New Patient Registration Form – Adult

Welcome to Celebration Family Physicians!

We look forward to working together with you towards good health.

Should you have any questions, please do not hesitate to reach out to us.

General Information

Patient First Name *

Patient Middle Name

Patient Last Name *

Date of Birth *

Sex *

Marital Status *

Social Security Number *

Primary Address *

Address Line 1

City

State

Zip Code

Home Phone *

Work Phone

Cell Phone *

Email *

Authorize Use of Email *

Yes

Employment Status *

Employed
Not Employed
Retired
Student

Employer

Occupation

Ethnicity *

Hispanic / Latino
Non-Hispanic / Latino

Race *

Patient ID Image Front and Back *

Click or drag files to this area to upload. You can upload up to 2 files.

Emergency Contact

Name *

Relationship *

Phone *

Primary Insurance

Do You Have Insurance? *

Yes
No

Insurance Name *

Policy Holders Name *

Relationship to Insured *

Social Security No. *

DOB *

Insurance ID No. *

Group No.

Insurance Card Image Front and Back *

Click or drag files to this area to upload. You can upload up to 2 files.

Secondary Insurance

Do You Have Secondary Insurance? *

Yes
No

Secondary Insurance Name *

Secondary Policy Holders Name *

Relationship to Insured *

Social Security No. *

DOB *

Secondary Insurance ID No. *

Secondary Insurance Group No. *

Secondary Insurance Card Image Front and Back *

Click or drag files to this area to upload. You can upload up to 2 files.

Referral Source

How did you find us? *

friend / family

Referring Physician

other

Pharmacy

Pharmacy Name *

Pharmacy Address *

Address Line 1

Address Line 2

City

State

Zip Code

Pharmacy Phone *

Pharmacy Fax

Consents and Acknowledgements

Please read this section carefully and mark all checkboxes below if you understand and agree.

General Consent For Treatment

I, the patient or patient’s legal representative, agree to allow Celebration Family Physicians and its Providers to provide all health care services to me or to the individual I am representing that are routine or otherwise deemed necessary.

I understand I have the right to refuse consent to any proposed procedure or treatment at any time prior to receiving it.

I understand that any treatment involving material risks will be explained to me and that I will have the opportunity to ask questions about the associated risks, alternatives and prognosis before allowing the treatment to be performed.

I agree that no guarantees have been given to me or the individual I am representing as to the outcome of any treatment.

I authorize my provider and Celebration Family Physicians to photograph me or the individual I am representing for medically related documentation or identification purposes.

General Consent For Treatment Agreement *

Agree

Consent To Perform Pelvic Exam (only female adult and pediatric patients)

A Pelvic Examination is an examination of the vagina, cervix, uterus, fallopian tubes, ovaries, rectum, or external pelvic tissue or organs. This procedure is used to diagnose and/or treat conditions that involve the pelvis. It may be performed using any combination of modalities, which may include the health care provider’s gloved hand or instrumentation. For purposes of this consent, vaginal sonography is included. By signing this consent, I, the patient or patient’s legal represantitive, authorize Celebration Family Physicians and any health care practitioners associated with the practice to perform a pelvic examination, including vaginal sonography, as described above. By my signature below I acknowledge that I have read and understand the contents of this form.

Consent To Perform Pelvic Exam Agreement *

Agree
Not Applicable

Patient To Authorize For E-Prescribe

ePrescribing is a physician's ability to electronically send an accurate, error free, and understandable prescription directly to a pharmacy from the practice. ePrescribing greatly reduces medication errors and enhances patient safety. Understanding all of the above, I, the patient or patient’s legal representative, hereby authorize the physician and/or staff of Celebration Family Physicians to enroll me in the ePrescribe Program.

Patient To Authorize For E-Prescribe Agreement *

Agree

Patient Authorization For Pharmacy Benefits Manager

I, the patient or patient’s legal representative, authorize the physician and/or staff of Celebration Family Physicians to request and obtain my prescription medication history from other healthcare providers, the pharmacy benefit manager and/or any third-party pharmacy payers for treatment purposes.

