New England Medical168 Main Street Suite 4 Claremont NH 03743 Phone: (603)555-1000 Fax: (603)555-4242

Office Hours: M-Thurs.: 8a.m.-5p.m., F: 9a.m.-7p.m.

Patient Information Packet

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New England Medical

New Patients,

Welcome to New England Medical! We are proud that you have decided to join our small family practice. We would like to introduce you to our staff.

John Harper, MD: Dr. Harper has been with New England Medical for 5 years. He studied at the Boston University School of Medicine. He has a wife and two boys. He enjoys helping anyone in any way that he can.

Mark Truman, MD: Dr. Truman is a new physician here at New England Medical. He has been here for a year. He studied at Duke University School of Medicine. He has a wife and a daughter. He enjoys having to really think on the job to help a patient get the help they need.

Aimee Smith, RN: Mrs. Smith has been with New England Medical since it opened its doors in 2005. She studied at Colby-Sawyer College. She has a husband and they have a newborn son. She enjoys helping people through tough times, she loves to make people smile.

Megan Drouin, AMA: Mrs. Drouin has just joined the New England Medical team. She studied at River Valley Community College. She has a husband, two sons and a daughter. She enjoys helping patients.

We are here to help you!

Sincerely,

The staff of New England Medical

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New England Medical

PATIENT INFORMATION

Name: _________________________________ D.O.B:___________ Sex: _____

Address: ___________________________________________________________

City/State/Zip: ______________________________________________________

Home telephone #: ______________________ SS#: _____________________

Occupation: _____________________ Work telephone #: ___________________

Guarantor Information (person responsible for medical bills)

Name: __________________________________ SS#: _____________________

Address: ___________________________________________________________

City/State/Zip: ______________________________________________________

Relationship to patient: _______________________________________________

Home phone #: _______________________ Work phone #: __________________

Occupation: ________________________________________________________

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New England Medical

Primary Insurance Information

Ins. Co. Name: ______________________________________________________

Address: ___________________________________________________________

City/State/Zip: ______________________________________________________

Ins. Co. Phone #: _____________________ Ins. Co. Fax: _____________________

Claim #: __________________________ Group #: ________________________

Secondary Insurance Information

Ins. Co. Name: ______________________________________________________

Address: ___________________________________________________________

City/State/Zip: ______________________________________________________

Ins. Co. Phone #: _____________________ Ins. Co. Fax: _____________________

Claim #: __________________________ Group #: ________________________

New England Medical4

New Patient Information

Name: _______________________________________ Date: ________________

HISTORY:

Chief complaint: _____________________________________________________Allergies: ______________________________________________________________________________________________________________________________Medication: __________________________________________________________________________________________________________________________Medical Illnesses: _______________________________________________________________________________________________________________________Injuries: ____________________________________________________________Surgeries: _____________________________________________________________________________________________________________________________Hospitalizations: ________________________________________________________________________________________________________________________

FAMILY HISTORY:

Mother: _____________________________________________________________________________________________________________________________Father: ______________________________________________________________________________________________________________________________Sibling(s): ____________________________________________________________________________________________________________________________Maternal Grandparents: ________________________________________________________________________________________________________________Paternal Grandparents: _________________________________________________________________________________________________________________

New England Medical

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Children: ____________________________________________________________________________________________________________________________

SOCIAL HISTORY:

Marital Status: S M SEP D WEducation: GS HS GED COLEmployment: _______________________________________________________Drugs: _____________________________________________________________Alcohol per week: _________________ Tobacco: Packs/day ______ Years ______

Emergency Information

Emergency Contact: _______________________ Home Telephone#: _____________________Relationship: _________________________ Work Telephone #: _________________________

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New England Medical

Scheduling Policy

Scheduling appointments

Monday – Thursday 8am – 6pmFriday 9am- 8pm

Making a sick appointment

Sick appointments are generally made on the same day as the phone call. Calling to make an appointment is preferred, rather than simply coming into the office. We would suggest you arrive 15 minutes prior to your appointment to fill out paperwork for the visit.

Making a follow-up appointment

After your visit with your physician, you should go back to the reception desk to make a follow-up appointment. This time frame can range from one week to six months.

We do understand that your time is precious and we do our best to meet the schedule, but there are times where we do run a little behind. With the help of your patience we will be able to get back on track. If you are not able to wait for your appointment, the receptionist will give you the option to reschedule.

I have read the above and fully understand the terms thereof.

