New Patient Forms and Documents

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Form 1 of 3

Note: All fields marked with an asterisk* are mandatory. Documents may be signed at your appointment.

NEW PATIENT INFORMATION

Patient (Full Name)

Date of Birth (MM/DD/YEAR)

Address

Primary Cell/Mobile

Secondary Cell/Mobile

Email Address

Parent Names

INSURANCE INFORMATION

Primary Insurance Name

ID Number

Provider or Member Services Phone Number on Card

Insurance Policy Holder Name

Insurance Policy Holder Date of Birth (MM/DD/YEAR)

PHYSICIAN

Referring Physician Name

Phone Number

Our Privacy Policy applies.

Note: Please fill out the fields marked with an asterisk.

After clicking the 'Send' Button above, Please scroll down to Form 2 of 3

Form 2 of 3

PERMISSION TO ACCESS/RELEASE MEDICAL RECORDS ON PATIENT BEHALFFOR AUTHORIZATION/CLAIM DENAL APPEALS

I, (Full Name)

Parent / Guardian of (Full Name)

Authorize Carbon Based, LLC and Anthony Cappa, CPO to receive medical records for the purpose of processing insurance claims, denials, appeals or any lawful purpose to my insurance company for services rendered. This authorization has no expiration date.

Sign Below at Office Visit:

Signature _________________________________________________________ Date: (MM/DD/YEAR) ________________________________________

PERMISSION TO ACT ON PATIENT BEHALF FOR APPEAL OF CLAIM DENIAL

I, (Full Name)

Parent / Guardian of (Full Name)

Authorize Carbon Based, LLC and Anthony Cappa, CPO to act on my behalf to file all appeals to my insurance company.

Sign Below at Office Visit:

Signature _________________________________________________________ Date: (MM/DD/YEAR) ________________________________________

Our Privacy Policy applies.

Note: Please fill out the fields marked with an asterisk.

After clicking the 'Send' Button above, Please scroll down to Form 3 of 3

Form 3 of 3

HIPAA COMPLIANCE AND PATIENT CONSENT

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows fore the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to your use of the disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

- Protective health information may be disclosed or used for treatment, payment, or healthcare operations.

- The practice reserves the right to change the privacy policy as allowed by the law.

- The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.

- The patient has the right to revoke the consent in writing at any time and all full disclosures will then cease.

- The practice may condition receipt of treatment upon execution of this consent.

May we phone, email, or send a text to you to confirm appointments?

Yes

May we leave a message on your answering machine/voicemail at home or on your cell phone?

Yes

May we discuss your medical condition with any member of your family?

Yes