New Patient Form | KampieDa Medical Group & Behavioral Health, Corp.

Patient Information

Please Print

Patient’s Name

Male Female

Address

City/Town

State

Zip Code

Date of Birth

Social Security Number

Home Phone

Cell Phone

Email

Marital Status

Employer’s Name

Employer’s Phone

Employer’s Address

Mother’s Name / DOB (if patient is under age 21)

Father’s Name / DOB (if patient is under age 21)

Name of Primary Insurance

Name of Secondary Insurance

Relationship to Insured

Self Spouse Child Other

Race

White Black/African American Native Hawaiian/Other Pacific Islander American Indian/Alaska Native Asian Declined/Unknown Other

Ethnicity

Hispanic/Latino Not Hispanic/Latino Declined/Unknown

Preferred Language

Preferred Pharmacy

General Medical History

Patient HIPAA Awareness

As a result of the Health Insurance Portability and Accountability Act (HIPAA), enforced by the U.S. Department of Health and Human Services Office for Civil Rights, we are not permitted to release patient information except as stated in our Notice of Privacy Practices, or in accordance with your wishes as stated below. This waiver authorizes KampieDa Medical Group & Behavioral Health to send/give medical information as noted.

1. Leave a voicemail recording including my Personal Health Information on my home/cell phone.

Yes No

2. Speak to an individual of my choosing (Personal Representative) regarding my Personal Health and Billing Information, and permit them to receive prescriptions and/or test results on my behalf.

Yes No

Name of Personal Representative

Relationship

Phone Number

3. Speak to an individual in the event of a medical emergency.

Yes No

Name of Emergency Contact

Relationship

Phone Number

4. Send an email notifying me to contact the office to discuss my lab/test results. We will not send Personal Health Information over the internet.

Yes No

Email Address

By signing, you confirm you received/reviewed KampieDa Medical Group & Behavioral Health’s Notice of Privacy Practices, and that authorizations above remain in effect until you notify us in writing, by certified mail, of requested changes.

Signature of Patient or Legal Guardian

Today’s Date

Patient Responsibility Disclosure Statement

Your signature forms a binding agreement between KampieDa Medical Group & Behavioral Health and the patient (or Responsible Party, for minors under 18). All charges for services rendered are due and payable at the time of service. Please initial each item below.

I am responsible and expected to pay for co-payments, unsatisfied deductibles, and any amount deemed my responsibility or non-covered by my insurance carrier.
Co-pays are due at the time of service; additional co-pays required by insurance will be billed to me.
Authorization to pay benefits directly to the physician; any insurance checks I receive must be signed over to KampieDa.
KampieDa may use and disclose my PHI to bill and collect payment, including with business associates such as billing and claims companies.
KampieDa is not a provider for No Fault or Workman’s Compensation injuries, and such claims cannot be submitted for reimbursement.
If charges go to collections, I agree to pay associated collection fees, attorney fees, court costs, and contingent fees up to 30%.
KampieDa may transfer unpaid balances to outside collection entities, which may report to credit bureaus.
KampieDa may terminate services based on noncompliance with this agreement. I am responsible for charges resulting from outdated or incorrect insurance information.

Patient Name

Date

Signature of Patient/Guardian

New Patient Registration Form

Patient Information

General Medical History

Patient HIPAA Awareness

Patient Responsibility Disclosure Statement

Ready to Submit?