Signature of Patient: ____________________________________ Date: __________________

Printed Name: ________________________________________________________________

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New England Medical

Telephone Policy

Our goal is to see every patient that calls to make an appointment for that day. It is best to call early in the day to make sure there is an appointment slot open. It is NOT in our policy to give medical advice over the phone. After hours our goal is to simply determine how urgent the situation is and how the best way to deal with it until you are able to be seen – NOT to diagnose or to treat. If you cannot wait to be seen, we will refer you to the nearest emergency room.

When you call our office after hours, you will be transferred to our answering service, and they will help you accordingly.

I have read the above and fully understand the terms thereof.

Signature of Patient: _____________________________________ Date: __________________

Printed Name: _________________________________________________________________

Automated Appointment Calls

The MedVoiceTM reminder service is a simple voice activated recording that calls all patients at their place of residence to remind them of their scheduled appointments. I hereby authorize New England Medical to use their automated system to remind me of all of my scheduled appointments. I understand that my signature on this form authorizes New England Medical to utilize the automated appointment call service for all my scheduled appointments.

I have read the above and fully understand the terms thereof.

Signature of Patient: _____________________________________ Date: __________________

Printed Name: ________________________________________________________________

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New England Medical Payment Policy

As a courtesy, New England Medical, verifies your benefits with your insurance company. Your claim will process according to your plan, if your claim processes differently from the benefit we were quoted, the insurance company will side with the plan and will not honor the benefit quote we received.

It is the policy of New England Medical that payment is due at the time of services unless other financial arrangements are made in advance. We require all patients to pay their deductible, copay, and/or coinsurance payment at the beginning of each visit. The office manager will explain this information to you prior to your first visit. At the conclusion of your visits with us you may be billed for any outstanding balances. If there is a credit, you will be provided a refund promptly.

Although we are contracted with most insurance carriers, our services may not be covered by your particular insurance plan. Being referred to our clinic by another physician does not necessarily guarantee that your insurance will cover our services. Please remember that you are 100 percent responsible for all charges incurred: your physician’s referral and our verification of your insurance benefits are not a guarantee of payment.

We recommend you contact your insurance carrier and check into coverage for primary care. Do not assume you will not owe anything if you have more than one insurance policy.

I have read the above and fully understand the terms thereof.

Signature of Patient: _____________________________________ Date: __________________

Printed Name: _________________________________________________________________

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New England MedicalNOTICE OF PRIVACY PRACTICES

As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

THIS NOTICE DESCRIBES HOW NEW ENGLAND MEDICAL MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY. OUR COMMITMENT TO YOUR PRIVACY

New England Medical is dedicated to maintaining the privacy of your individually identifiable health information (IIHI). In the course of treating you, we will create records of the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and our privacy practices. The terms of this notice apply to all records containing your IIHI that we create or retain in our practice. We reserve the right to revise or amend thisNotice of Privacy Practices. Any revision or amendment to this Notice will be effective for all of your records created or maintained by this office in the past and in the future. New England Medical will post a copy of our current Notice of Privacy Practices in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.

IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT OUR PRIVACY OFFICER:

Melinda Gordon: 168 Main Street, Suite 4, Claremont, NH 03743 Phone: (603)555-1000 Ext: 4242

I. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTHINFORMATION (IIHI) IN THE FOLLOWING WAYS:The following categories describe the different ways in which we may use and disclose your IIHI:

1. Treatment.Our practice may use your IIHI to treat you. We may ask you to have diagnostic studies (such as an MRI or x-ray), and we will use the results of these tests to help us reach a diagnosis. We may use your IIHI in order to write a prescription for you, or we may disclose your IIHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice –

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including, but not limited to, our doctors and nurses – may use or disclose your IIHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your IIHI to others, upon your designation.

2. Payment.Our practice may use and disclose your IIHI in order to bill and collect payments for the services and items that we provide. We may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if our insurer will cover, or pay for, your treatment. We may also use and disclose your IIHI to obtain payment from third parties that may be responsible for such costs. Also, we may use your IIHI to bill you directly for services and items.

3. Health Care Operations.Our practice may use and disclose your IIHI to operate our business operations. These uses and disclosures are necessary to monitor the quality of care that we provide. Our practice may use your IIHI to evaluate New England Medical’s services, including the performance of our staff.

4. Appointments.In order to protect you IIHI, appointments, cancellations and rescheduling cannot be made with the answering service. All calls of this nature must be made during office hours between 8:00 a.m. to 5:00 p.m. and must be made directly with practice personnel.

5. Appointment Reminders.Our practice may use and disclose your IIHI to contact you and remind you of an appointment either by mail or phone, including leaving messages on your designated answering machine.

6. Test Results.Normally, test results will not be communicated to the patient over the phone. These results will typically be discussed in the office. Should you desire to have results mailed to your home or any other desired location, a specific request must be submitted in writing.

