Online Forms - Horizon Family Medicine

ONLINE PATIENT FORMS
After you have filled out the form, hit the submit button at the bottom of the screen.
You will be redirected to a page indicating "Your Form Has Been Submitted to HFM."
- Are you a New or Established patient? (REQUIRED)*
  - New Patient
  - Established Patient
- 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
  - Jenah Manzano, PA-C
  - Rebecca Johnson, FNP-BC
- Which Four Oaks Provider do you see? (REQUIRED)*
  - Dr. Watson
  - Dr. Olivia Johnson
  - Hannah Brame, PA-C
- Which Riverwood Provider do you see? (REQUIRED)*
  - Dr. Hebda
  - Caroline Lewis, PA
Note: These emails will not go out while in beta testing.
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Online Patient Forms

Are you a new patient or an established patient?
- New Patient
- Established Patient
PATIENT REGISTRATION
PATIENT INFORMATION
- Legal Name (First, Middle, Last):
- Suffix:
- SSN#:
- Date of Birth:
- Home Address:
- Home City State Zip:
- Mailing Address:
- Mailing City State Zip:
- Home Phone:
- Work Phone:
- Cell Phone:
- Email Address :
- Note: Your email address is part of your protected health record and will not be sold or spammed
- Employer:
- Occupation:
- Marital Status:
  - Single
  - Married
  - Divorced
  - Widowed
- Gender:
  - Male
  - Female
- Race:
  - White/Caucasion
  - Black/African American
  - Other (specify below)
- First Language:
  - English
  - Spanish
  - Other (specify below)
- Ethnicity:
  - Hispanic
  - Non-Hispanic
Other race/language:
EMERGENCY CONTACT - Who may we contact in case of an emergency?
- Name:
- Relationship to Patient:
- Home Phone:
- Work Phone:
- Cell Phone:
RESPONSIBLE PARTY - Custodial parent/guardian if patient is under 18 years old
- Legal Name (First, Middle, Last):
- ID#, DL#, or SS#:
- Relationship to Patient:
- Date of Birth:
- Employer:
If Patient is a MINOR: Please complete this section
- Parent 1
- Parent 1 Name:
- Parent 1 Birthdate:
- Parent 1 Phone:
- Is Parent 1 the Guarantor?
  - Yes
  - No
- Parent 2
- Parent 2 Name:
- Parent 2 Birthdate:
- Parent 2 Phone:
- Is Parent 2 the Guarantor?
  - Yes
  - No
PRIVACY INFORMATION (HIPAA)
- I authorize Horizon Family Medicine to contact me and/or to leave telephone messages in the following ways:
- Home Phone:
- Work Phone:
- Cell Phone:
- Email:
- I authorize Horizon Family Medicine to release my medical information to the named persons listed below:
- Spouse/Parents/Children (Print Name):
- Other (Print Names and Relationship to the Patient):
- HIPAA Acknowledgement (REQUIRED)*
  - I have read/received the Notice of Privacy Practices
- HORIZON FAMILY MEDICINE, P.A.
  
  NOTICE OF PRIVACY PRACTICES
  
  This notice describes how health and personal information about you may be used and disclosed, and how you can get access to this information.
  Please review it carefully.
  The privacy of your health and personal information is important to us.
  
  OUR LEGAL DUTY
  We are required by applicable federal and state law to maintain the privacy of your health and personal information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your health and personal information. We must follow the privacy practices that are described in the notice while it is in effect. This notice takes effect April 14, 2003, and will remain in effect until we replace it.
  
  We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all health and personal information that we maintain, including health and personal information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request.
  
  You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.
  
  USES AND DISCLOUSURES OF HEALTH AND PERSONAL INFORMATION
  We use and disclose health and personal information about you for treatment, payment, and healthcare operations. For example:
  
  Treatment: We may use or disclose your health and personal information to a physician or other healthcare provider providing treatment to you.
  
  Payment: We may use and disclose your health and personal information to obtain payment for services we provide to you.
  
  Healthcare Operations: We may use and disclose your health and personal information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
  
  Your Authorization: In addition to our use of your health and personal information for treatment, payment or healthcare operation, you may give us written authorization to use your health and personal information or to disclose it to anyone for any purpose. If you give us written
  authorization, you may revoke it in writing at anytime. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health and personal information for any reason except those described in this notice.
  
  To Your Family and Friends: We must disclose your health and personal information to you, as described in the Patient Rights section of this notice. We may disclose your health and personal information to a family member, friend, or other person to the extent necessary to help with your healthcare, but only if you agree we may do so.
  
  Persons involved in care: We may use or disclose health and personal information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure or your health and personal information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health and personal information based on a determination using our professional judgment disclosing only health and personal information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health and personal information.
  
