New Patient Registration NameThis field is for validation purposes and should be left unchanged.NEW PATIENT REGISTRATIONCurrent PCP: Please select your HFM location: (REQUIRED)* Clayton Four Oaks Riverwood Which Clayton Provider do you see? (REQUIRED)* Dr. Williams Dr. Harris Dr. Kahn Dr. McGill Dr. Selak Dr. Norris Megan Wester, PA Brittany McCall, FNP-C Morgan Smith, FNP-C Deborah Roberson, FNP-C Nicole Malfi, FNP-C Which Four Oaks Provider do you see? (REQUIRED)* Dr. Olivia Johnson Hannah Brame, PA-C Which Riverwood Provider do you see? (REQUIRED)* Dr. Zenchenko (Dr. Z) Caroline Lewis, PA-C Patient InformationLegal Name:Suffix:SSN:Date of Birth:Email:Home Address:City State Zip:Mailing Address:City State Zip:Home Number:Cell Number:Work Number: Marital Status: Single Married Divorced Widowed Gender: Male Female Race: White/Caucasion Black/African American Other First language: English Spanish Other Ethnicity: Hispanic Non-Hispanic Emergency Contact - Who may we contact in case of an emergency?Name:Relationship to Patient:Home Number:Cell Number:Work Number:Privacy Information – HIPAA – Communicating with your Family, Friends, or CaregiversI authorize Horizon Family Medicine to contact me and/or to leave telephone messages in the following ways: Home Phone: Home Phone: Work Phone: Cell Phone: Email: I authorize Horizon Family Medicine to release my medical information to the named persons listed below: Spouse: Phone Number: Relative: Phone Number: Other: Phone Number: I DO NOT wish to release my health information to anyone besides myself. Insurance InformationPrimary InsuranceCompany:Policy #:Group #:Policy Holder's Name:Policy Holder's DOB:Relationship to Patient:Secondary InsuranceCompany:Policy #:Group #:Policy Holder's Name:Policy Holder's DOB:Relationship to Patient:Read and Sign BelowI certify that the information provided is correct and complete to the best of my knowledge. Signature of Patient (or Legal Guardian):*Date:*VACCINATION POLICY At Horizon Family Medicine, we are committed to providing the highest standard of care to all our patients. Based on evidence-based guidelines and recommendations from the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), and other public health authorities, we require that all patients follow the routine childhood immunization schedule. OUR POLICY We do not accept patients who are unvaccinated or whose parents/guardians choose to decline routine childhood immunizations without a valid medical contraindication. This policy is in place to: Protect the health and safety of all children and families who visit our practice. Prevent the spread of vaccine-preventable diseases. Support community immunity, especially for those who are too young or medically unable to be vaccinated. We recognize that parents and guardians have the right to make medical decisions for their children. However, we believe that not vaccinating poses a risk to other patients and staff in our practice and contradicts our commitment to public health and safety. EXEMPTIONS Only documented medical exemptions signed by a licensed medical provider will be considered on a case-by-case basis. We do not accept philosophical or religious exemptions. AGREEMENT * *By signing below, you acknowledge that you have read, understand, and agree to comply with our practice's vaccination policy. You also understand that failure to comply may result in discharge from the practice. Parent/Guardian Name: Child's Name(s):Date:* Signature:*FINANCIAL & OFFICE POLICYFINANCIAL POLICYLegal Name (First, Middle, Last):*Date of Birth:* Thank you for choosing Horizon Family Medicine, PA for your family's medical care. We are committed to providing you with quality health care. We appreciate your commitment to adhere to this agreement. INSURANCE – Your medical insurance is a contract between you and your insurance company. Horizon Family Medicine is not a party to that contract. We will file insurance claims on your behalf, as a courtesy. In order for your claims to be processed timely and accurately you must present a current insurance card and state issued photo ID at each visit. If you arrive without your card, you will be responsible for all charges until the billing office has received complete, current and accurate insurance information. Horizon Family Medicine policy is to have Social Security numbers on all patients to file insurance claims – this helps protect the patient and Horizon Family Medicine from insurance fraud. All information provided to us is part of your confidential health record and is protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Claim Submission – If your insurance company requires you to supply information to them for processing of a claim you must comply with their request in a timely manner. If your insurance company has not processed a claim on your behalf within 90 days of submission due to information that you have not provided, the balance will be transferred to your responsibility. If a payment is received for that claim, you may request reimbursement from Raleigh Durham Medical Group Billing Department at 866-557-2612 or choose to leave the amount as a credit on your account. Medicare – Medicare deductibles and co-insurances are expected at the time of service. As a participating provider with Medicare, we will file your claim to Medicare and if applicable, to your secondary insurance carrier. Please notify the front desk staff if you have recently changed Medicare plans. Third-party claims are the responsibility of the patient. Non-Contracted Insurance Plans – Payment is required at time of service. CO-PAYMENTS/DEDUCTIBLES/PAYMENTS –Payment is required at the time of service. We currently accept Cash, Personal Checks, Visa, MasterCard, and Discover. If you have a financial hardship or if you are unable to pay your bill in its entirety, please contact our billing office PRIOR to your appointment to discuss payment arrangements. There will be a $35.00 service charge for all returned checks. Self-Pay – Uninsured patients are classified as Self-Pay. We can provide an estimate of our fees prior to services in the office. This is only an estimate actual charges may be higher or lower. Self-Pay patients may be given a 30% "Prompt Pay" savings when their balance is paid at the time of service. You may also contact the Billing Office for payment arrangements. MINORS – Parents and guardians are responsible for payments for their dependents at the time of service. Patients between the ages of 16 and 18 can be seen without a parent or guardian present as long as parent or guardian is reachable by phone. MISSED APPOINTMENTS – Unless canceled at least 24 hours in advance, a charge will be accessed for missed appointments. This fee is NOT covered by your insurance plan and is your responsibility. OFFICE POLICY LATE – If you arrive more than 10 minutes late for your appointment you will be asked to reschedule. PRESCRIPTION REFILLS – Call your pharmacy and ask them to fax a refill request to our office. DO NOT wait until you are out of medicine. Refill requests take 24-48 business hours. FORMS – Forms requiring medical review and physician signature – including school, day care, and camp physicals, prior authorizations, FMLA, disability or other paperwork – will be completed within 7-10 business days which may be subject to a $15 fee. Please make sure to allow plenty of time for completion. Emergencies will be handled on a case by case basis. PATIENT CONFIDENTIALITY – In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), a copy of the Horizon Family Medicine Notice of Privacy Practices is available to all patients in the office or online at www.horizonfamilymed.com. READ & SIGN BELOW I have read, understand and agree to the above Financial and Office Policy. I authorize Horizon Family Medicine to furnish medical information regarding my examinations and treatments to my insurance carriers, and assign all benefits payable to Horizon Family Medicine to be used towards the payment of my account.Date:*Signature:*This field is hidden when viewing the form