7. Prescriptions.Prescription requests must be made during office hours only (8:00 a.m. to 5:00 p.m.). The practice’s answering service is not authorized to accept prescription requests.

8. Release of Information to Family/Friends.Our practice may release your IIHI to a friend or family member who is involved in your care, or who assists in taking care of you. For example, a parent or guardian may obtain information concerning the course of your treatment, provided proper consent has been provided.

9. Disclosures Required by Law.Our practice will use and disclose your IIHI when we are required to do so by federal or state law. Some of these required disclosures are listed in section II (1) below.

II. USE AND DISCLOSURE OF YOUR INDIVIDUAL IDENTIFIABLE HEALTH INFORMATION IN SPECIFIC SPECIAL CIRCUMSTANCES.

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The following categories describe unique scenarios in which we may use or disclose your individually identifiable health information: 1. Public Health Risks.Our practice may be required to disclose your IIHI to public health authorities that are authorized by law to collect information for the purpose of:

Maintaining vital records, such as births and deaths, Reporting child abuse or neglect, Preventing or controlling disease, injury or disability, Notifying certain government agencies about the diagnoses of certain conditions that create a public risk, Notifying a person regarding a potential risk for spreading or contracting a disease or condition, Reporting reactions to drugs or problems with products or devices, Notifying individuals if a product or device they may be using has been recalled, Notifying appropriate government agencies and authorities regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information, and Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

2. Health Oversight Activities.Our practice may disclose your IIHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures and actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

3. Lawsuits and Similar Proceedings.Our practice may use and disclose your IIHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We may also disclose your IIHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

4. Law Enforcement.We may release your IIHI if asked to do so by a law enforcement official: Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement, Concerning a death we believe has resulted from criminal conduct, Regarding criminal conduct at our offices, In response to a warrant, summons, court order, subpoena or similar legal process, To identify/locate a suspect, material witness, fugitive or missing person.

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In an emergency, to report a crime (including the location or victim(s) of a crime, or the description, identity or location of the perpetrator).

5. Deceased Patients.Our practice may release your IIHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we may also release information in order for funeral directors to perform their jobs.

6. Organ and Tissue Donation.Our practice may release your IIHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation or transplantation if you are an organ donor.

7. Research.Our practice may use and disclose your IIHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your IIHI for research purposes except when: (a) our use or disclosure was approved by an Institutional Review Board or a Privacy Board; (b) we obtain the oral or written agreement of a researcher that (i) the information being sought is necessary for the research study; (ii) the use or disclosure of your IIHI is being used only for the research; and (iii) the researcher will not remove any of your IIHI from our practice; or (c) the IIHI sought by the researcher relates only to decedents and the researcher agrees either orally or in writing that the use or disclosure is necessary for the research and, if we request it, to provide us with proof of death prior to access of IIHI of the decedents.

8. Serious Threats to Health or Safety.Our practice may use and disclose your IIHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

9. Military.Our practice may disclose your IIHI if you are a member of U.S. or foreign military force (including veterans) and if required by the appropriate authorities.

10. National Security.Our practice may disclose your IIHI to federal officials for intelligence and national security activities authorized by law. We may also disclose your IIHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

11. Inmates.Our practice may disclose your IIHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.

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New England Medical

ACKNOWLEDGEMENT OF RECEIPTS OF NOTICE OF PRIVACY PRACTICES

I, ________________________________________________________________, acknowledge that I have received a copy of the Notice of Privacy Practices, which summarizes the ways my protected health information may be used and disclosed by the practice and states my rights with respect to my protected health information. I understand the practice has the right to revise these information practices and to amend the Notice of Privacy Practices. I have been informed that in the event the practice changes this Notice, a revised Notice will be posted in the practice and that I may obtain a current Notice of Privacy Practices at any time from the Privacy Officer.

Date: _______________________________________________

Signature of Patient: ________________________________________________________

Printed Name: _____________________________________________________________

Signature of legal representative, if resident is legally incompetent or incapacitated:

_________________________________________________________________________

Printed Name: _____________________________________________________________

Relationship to Patient: ______________________________________________________

Signature of Witness: ________________________________________________________

Printed Witness Name: _______________________________________________________

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Bibliography:

Payment Policy

www.physicianspractice.com/tools/sample-payment-policy-medical-practices

Scheduling Policy

www.the childhealthcenter.com/scheduling_policies.htm

Telephone Policy

www.chmed.com/working-with-us/our-policies/telephone-policy/

Patient ConfidentialitySample 1 on blackboard

Automated Appointment CallsSample 1 on blackboard

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