Patient Authorization For Pharmacy Benefits Manager Agreement *

Agree

Patient Authorization To Release Information To Insurance Carrier

I, the patient or patient’s legal representative, authorize the providers and/or staff of Celebration Family Physicians to release to my insurance company or its representative any information including the diagnosis and records of any treatment or examination rendered to me during medical or surgical care. I authorize and request the insurance company to pay directly to Celebration Family Physicians the amount due for medical or surgical services. I understand that I, the patient or patient’s legal representative, am financially responsible for any services deemed non-covered by my insurance company.

Patient Authorization To Release Information To Insurance Carrier Agreement *

Agree

Acknowledgement Of Receipt Of Privacy Practices

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. We provide this form to comply with the Health Insurance Portability and Accountability Act (HIPPA). You have the right to review our notice before signing this consent. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy by requesting the same at the front desk. By signing this form, you acknowledge that our practice may use and disclose PHI about you for treatment, payment, and healthcare operations. You have the right to request that we restrict, in writing, how PHI about you is used or disclosed for treatment, payment or healthcare operations. By my signature below, I, the patient or patient’s legal representative, acknowledge that I had the opportunity to review Celebration Family Physician’s Notice of Privacy Practices.

Acknowledgement Of Receipt Of Privacy Practices Agreement *

Agree

Consent to Share Information

Please choose which contact method(s) you prefer for Appointment Reminders (You may select more than one): *

Email
Phone
Text Message (message and data rates may apply)
Patient Portal (if activated)

Please choose which contact method(s) you prefer for Test Results Notifications (You may select more than one): *

Email
Phone
Text Messages (message and data rates may apply)
Patient Portal (if activated)

Email Consent:

I choose to communicate via e-mail on matters related to my health and/or my medical treatment. I understand that any Confidential Health Information that I send to the practice using may not be secure and is sent at my own risk. I will not hold the practice, nor any of its workforce members, liable for loss of any confidentiality associated with information transmitted via e-mail. I also understand that it is not the policy of the practice to encrypt any Confidential Health Information I request to be sent to me via e-mail. Because this information is not encrypted, I understand that it is not secure. I acknowledge this risk and will not hold the practice or any of its workforce members liable for any loss of confidentiality associated with such transmissions.

Email Consent *

Agree

Phone Consent: Leave a detailed message on voice mail/machine/cell: *

Yes
No

Phone Consent: Leave a detailed message with individual answering the phone: *

Yes
No

Consent To Discuss Medical Information

We cannot discuss your health information with anyone other than yourself unless you authorize us to do so. Please list below names of the individual(s) you authorize the providers and office staff of Celebration Family Physicians to discuss care with.

Name

Relationship

Name

Relationship

Name

Relationship

Preventative vs Problem Focused Visit

We all need good preventive care! Early detection and prevention are key to maintaining good health and often saves money. Preventive care includes exercise, eating healthy, and getting regular wellness exams with your doctor.

What are preventative services?

Typically, the following services are considered preventative services:

Review of your health history and family health history
Physical exam (must be one year from previous exam)
Vaccinations/Immunizations
Men and Women's Health Screenings (i.e. mammogram, pap smear)
Screening exams (i.e. blood pressure, cholesterol screening, diabetes screening, STD screening)
Education about wellness, diet, exercise, and prevention
***Other routine screening labs/services may be ordered by your physician and, as every insurance company differs in coverage, it is the patient's responsibility to make sure these are covered prior to being completed.***

What if I have a medical problem to discuss?

Per insurance regulations, an annual preventive exam is not the same thing as a normal office visit. An annual preventive exam does not include a discussion of a new medical problem or detailed evaluation of chronic medical conditions. Due to those regulations and our desire to run on time, we may ask you to schedule a separate visit to address these concerns. This will allow your physician time to adequately address your medical problems. Instead of scheduling a separate office visit, you may have the option of addressing these chronic conditions or new problems at the same time as your annual wellness exam. Two claims will be submitted to your insurance: one for the annual wellness and one for an office visit addressing the chronic condition(s) or new problem(s). If you have a co-pay or co-insurance, you will be responsible for that amount as with a normal office visit.

