s fees. I understand that any outstanding balance not paid within 90 days of my office visit date, may be subject to a late fee.

By typing my name below, I am attesting that I have reviewed and understand the Payment policy at Pride Family Medicine and Aesthetics.

Full legal name * Relation to patient * Guardian name (if applicable):