PATIENT INFORMATION

11 Years to 17 Years

 

Can messages be left on email?
Yes   No

Can messages be left on the phone?
Yes   No

Can messages be left on this phone?
Yes   No

Sex at Birth    
Male
Female

Gender Identity    
Male
Female

Sexual Orientation
Straight/Heterosexual   Gay/Homosexual
Bisexual   Other  

Can messages be left on this phone?
Yes   No

Race
White/Caucasian
Black/African American
Asian
Hispanic
Native American
Multiracial
Other  

Ethnicity
Non-Hispanic
Hispanic
Other/Unknown

Preferred Language
English
Spanish
Other  

Are you hearing    
impaired?
Yes
No

Do you require    
an interpreter?
Yes
No

(Person Responsible for Paying Bill)
Name

Relationship to Patient

Date of Birth

Do you have healthcare insurance?
Yes
No

Patient or Legal Representative Signature (required) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.

MEDICAL HISTORY

11 Years to 17 Years

 

(Dosage example: “10 mg.” –  How Taken example: “1 tablet daily”)
        

Add another medication?

Please list any Allergies to medications/foods (Reaction example: “rash, nausea, swelling”}
Add another substance?

Tetanus-Diphtheria Booster
Yes   No     Date

Influenza Vaccine (Flu shot)
Yes   No     Date

Pneumococcal Vaccine
Yes   No     Date

Tuberculosis (TB) Skin Test
Yes   No     Date

Hepatitis A Vaccine
Yes   No     Date

Hepatitis B Vaccine
Yes   No     Date

Human Papilloma Virus (HPV)
Yes   No     Date

Varicella Vaccine
Yes   No     Date

Please provide a copy of immunization record

Please tell us about any Surgeries you have had – you may indicate the month/year if known

 

Who lives with your child?

Any history of abnormal Pap Smear?
Yes
No

Are your periods regular?
Yes
No

Do you have pain with periods?
Yes
No

Is flow
Normal
Heavy
Light
Spotting

Notice of Privacy Practices

ACKNOWLEDGEMENT

 

Patient/Parent/Legal Guardian/Legally Responsible Person Signature (required) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.

PATIENT CONSENT

 

I consent to Barry Pointe Family Care (BPFC) physicians, practitioners, and other providers (“Provider”), their assistants and staff to provide medical and/or surgical treatment, testing, supplies, medications, services, equipment and other items deemed necessary for the patient named below. I have been informed of the nature and purpose of the proposed treatment, common side effects, risks, benefits, alternatives and estimated duration of treatment as applicable. I understand that I may withdraw consent to treatment and will inform the attending Provider of any decision to terminate treatment. I agree to provide at least 24 hours notice prior to cancelling an appointment and understand that failure to provide notice may result in a cancellation fee. In the event of an emergency while receiving care at BPFC, I authorize BPFC staff to arrange for care and treatment necessary to address the emergency medical condition.

I acknowledge that the patient or guarantor signing below is financially responsible for all charges for medical services provided by BPFC and payment is due on the date of service. If an insurance/health plan claim is filed by BPFC, I request that payment of all benefits be made directly to BPFC. I agree to pay for any services or out-of-pocket expenses which are not covered by insurance. I acknowledge receipt and acceptance of BPFC’s Payment Policies provided with this form. I acknowledge that I will be responsible for payment of legal and collection fees in addition to the outstanding balance should BPFC refer my account to an outside agency for collection.

I consent to BPFC’s release of the patient’s protected health information (PHI) for treatment, payment and operations purposes in accordance with HIPAA. I acknowledge that BPFC may release medical records and PHI to the third-party health plan or payer, including Medicare, Medicaid, health insurer, HMO, or other company or program that arranges or pays for the cost of some or all of the patient’s health care. BPFC may also release PHI to other health care providers involved in treating the patient including physicians, hospitals, laboratories, pharmacies and others. I have been provided with BPFC’s Notice of Privacy Practices that further describes the uses and disclosures of certain PHI by BPFC.

To facilitate treatment or payment, including communication of appointment reminders, prescriptions/refills, laboratory results and other information, I consent to BPFC sharing PHI with the following individuals:

Medical   Billing   All

---

Medical   Billing   All

---

Medical   Billing   All

Patient/Guardian/Legal Representative Signature (required) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.