  Marketing Health-Related Services: We will not use your health and personal information for marketing communications without your written authorization.
  
  Required by Law: We may use or disclose your health and personal information when we are required to do so by law.
  
  Abuse or Neglect: We may disclose your health and personal information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health and personal information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
  
  National Security: We may disclose to military authorities the health and personal information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health and personal information required for lawful intelligence, counter intelligence, and other national security activities. We may disclose to correctional institution or a law enforcement official having lawful custody of protected health and personal information of inmate or patient under certain circumstances.
  
  Appointment Reminders: We may disclose your health and personal information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
  
  PATIENT RIGHTS
  Access: You have the right to look at, or get copies of, your health and personal information, with limited exceptions. You must request in writing to obtain access to your health and personal information. You may obtain a form to request access by using the contact information listed at the end of this notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. If you request copies, we will charge you for each page; and for postage, if you want the copies mailed to you. If you prefer, we will prepare a summary or explanation of your health and personal information for a fee. Contact us using the information listed at the end of this notice for full explanation of our fee structure.
  
  Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclose your health and personal information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last six years, but not before April 14, 2003. If you request this accounting more than once in a 12 month period, we may charge you a cost-based fee for these additional requests.
  
  Restriction: You have the right to request that we place additional restrictions on our use of disclosure of your health and personal information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in emergencies).
  
  Alternative Communication: You have the right to request that we communicate with you about your health and personal information by alternative means or to alternative locations. (You must make this request in writing). Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.
  
  Amendment: You have the right to request that we amend your health and personal information. (Your request must be in writing and it must explain why the information should be amended). We may deny your request under certain circumstances.
  
  Electronic Notice: If you receive this notice on our web-site or by electronic mail, you are entitled to receive this notice in written form.
  
  QUESTIONS AND COMPLAINTS
  If you want more information about our privacy practices or have questions or concerns, please contact us.
  
  If you are concerned that we may have violated your privacy rights, or you disagree with a decision we have made about access to your health and personal information, or in response to a request you made to amend or restrict the use or disclosure of your health and personal information, or to have us communicate with you by alternate means or at alternate locations, you may complain to us using the contact information listed at the end of this notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Service upon request.
  
  We support your right to the privacy of your health and personal information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health
  and Human Services.
  
  Contact Officer:
  Telephone: (919) 963-3148 Fax: (919) 963-2900
  864 Black Creek Road, Four Oaks, NC 27524
- Click here to print the Notice of Privacy Practices
INSURANCE
- Primary Insurance
- Company:
- Policy #:
- Group #:
- Policy Holder's Name:
- Relationship to Patient:
- Secondary Insurance
- Company:
- Policy #:
- Group #:
- Policy Holder's Name:
- Relationship to Patient:
- Please list your primary insurance company’s address and phone number for claims processing:
  (If you do not have access to your insurance card, enter "not sure")
- Primary Insurance Claims Address:
- Primary Insurance Claims Phone:
FINANCIAL POLICY
- 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. New Patients who missed their New Patient scheduled appointment may not be eligible to reschedule with our practice.
OFFICE POLICY
- LATE – If you arrive more than 15 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 $35 fee. This fee is not billed to the insurance company and is the financial responsibility of the patient. 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.
PAYMENT SOURCES
If you are PRIVATE PAY, you are acknowledging that you are a self paying patient seeking medical attention. You agree to pay your balance in full at the time of service or to pay 50% of your balance now and the remainder in full within 30 days or you agree to a payment arrangement with the Billing Office before leaving the building and satisfying your agreement before your next scheduled visit.

If you are INSURED, you are acknowledging that your claim will be sent to your insurance carrier for reimbursement. You will be responsible for the remaining balance (if any) in accordance with your insurance plan. Such payments will be paid within 30 days of receipt of statement or you will contact the Billing Office to make payment arrangements.

If your visit with our practice is for WORKMANS COMPENSATION, you are acknowledging that a claim will be filed with your workman compensation carrier. If your claim is denied, you will be responsible for all charges on the account. Such payments will be paid within 30 days of receipt of statement. It is your responsibility to supply Horizon Family Medicine, PA with the information needed to process any and all claims.

