New Patient Paperwork - Liberty Healthcare Partners

Please select which provider you wish to establish care with:

Emergency Contact Person:

Emergency Contact Number:

INSURANCE INFORMATION

Primary Insurance Carrier:

Member/Subscriber ID #:

Secondary Insurance Carrier:

Member/Subscriber ID #:

Person responsible for payment:

(If other than patient)

Relationship to patient:

Responsible Party Address (if different from patient):

How did you hear about our office:

Preferred Pharmacy Address:

Mail Order Pharmacy:

Medical History - List any problems/medical conditions you currently take medications for.

if none, please write "NONE"

Surgical/Hospitalization History - List any surgeries/hospitalizations with Dates.

If none, please write “NONE”

Allergies - List medications and/or materials/foods you are allergic to and reaction type.

If none, please write “NONE”

Current Medications - List all (prescribed and/or non-prescription) medications, and the dose/frequency.

If none, please write “NONE”

Family History - List ANY family history of medical problems.

If none, please write “NONE”

Tobacco/Nicotine use:

Select all that apply

Are you routinely exposed to second-hand smoke?

Preventative Health Testing - List Month/Year and Result Options

If none, please write “NONE”

Bone Density/Dexa Scan:

Colonoscopy/ColoGuard:

Select a policy to read:

I have read and understand the policies listed above. I understand that should I have any questions, I will be directed to a staff member who can address my concerns.

PLEASE FILL OUT THE BELOW SECTION FOR OUR OFFICE TO REQUEST MEDICAL RECORDS FROM PREVIOUS PROVIDER/SPECIALIST OFFICE:

Medical Records Release Authorization - Patient Information

HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.

New Patient Paperwork - Liberty Healthcare Partners

Please select which provider you wish to establish care with:

PATIENT INFORMATION

First Name:

Middle Initial:

Last Name:

Birth Date:

Social Security:

Age:

Gender (at birth):

Address:

City:

State:

Zipcode:

Home Phone:

Cell Phone:

Email:

Marital Status:

Race:

Language:

Emergency Contact Person:

Emergency Contact Number:

Relationship

INSURANCE INFORMATION

Primary Insurance Carrier:

Member/Subscriber ID #:

Secondary Insurance Carrier:

Member/Subscriber ID #:

Person responsible for payment:

Relationship to patient:

Responsible Party Address (if different from patient):

How did you hear about our office:

Previous PCP:

Previous PCP Phone:

Preferred Pharmacy:

Preferred Pharmacy Address:

Mail Order Pharmacy:

Medical History - List any problems/medical conditions you currently take medications for.

Surgical/Hospitalization History - List any surgeries/hospitalizations with Dates.

Allergies - List medications and/or materials/foods you are allergic to and reaction type.

Current Medications - List all (prescribed and/or non-prescription) medications, and the dose/frequency.

Family History - List ANY family history of medical problems.

Social History

Alcohol use:

Tobacco/Nicotine use:

Are you routinely exposed to second-hand smoke?

Preventative Health Testing - List Month/Year and Result Options

Mammogram:

Pap Smear:

Bone Density/Dexa Scan:

Colonoscopy/ColoGuard:

Prostate Exam:

Eye exam:

Consents

Select a policy to read:

I have read and understand the policies listed above. I understand that should I have any questions, I will be directed to a staff member who can address my concerns.

Patient Signature:

Date:

PLEASE FILL OUT THE BELOW SECTION FOR OUR OFFICE TO REQUEST MEDICAL RECORDS FROM PREVIOUS PROVIDER/SPECIALIST OFFICE:

Medical Records Release Authorization - Patient Information

Full Legal Name:

Date of Birth:

Last 4 of Social Security:

Patient Phone:

Authorized Disclosure - Facility/Physician Name:

Facility/Physician Full Address:

Phone:

Fax:

Information to be Disclosed:

Purpose of Disclosure:

Patient or Legal Representative Signature:

Date:

If signed by the Legal Representative, indicate the patient relationship: