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

Shandle Shrable
APRN, Nurse Practitioner

Eva Elliott
APRN, Nurse Practitioner

Lisa Thorne
FNP-BC, Nurse Practitioner

Melody Draper
RN, APN, Nurse Practitioner

Christopher Fleming
APRN, Nurse Practitioner

Michelle Tyrrell
FNP, PMHNP, Nurse Practitioner

Dr. Melinda Henderson
Owner, Physician

Christie Wheeley
Practice Administrator & Community Liaison

Ayesha Jones
Patient Services Representative

Desiree Valadez
Patient Services Representative

Dana Stofel
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.
We encourage family members or POAs to attend the intake appointment to provide valuable medical history, assist with care planning, and ensure the best possible support for the patient.

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. Assignment of an NP Housecalls provider as your PCP is required for CIGNA insurance. 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. * Before our initial visit, we must receive a copy of the front and back of your insurance card, along with all paperwork.

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

Prefix

First Name *

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

Date of Birth *

Social Security No.

Primary Phone *

Alternate Phone

Would you like to be enrolled in our patient portal? *
Yes No

Consent to Receive Messages via SMS *
I agree to receive text messages from NP Housecalls PLLC. I understand that message frequency varies, and data rates may apply. I understand that I may opt-out by replying "STOP" at any time. I understand that I may reply "HELP" for assistance. I understand consent is not required to purchase goods or services.
I decline communication via SMS messaging

How would you like to be notified of upcoming appointments? *
Phone Call SMS Messaging

Gender *
Male Female

Marital Status
Single Married Divorced Legally Separated

Residence *
Home Independent Living Assisted Living Memory Care

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

Is there an individual, other than the patient, that should be contacted for appointment confirmation calls and scheduling? *
Yes No

May we 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 *

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

Please list any Specialists the patient is currently or has seen within the last 2 years

Name

Specialty

Phone

Add another Specialist?

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

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

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.

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.

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. This includes sharing prescription information and prior medical records via the Health Information Exchange. 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. *

My medical information may be disclosed to the following individuals or organizations:

Name

Relationship

Add another?

Date *

First Name *

Last Name *

Relationship to Patient *

Medications

Are you currently taking any medications? *
Yes No

Allergies

Do you have any known allergies? *
Yes No

Pharmacy Information

Preferred local/facility pharmacy *

Address

City *

State

Zip

Phone *

Fax

Previous Primary Care Provider

Phone

City

State

Patient Height

Patient Weight

Recent Hospitalizations (within the last 2 years):

Facility Name

City

State

Estimated Dates

Add another?

Current Medical Conditions

Current Medical Devices

Date *

First Name *

Last Name *

Relationship to Patient *

Advanced Primary Care Management

AGREEMENT TO RECEIVE MEDICARE ADVANCED PRIMARY CARE MANAGEMENT (APCM) SERVICES

Medicare covers Advanced Primary Care Management (APCM) services provided monthly by physician practices. In agreeing to receive APCM, I understand that the NP Housecalls providers and care team are willing to provide such services to me, including the following:

Access and continuity of care

24/7 access to the care team for urgent needs.
The ability to get successive, routine appointments with a member of the care team.
Alternatives to traditional office visits (for example, home visits or expanded clinic hours).

Comprehensive Care Management (CCM)

Needs assessment, including medical and psychosocial.
Helping ensure I receive recommended preventive services.
Medication management and support.
A personalized care plan that outlines my health goals and needs and is regularly reviewed and updated.
A copy of my care plan accessible to me, my caregivers, and members of my care team.

Care Coordination

Coordinating my care across settings, such as:
- Referrals to other physicians and health care providers.
- Communicating with home- and community-based providers, community-based service providers, hospitals, and skilled nursing facilities others.
Follow-up care after emergency department visits or discharge from a hospital, skilled nursing facility, or other health care facility.

Enhanced Communication Opportunities

Additional ways for me and my caregivers to communicate with my physician and care team, such as patient portals, secure messaging, and e-visits.

I also understand that I can revoke this agreement at any time (effective at the end of a calendar month) and can choose, instead, to receive these services from another health care professional after the calendar month in which I revoke this agreement. Medicare will only pay one physician or health care professional to furnish me APCM services within a given calendar month.

I understand these APCM services are subject to the usual Medicare deductible and coinsurance applied to physician services.

My signature authorizes my primary care physician to electronically communicate my medical information with other treating providers as part of the care coordination involved in APCM.

This designation is effective as of the date below and remains in effect until revoked by me.

Date

Patient First Name

Patient Last Name

Signature of Patient/Beneficiary Providing Consent – 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

Date of Birth

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