New Patient Intake Packet
Welcome
Welcome to NP Housecalls! We appreciate your trust in us and willingness to create a partnership that will support you in accomplishing your health-related goals.
Who We Are
Robin Berman
APRN, GNP-BC
Shandle Shrable
APRN, FNP-C
Lisa Thorne
APRN
Eva Elliott
APRN
Melinda Henderson
MD, CMD, FAAHPM
Keith Winfree
FNP
Christie Wheeley
Community Liaison
Jenifer Mullins
MBA - HCM, Patient Services Manager
Lauren Estes
LPN
Hours of Operation and Contact Information
Monday - Friday from 8:30 am - 4:30 pm
Please contact our office for assistance with any questions at 615-645-3031.
After hours urgent calls 615-645-3031. Please note no refills will be given after hours. Refills must be requested as part of the visit with the provider
OR
through your pharmacy.
Insurance
For the benefit of our Patients, we are in-network with most insurance companies; however, you will want to check with your insurance carrier to verify if we are on their list of providers. If your insurance company requires you to select a primary care provider,
please call them immediately and select your NP Housecalls Provider as your new PCP
. As part of our contract with these companies, we are legally required to collect co-pays and deductibles from you. All bills from our practice will come from NP Housecalls.
We strive to meet all your health care needs and provide you with the highest quality care.
Your satisfaction is of the utmost importance to us!
Today's Date
Patient Information
Patient Information
Prefix
First Name
*
MI
Last Name
*
Suffix
Preferred Name
Facility/Home Address
*
Room/Apt. #
City
*
State
*
Zip
*
Is this the same address on file with your insurance company?
Yes
No
Address on file
Room/Apt. #
City
State
Zip
Date of Birth
*
Social Security No.
Primary Phone
*
Email
Gender
*
Male
Female
Marital Status
Single
Married
Divorced
Legally Separated
Residence
*
Home
Independent Living
Assisted Living
Memory Care
Facility Name
*
Facility Contact
Facility Phone
Emergency Contact
Same as Power of Attorney?
Yes
No
Name
Primary Phone
Relationship
Address
City
State
Zip
Email
Is there anyone else you'd like for your medical information to be shared with?
*
Yes
No
Name
Primary Phone
Email
Address
City
State
Zip
Add another?
Name
Primary Phone
Email
Address
City
State
Zip
Add another?
Name
Primary Phone
Email
Address
City
State
Zip
Add another?
Name
Primary Phone
Email
Address
City
State
Zip
Is there an individual, other than the patient, that should be contacted for appointment confirmation calls and scheduling?
*
Yes
No
Name
Primary Phone
Email
Address
City
State
Zip
May we routinely share your medical information with your power of attorney and emergency contact?
*
Yes
No
N/A
Please attach a scan or photo of your Power of Attorney documents
*
Power of Attorney (must include documentation)
Name
Primary Phone
Relationship
Address
City
State
Zip
Email
Patient Authorizations
First Name
*
Last Name
*
Provider Services Authorization
I hereby authorize NP HOUSECALLS, PLLC to be my
Primary
Care Provider
I hereby authorize NP HOUSECALLS, PLLC to be my
Secondary
Care Provider
Signature of Patient, Power of Attorney or Responsible Party
*
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
*
First Name
*
Last Name
*
Relationship to Patient
*
Medical Records Release
I hereby give my permission to release all medical records, including psychiatric records to NP Housecalls, PLLC for continuity of care.
First Name
*
Last Name
*
Date of Birth
*
Social Security No.
Address
*
City
*
State
*
Zip
*
Applicable time period
PLEASE FAX RECORDS TO: 615-678-5676
Are there any providers we should request records from?
Yes
No
Provider Name
Phone
Address
City
State
Zip
Add another provider?
Provider Name
Phone
Address
City
State
Zip
Add another provider?
Provider Name
Phone
Address
City
State
Zip
Add another provider?