PAYMENT POLICIES

 

We accept cash, check, debit, Visa, MasterCard and most health plans/insurance programs. You may consent to pay by automated payment card by signing a separate authorization.

If the patient is covered by insurance, the following apply:

1. The patient/responsible party or guarantor signing below (“you”) must provide us with the patient’s current and correct medical coverage/insurance/health plan (“health plan”) or other responsible third-party payor.
2. You must follow the rules of the health plan such as providing a valid referral form and precertification of testing and/or surgery when required by the health plan for payment. We will assist with this process, but if claims are denied because of your failure to comply with coverage/payment rules, you will be responsible for paying the denied claim(s).
3. You are responsible for paying any deductibles and co-payments in the amount specified by the health plan as well as non-covered services or other costs not covered by the health plan.
4. Co-payments, non-covered services and other point of service payments must be paid at the time of service including amounts due for a child regardless of who has the legal obligation, or payment obligation under parental custody, divorce or separation terms.
5. WORK RELATED INJURIES:
   1. If the patient’s employer has approved treatment, you will not be charged or billed.
   2. If the patient’s employer does not approve treatment and YOU SELECT US FOR YOUR TREATMENT, you may be billed and you may be responsible for payment of services not approved by the employer.
6. If the patient is involved in a claim or lawsuit that affects the payment of our services, we hold you responsible for payment of our regular fees.
7. We file group health plan claims and by law, must file Medicare claims.
8. If you think your bill contains an error or if you need more information about an item on your bill, contact us at the address or telephone number on your statement.

We expect payment in full at time of service for all charges which are not covered by the patient’s health plan. It is your responsibility to contact us in the event of a need for an alternative payment plan or to apply for a discount if you do not have insurance.

In the event of non-payment, you will be responsible for any legal and collections fees. Legal and collection fees will be added to the outstanding balance on the account should the account be referred to an outside agency for collection.

I have read and agree to the above terms and hereby assume full responsibility for paying any medical service charges and collection fees according to these terms.

Patient/Guarantor/Responsible Party Signature (required) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.

NO-SHOW POLICY

 

It is the policy of Barry Pointe Family Care, its practices and physicians/providers (“Signature”) to maintain a therapeutic and trusting relationship with all patients. When such a relationship has not been formed or the relationship with a patient is no longer proceeding in an effective manner, the attending provider may terminate his/her relationship with the patient which would include ALL members of the patient’s family and it would also include being seen by any other provider in this practice. Any such termination shall be carried out within the bounds of applicable state and federal laws, rules, regulations and professional guidelines such as the American Medical Association guidelines, and this policy. Termination of the relationship may occur with the goal of assuring appropriate continuity of care for the patient. When a patient cancels appointments, procedures or other scheduled care on a repetitive basis without cause or enough notice, quality and continuity of care are adversely impacted, office schedules are disrupted, and it impedes other patient(s) appointments. In order to decrease the incidence of such cases, a “No-Show fee of $25.00” may be assessed and/or when indicated, which can result in the physician/patient relationship to be terminated.

The physician or his/her designee identifies a patient with whom the physician-patient relationship has been affected negatively or is no longer therapeutic. The types of circumstances that can result in termination include, but are not limited to, the following:

• Repeated noncompliance with therapies or treatments essential to the patient’s safety as deemed medically necessary by the physician or other attending healthcare provider (“Provider”)
• Failure to meet financial obligations to Barry Pointe Family Care regarding care provided or to cooperate with payment processes consistent with Barry Pointe Family Care payment policies
• Consistent or repeated failure to keep appointments without good cause and/or without notice of intent to cancel appointments
• Threatening, violent, abusive or patterns or repetitive rude or offensive behavior directed at a Provider, other Barry Pointe Family Care staff, or other patients or visitors
• Attempts by the patient to use the relationship to illegally or improperly obtain controlled substances for non-therapeutic purposes, abuse of controlled substances or otherwise refusing to obtain treatment for controlled substance abuse or addiction, seeking multiple prescriptions from different physicians or diverting controlled substances
• The patient elects to terminate or expresses a desire to terminate the relationship

It is Barry Pointe Family Care’s desire to do our best to have the best applicable care for all our patient’s healthcare needs so we can keep the provider/patient relationship trustworthy and respectful.

Patient/Guarantor/Responsible Party Signature (required) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.