By signing below, you acknowledge that you have read and understand the policies stated above.

Preventative vs Problem Focused Visit Agreement *

Agree

Agree to Terms and Conditions *

By printing my name and signing below, I, the patient or patient's legal representative, have read, understand, and agree to the terms, policies, and conditions above.

Printed Name of Patient or Patient's Legal Representative *

Signature Date *

Signature of Patient or Patient's Legal Representative *

Financial Policy

Payment is required for all services at the time they are rendered including deductibles, co-payments and any outstanding balances. I, the patient or patient’s legal representative, understand that I am financially responsible for all services rendered and for the following reasons:

• I do not have the proper referral at the time of service.
• My referral is invalid/expired.
• I have given incorrect/invalid insurance information.
• Expenses are not covered by my insurance company.
• I have not met my deductible.
• The services rendered are deemed medically unnecessary by my insurance company. (This applies to present and future visits).

I, the patient or patient’s legal representative, agree to assign insurance benefits to Celebration Family Physicians whenever necessary. Celebration Family Physicians will bill participating insurance companies. If Celebration Family Physicians has not received payment from my insurance company within 45 days of the date of service, I may be expected to pay the balance in full. I am responsible for ensuring that all charges are paid whether by myself or by my insurance carrier.

If my account must be turned over to collections, a $25.00 collection fee will be added to my account. I understand that I will be financially responsible for any and all costs and fees relating to the collection of my debt.

If it is necessary to cancel an appointment, I am required to call at least 1 business day AND 24 hours before my appointment time. If I am more than 15 minutes late after my scheduled appointment, this is considered a late arrival and my appointment will be rescheduled.

Celebration Family Physicians reserves the right to charge:
• $5.00 for missed, cancelled, or late arrivals to nurse visits
• $25.00 for missed, cancelled, or late arrivals to provider visits
• $50.00 for missed, cancelled, or late arrivals to procedures

Per insurance regulations, an annual wellness exam is not a visit to discuss chronic condition(s) or new problem(s). I understand that instead of scheduling a separate office visit to address these condition(s) or new problem(s), I have the option of addressing them at the time of my annual wellness exam. Two claims will be submitted to my insurance: one for the annual wellness and one for an office visit addressing my chronic condition(s) or new problem(s). If I have a co-pay or co-insurance, I will be responsible for that amount as with my normal office visit.

Should I require special accommodations for my appointment, I must notify Celebration Family Physicians of the needed accommodation one week prior to the appointment. If I do not provide at least 24 hour notice prior to cancelling my appointment or do not show to the scheduled appointment, all charges incurred by Celebration Family Physicians is my responsibility.

By signing below, I understand and accept the Celebration Family Physicians Financial Policy as stated above.

I understand that if I request (a) specific lab test(s) that is/are not part of the routine physical examination, the lab test(s) may not be covered by insurance. Lab tests usually covered in a routine physical exam includes fasting blood glucose, lipid panel and PSA. Lab tests NOT usually covered by insurance at a routine physical examination include complete blood count, complete metabolic panel (including liver function tests), Hg A1C, urinalysis, vitamin levels, thyroid levels, hormone levels (including testosterone), auto-immune labs and allergy tests.

I understand that the lab facility processing the specimen(s) is responsible for billing the insurance company for the test. Celebration Family Physicians collects specimens for your convenience and sends the specimen(s) to an outside laboratory. Celebration Family Physicians DOES NOT process the lab. Billing disputes need to be addressed with the lab facility processing the specimen.

Financial Policy Agreement *

Agree

Agree to Terms and Conditions *

By printing my name and signing below, I, the patient or patient's legal representative, have read, understand, and agree to the terms, policies, and conditions above.