Provider Name
Phone
Address
City
State
Zip
Signature of Patient, Power of Attorney or Responsible Party
*
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
*
First Name
*
Last Name
*
Relationship to Patient
*
Medicare Assignment of Benefits
First Name
*
Last Name
*
Date of Birth
*
Facility
Social Security No.
Medicare/Medicare Advantage No.
Medicaid No.
Please attach a scan or photo of the front of your insurance card
*
Please attach a scan or photo of the back of your insurance card
*
Do you have secondary insurance?
Yes
No
Secondary Insurance
ID No.
Please attach a scan or photo of the front of your insurance card
Please attach a scan or photo of the back of your insurance card
Do you have tertiary insurance?
Yes
No
Tertiary Insurance
ID No.
Please attach a scan or photo of the front of your insurance card
Please attach a scan or photo of the back of your insurance card
I request that payment of authorized Medicare, Medicaid and Secondary Insurance benefits be made on my behalf to NP Housecalls, PLLC for any services provided and documented by NP Housecalls, PLLC. I authorize any holder of medical information to release to the Health Care Financing Administration, and its agents, any information needed to determine these benefits and/or the benefits payable for related services. The intent of this paragraph is to authorize any insurance provider/company that may be billed for co-insurance to pay NP Housecalls, PLLC directly. I permit a copy of this Authorization to be used in place of the original. I understand that this is a lifetime authorization.
Signature of Patient, Power of Attorney or Responsible Party
*
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Signature
Date
*
First Name
*
Last Name
*
Relationship to Patient
*
Where should bills for deductibles, co-pays and non-covered items be sent?
Name
Primary Phone
Relationship
Address
City
State
Zip
I (
or my Power of Attorney/Responsible Party
) further understand that I (
or my Power of Attorney/Responsible Party
) will be billed for any deductibles and/or co-pay amounts as required by the Health Care Financing Administration, and I (
or my Power of Attorney/Responsible Party
) hereby agree to pay any and all such amounts promptly.
Signature of Patient, Power of Attorney or Responsible Party
*
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
*
First Name
*
Last Name
*
Relationship to Patient
*
Notice of Privacy Practices and Patient Consent for Use and Disclosure of Protected Health Information
I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), I have certain Patient Rights regarding my protected health information.
*
I understand that NP Housecalls, PLLC may use or disclose my protected health information for treatment, payment or health care operations, including but not limited to providing health care to me, the Patient, handling billing and payment and taking care of other health care operations. Unless required by law, there will be no other uses and disclosures of this information without my authorization.
*
NP Housecalls, PLLC has a detailed document called The Notice of Privacy Practices. It contains a more complete description of your rights to privacy and how we may use and disclose protected health information. I understand that I have the right to read The Notice of Privacy Practices before signing this agreement. You may obtain a copy of The Notice of Privacy Practices at any time by contacting the office.
*
I understand I will need to provide a copy of my POA, DNR and other important legal documents.
*
I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to NP Housecalls, PLLC. I understand that the revocation will not apply to the information that has already been released in response to this authorization.
*
I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws and regulations. I also understand authorizing the use or disclosure of the information is voluntary. I need not sign this form to ensure health care treatment.
*
Signature of Patient, Power of Attorney or Responsible Party
*
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
*
First Name
*
Last Name
*
Relationship to Patient
*
Medications
Are you currently taking any medications?
*
Yes
No
Please list the medication, with dosages and instructions that you currently use (a copy of current list acceptable). Please include over-the-counter and herbal medications.
Add another medication?
Add another medication?
Add another medication?
Add another medication?
Add another medication?
Add another medication?
Add another medication?
Add another medication?
Add another medication?
Add another medication?
Add another medication?
Add another medication?
Add another medication?
Add another medication?
Allergies
Do you have any known allergies?
*
Yes
No
Please list any drug allergies you have.
Add another substance?
Add another substance?
Add another substance?
Add another substance?
Add another substance?
Add another substance?
Add another substance?
Pharmacy Information
Preferred local/facility pharmacy
*
Address
City
*
State
Zip
Phone
*
Fax