Patient Demographics

Please fill in all relevant information.

* NOTE * You must expand each section to fill out the information

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Patient First Name

Middle Initial

Patient Last Name

Date of Appointment

Is this your first time being seen by one of our physicians?yesno

Personal Information

Address

City

State

Zip Code

Phone Type

Primary Phone (Must be in XXX-XXX-XXXX format, including dashes)

Secondary Phone (Must be in XXX-XXX-XXXX format, including dashes)

Phone Type

Email address (if none, type none)

Marital Status

Date of Birth (Must be MM/DD/YYYY format, including the forward slash)

Sex

Ethnicity

Race

Employment Information

Employment Status

Occupation

Emergency Contact

Emergency Contact Name

Emergency Contact Phone Number

Pharmacy Information

Preferred Pharmacy

Preferred Pharmacy Address

Preferred Pharmacy City

Insurance Information

No insurance / self pay

Primary Health Insurance (If "self pay," write "none" and check box to the left.)

Policy Number (MUST PUT NUMBER IN HERE)

Name of Policyholder

Policyholder Date of Birth

Policyholder address (if same as patient, state "same")

Relationship to Patient

Secondary Health Insurance

Policy Number

Name of Policyholder

Policyholder Date of Birth

Policyholder address (if same as patient, state "same")

Relationship to Patient

Accident Information

If accident related, please select type

Accident Related Insurance Company (if applicable)

Accident Date

Accident Description

Insurance Company Contact Person Name

Insurance Company Claim Number

Cancellation/No Show Policy/Authorizations

Cancellation Policy:

Cancellation of an Appointment
In order to be respectful of the medical needs of our Community, please be courteous and call promptly if you are unable to attend an appointment. This time will be reallocated to someone who is in urgent need of treatment. This is how we can best serve the needs of our Community. If it is necessary to cancel your scheduled appointment, we require that you call 24 business hours in advance. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to timely medical care.
How to Cancel Your Appointment
To cancel appointments, please call (339) 469-2707. If you do not reach the receptionist, you may leave a detailed message on the voice mail.
Late Cancellations
Late cancellations will be considered as a “no show.”

No-Show Policy:

No-Show for an Appointment
A “no show” is someone who misses an appointment without cancelling it 24 business hours in advance of your scheduled appointment. (Example: your appointment is at 3 p.m. on Tuesday, you need to call by 3 p.m. on Monday.) No-shows inconvenience those individuals who need access to medical care in a timely manner. A failure to present at the time of a scheduled appointment will be recorded in your chart as a “no show.” If you “no show” for an appointment, a fee of $50.00 will be billed to your account and an invoice will be sent to you. This fee covers administrative tasks associated with your appointment. This fee will need to be paid in full before scheduling any further appointments. Three follow-up “no shows” will result in discharge from the practice.

I have read and understand the above Cancellation/No Show Policy

HIPAA Use and Disclosure Authorization (DO NOT NEED TO LIST SELF. THIS IS IF YOU WOULD LIKE SOMEONE ELSE TO BE ABLE TO OBTAIN YOUR PROTECTED HEALTH INFORMATION.)

Name and Relationship to Patient

Notice of Privacy Practices

I have been given the opportunity to read a copy of Circle of Life Family Medicine's Notice of Privacy Practices (posted in office). This Notice describes how Circle of Life Family Medicine may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.

I acknowledge that I have read and understand the above privacy statement.

Insurance and Payment Authorization

Should a dispute arise concerning injury related claims, or should this office not be able to verify coverage, the patient is ultimately responsible for payment, regardless of any claims pending.

I hereby authorize Circle of Life Family Medicine to furnish information to insurance carriers concerning my illness and treatments, and I hereby assign to Circle of Life Family Medicine all payments for medical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by my insurance.

I acknowledge that I have read and understand the above insurance payment statement.

Verification Text