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6. Existing patient update Demographics

*** For existing pt: Thank you for filling-out this form. REQUIRED fields: 1 last name, 2 first name, 3 birthday, 6 phone, 9 emergency contact, 14 Consent ***

We normally text pt. If you choose not to get a text, please let us know.

9a. Emergency Person's Name, relationship to patient, phone#

**** 1) PATIENT WILL BE CHARGE A $30 NO-SHOW FEE. To avoid the NO-SHOW fee, we are asking you to call us before your appointment if you are not able to show-up. Thank you.

**** 1) You are ultimately responsible for knowing what your plan does and does not cover and the administrative rules. (i.e. in-network / out-network; out-of-pocket balance, copayment, coinsurance, deductible , Health-Saving-Account balance; Labs/Radiology/EKG; authorizations and referrals) **** 2) As a courtesy, we will verify your insurance eligibility and benefits. However, we cannot guarantee that the information received, is accurate due to insurance policy changes and real-time/up-to-date system information. We will bill your insurance company with whom we have a contract agreement with.**** 3) Once your insurance company has processed a claim, any balance as determined by your insurance plan to be "patient's responsibility" and/or "non-covered service", will be your responsibility. ie. any copays, coinsurance, deductible, and fees. **** 4) If you disagree with the "patient responsibility" amounts due to our office per your insurance's Explanation-of-Benefits(EOB), please immediately call your insurance company and our office for further explanation. **** 5) Failure to provide current insurance information to our office and/or reply back to insurance's request for additional information may result in the entire bill being your responsibility.

CONSENT FOR TREATMENT: I have a condition or physical checkup requiring diagnostic, medical or surgical treatment; I hereby voluntarily authorize consent to such procedures, medical/surgical care and other services under the general and specific instructions of ST. MICHAEL MEDICAL CLINIC's Physicians, Nurse Practitioners, Medical Staff or their designee as is necessary in their judgment. *** I also acknowledge that the practice of medicine is not an exact science and that no guarantees have been made to me as to the result of treatment or examination by St. Michael Medical Clinic's Physicians, Nurse Practitioners, or Medical Staff. ***

I authorize ST. MICHAEL MEDICAL CLINIC, P.A. (a covered entity) which includes its Physicians, Nurse Practitioners, and Medical Staff to release any identifiable health and/or accounting information to other health care providers, health plans, health care clearinghouse, public health authority and life insurers deemed necessary to carry out health care operations and/or covered transactions on my behalf. *** I understand that I can revoke this authorization at anytime with a signed written consent except to the extent that the covered entity has already acted in reliance upon the authorization and/or for the purpose of obtaining payment for the covered transactions. ***


Narcotics (Norco, Hydrocodone, Fentanyl, Hydromorphone ...) -1- We are NOT a pain management clinic. -2- We will provide a short-term prescription for narcotics for acute pain, NOT for chronic pain management. -3- Urine drug screen will be checked every 3month (at your cost) with the prescription. -4- There will be intermittent blood work to monitor for any complication at least once per year. -5- We refer to pain management for chronic pain medication. -6- We will check the database for prescription of Control substances as required by regulations.


Benzodiazepines (Xanax, Ativan, Valium, Ambien, Klonopin, Librium ...) -1- We are NOT psychiatrists. -2- We will provide a short-term prescription for acute episodes of anxiety/panic attacks. -3- Urine drug screen will be checked periodically (at your cost) with the prescription to keep up with regulations. -4- We will refer to psychiatry for long-term management with benzodiazepine. -5- We will NOT write long-term benzodiazepine more than one month at a time. -6- We will require 3 months follow-up and monitoring for renewal of prescription. -7- There will be blood work to monitor for any complication at least once per year.


Amphetamines/stimulants and ADD medication (Vyvanse, Adderall, Dexedrine, Mydayis, Concerta ...) -1- We are NOT psychiatrists. -2- We will refer to psychiatry for diagnosis and evaluation to initiate ADD medication, and periodically if there is concerns about medication effectiveness -3- We will not write more than one month at a time. -4- Urine drug screen will be checked every 3month (at your cost) with the prescription. -5- Once established as our patient and confirmed diagnosis, we will manage the prescription writing one month at a time with follow-up every 3 months. -6- There will be blood work and an EKG to monitor for any complication at least once per year.


NOTE: Once you are done, click submit and you should see a green messages "... successfully submitted". *** A RED messages is an error. You need to correct and then click submit. THANK YOU

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