Printed Name of Patient or Patient's Legal Representative *

Signature Date *

Signature of Patient or Patient's Legal Representative *

Informed Consent To Telehealth Services

"I understand and agree that I have reviewed, understand and accept the risks and benefits of telehealth services as described below and wish to receive such services. If I am signing on behalf of a minor, incapacitated or otherwise legally dependent patient, I certify that I am a person with legal authority to act on behalf of the patient, including the authority to consent to medical services, and I accept financial responsibility for services rendered.

1. By using the Celebration Family Physicians telehealth portal, I agree to receive telehealth services. Telehealth involves the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive audio, video, and data communications. During my visit, my Celebration Family Physicians provider and I will be able to see and speak with each other from remote locations.

2. I understand and agree that:

▪ I will not be in the same location or room as my medical provider.

▪ My Celebration Family Physicians provider is licensed in the state in which I am receiving services. I will report my location accurately during registration.

▪ Potential benefits of telehealth (which are not guaranteed or assured) include: (i) access to medical care if I am unable to travel to my Celebration Family Physicians provider’s office; (ii) more efficient medical evaluation and management; and (iii) during the COVID-19 pandemic, reduced exposure to patients, medical staff and other individuals at a physical location.

▪ Potential risks of telehealth include: (i) limited or no availability of diagnostic laboratory, x-ray, EKG, and other testing, and some prescriptions, to assist my medical provider in diagnosis and treatment;

(ii) my provider’s inability to conduct a hands-on physical examination of me and my condition; and (iii) delays in evaluation and treatment due to technical difficulties or interruptions, distortion of diagnostic images or specimens resulting from electronic transmission issues, unauthorized access to my information, or loss of information due to technical failures. I will not hold Celebration Family Physicians responsible for lost information due to technological failures.

▪ I further understand that my Celebration Family Physicians Provider’s advice, recommendations, and or decisions may be based on factors not within his/her control, including incomplete or inaccurate data provided by me. I understand that my Celebration Family Physicians provider relies on information provided by me before and during our telehealth encounter and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability.

▪ I may discuss these risks and benefits with my Celebration Family Physicians provider and will be given an opportunity to ask questions about telehealth services. I have the right to withdraw this consent to telehealth services or end the telehealth session at any time without affecting my right to present or future treatment by Celebration Family Physicians.

▪ I understand that the level of care provided by my Celebration Family Physicians provider is to be the same level of care that is available to me through an in-person medical visit. However, if my provider believes I would be better served by face-to-face services or another form of care, I will be referred to visit the office of Celebration Family Physicians, hospital emergency department or other appropriate health care provider.

▪ I have the right to receive face-to-face medical services at any time by traveling to a Celebration Family Physicians medical center that is convenient to me.

▪ In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.

3. I consent to, understand and agree that:

▪ I have the right to discuss the risks and benefits of all procedures and courses of treatment proposed by my health care provider(s), together with any available alternatives.

▪ Celebration Family Physicians will provide care consistent with the prevailing standards of medical practice but makes no assurances or guarantees as to the results of treatment.

▪ Before prescribing any controlled substance to me, Celebration Family Physicians may review information from the Prescription Drug Monitoring Program in my state of residence regarding my prior receipt of controlled substances.

▪ My Celebration Family Physicians provider will not prescribe opioids to me during a telehealth visit.

▪ I have the right to review and receive copies of my medical records, including all information obtained during a telehealth interaction, subject to Celebration Family Physicians’ standard policies regarding request and receipt of medical records and applicable law.

▪ The laws of the state in which I am located will apply to my receipt of telehealth services."

Informed Consent To Telehealth Services Agreement *

Agree

Agree to Terms and Conditions *

By printing my name and signing below, I, the patient or patient's legal representative, have read, understand, and agree to the terms, policies, and conditions above.

Printed Name of Patient or Patient's Legal Representative *

Signature Date *

Signature of Patient or Patient's Legal Representative *