If your visit with our practice is for PERSONAL INJURY, you are acknowledging that a claim will be filed with your attorney, private insurance and/or claim adjuster. You will be responsible for all claims if payment is not received within 30 days. Such payments will be paid upon receipt of statement. It is your responsibility to supply Horizon Family Medicine, PA with the information needed to process any and all claims.
EXAM TYPES/BILLING CODES
- ATTENTION: There may be two (2) billing codes at the time of an Annual Preventive Exam.
  Insurance billing guidelines require separate billing for such services and/or tests when performed during the Preventive Exam.
  - Preventive Exam itself
  - Medical Management of current conditions or the diagnosis of new conditions. (See "Things NOT included in a Preventative Medical Exam" below).
- Acknowledgement Initials:*
- - If you prefer, we can often do both at one visit, if time allows, or you may choose to do this at two separate visits. In such instances, the patient is responsible for any co-pays or deductibles associated with such tests or service, in addition to the normal charge for the Preventive Exam.
- Acknowledgement Initials:*
- A Preventive Exam is a checkup to assess your overall health and includes the following:
  - Preventive Exams are also referred to as "physicals," "wellness exams," or "annual exams."
  - An age and gender appropriate history and examination
  - Prevention and health maintenance issues related to age, sex, and family history
  - A review of risk factors and strategies to reduce those risk factors
  - Preventive tests, routine labs, age appropriate cancer screening, mood screening, appropriate screenings for diabetes, cholesterol, anemia, kidney and liver diseases.
  - Administration of age appropriate immunizations/vaccines
  - Guidance about diet, exercise, and other advice/strategies to improve health
- Things NOT included in a Preventive Exam appointment:
  - Management of your current health conditions (example: high blood pressure, diabetes, high cholesterol, depression, anxiety, insomnia, arthritis, etc.)
  - Issuing new or refill of prescriptions
  - The diagnosis of any new problem that requires testing, referrals, diagnostic test, medications, etc.
  - If we see any questionable indicators, we will usually ask that you schedule a return visit to allow time for proper time and treatment of new problems or chronic conditions. Your health is our priority and your time matters. We appreciate you helping us maintain our appointment schedule as closely as possible.
  Your health is our priority and your time matters. We appreciate you helping us maintain our appointment schedule as closely as possible.
HEALTH HISTORY QUESTIONNAIRE/PREVENTIVE HEALTH SCREENING
PATIENT INFORMATION
- Patient Name:
- Date of Birth:
- Address:
- Home Phone:
- Cell Phone:
- Preferred Pharmacy:
- Pharmacy Phone:
- Briefly specify reason for visit:
Special Communication Needs
- Language Preference:
- If 'yes' to any of the questions below, how can we assist?
Special communication needs:
- Visual impairment
- Hearing impairment
- Speech impairment
- Cognitive impairment
- Sensory impairment
- Other (please specify)
- Other communication needs:
Personal Health History
Please check past or current problems or conditions:
Condition:
- Hypertension
- High cholesterol
- Diabetes
- Heart attack or angina
- Irregular heart rythm
- Congestive heart failure
- Asthma
- Emphysema/chronic bronchitis
- Pneumonia
- Gastroesophageal reflus disease
- Stomach ulcer
- Kidney problem
- Liver disease/hepatitis
- Colon cancer
- Seizures
- Headaches
- Stroke (CVA)
- Prostate problem
- Breast problem
- Urinary tract infections
- Osteoarthritis
- Cancer (Please list type)
- Thyroid problem
- Bleeding disorder
- Addiction ssues
- Depression or anxiety
- Mental illness
- Other (please describe)
Briefly describe additional conditions or problems:
Previous Surgical Procedures
Please check if you have had any of the following (specify dates below):
Procedure:
- Heart surgery
- Carotid artery surgery
- Vascular surgery / stent
- Abdominal aneurysm repair
- Hysterectomy
- Gallbladder removed
- Appendix removed
- Tonsillectomy
- Joint replacement
- Breast cancer surgery
- Prostate cancer surgery
- Hernia
- Pacemaker
- Other (please specify)
- (no change since previous year)
Please enter dates of the above procedures and/or additional procedures:
Specialty Providers
In order that we can best coordinate your care, please list any medical providers you see outside of this practice and specify year last seen below:
Specialties:
- Eye doctor
- Cardiologist
- Oncologist
- Gastroenterologist
- Endocrinologist
- Nephrologist
- Psychiatrist
- Allergist
- Vascular
- Pulmonologist
- Other (please specify)
- (no new specialist visits since previous year)
Specialty
Specialty Type Doctor's Name Last Seen (month and year)
Please enter any additional specialty providers and the month/year last seen:
Medications
Please list any medications you take, including over-the-counter, herbs and supplements. Also, include any medications prescribed by specialists or providers other than your PCP. Include dose and frequency:
Meds
It is very important that you take the medication(s) your health care professional has given you. Please check any of the following:
- Are you unable to fill your prescription(s) because of the cost?
  - Yes
  - No
- Are you unable to fill your prescription(s) because of lack of transportation?
  - Yes
  - No
- Have you ever applied for any pharmacy assistance?
  - Yes
  - No
Allergies
Please list any allergies to medications or foods:
Family History
Please enter the medical history for your parents, siblings and children.
NOTE: You can click the plus sign on the far right to add additional rows.
List
Relationship Living Y/N Age Major Medical Problems and/or Cause of Death
- Specifically have any of your relatives had the following conditions?
  - Mental illness
  - Chemical dependency
  - Opioid dependency
- Family Mental illness/Dependency information:
Opioid History and Current Usage
It is very important that you take the medication(s) your health care professional has given you. Please check any of the below:
Have you ever taken drugs called Opioids (ex: Morphine, Oxycontin, Dilaudid, Fentanyl)?
- Yes
- No
Are you currently taking any Opioid for chronic pain?
- Yes
- No
Did you utilize non-medication treatments for your pain before taking medication? (Heat/Cold/Physical Therapy)
- Yes
- No
Social History
- Marital status:
  - Single
  - Married
  - Divorced
  - Widowed
  - Life partner
- Education level:
  - Did not graduate
  - High school
  - Some college
  - Bachelor's degree
  - Master's degree or higher
- Job concerns:
  - Stress
  - Hazardous substances
  - Heavy lifting
  - Transportation
- How stressful would you rate your current living situation (1 star=Not very stressful, 10 stars=Very stressful)?
  10987654321
- Do you fear for your safety in your current living situation?
  - Yes (please describe)
  - No
- Living situation concerns:
- Are there financial concerns that affect your ability to go to the doctor?
  - Yes (please describe)
  - No
- Are there financial concerns that affect your ability to obtain food and shelter?
  - Yes (please describe)
  - No
- Financial situation concerns:
- Are there any religious or cultural factors that you would like us to take into account when planning your healthcare?
  - Yes (please describe)
  - No
- Religious or cultural factors:
Current Health Concerns
Please check problems or conditions that you are CURRENTLY experiencing (check NO CURRENT HEALTH CONCERNS if you are not currently experiencing any problems or conditions):
- Chest pain
- Shortness of breath
- Wheezing
- Cough
- Coughing up blood
- Sore throat
- Nasal congestion
- Irregular heartbeat
- Fast heartbeat
- High blood pressure
- Low blood pressure
- Lightheadedness
- Dizziness/fainting
- Abdominal pain
- Heartburn
- Indigestion
- Ankle swelling
- Nausea
- Vomiting
- Vomiting blood
- Change in bowel habits
- Rectal bleeding
- Black/tarry stools
- Weight loss
- Weight gain
- Loss of appetite
- Difficulty Swallowing
- Diarrhea
- Constipation
- Painful urination
- Blood in urine
- Urine frequency
- Decrease in urine flow
- Urine leakage
- Headache
- Weakness
- Loss of strength
- Balance problems
- Eye pain
- Loss of vision
- Double vision
- Memory loss
- Ringing in ears
- Pain in ears
- Nose bleeds
- Hoarseness
- Easy bleeding
- Easy bruising
- Rash
- Changes in mole
- Sore that won't heal
- Fatigue/lethargy
- Insomnia
- forgetfulness
- Depression
- Nervousness
- Pain in testicles
- Loss of libido
- Impotence
- Breast pain
- Breast discharge
- Other (please describe)
- NO CURRENT HEALTH CONCERNS
Pain, weakness, or numbness in:
- Arms
- Legs
- Hands
- Hips
- Neck
- Feet
- Back
- Shoulders
Other CURRENT health concerns:
Females - Please Complete
Menstrual flow:
- Regular
- Irregular
- Pain/cramps
- Pain/bleeding after sex
Menstrual days of flow:
Menstrual length of cycle:
1st day of last period:
Number of pregnancies:
Number of miscarriages:
Birth control method:
Health Literacy Questionnaire
It is really important to your provider that you understand the information related to your health. Please rate the following questions on a scale of 1 to 10 (1=strongly disagree and 10=strongly agree).
- I feel that I have a thorough understanding of the instructions that my doctors and nurses give me about my health:
  10987654321
- I feel that I remember the instructions given to me at my doctor’s office when I get home:
  10987654321
- I feel that I have a strong understanding of medical language:
  10987654321
Health Maintenance
Please check whether you have had the following preventive services and enter the year of the service.
- Immunizations (if selected, specify year):
  - Tetanus vaccine / Tdap
  - Pneumonia vaccine
  - Influenza vaccine
  - Shingles vaccine
  - Covid vaccine
  - Other (please specify)
- Tests (if selected, specify year):
  - Pap smear/pelvic
  - Mammogram
  - Bone dexascan
  - Colonoscopy
  - Prostate test
- Specify the year(s) of your immunizations and tests:
Health Behaviors (age 11 years and older)
- Tobacco use:
  - Never
  - I quit smoking (specify when quit)
  - Current smoker (specify how many packs/day for how many years)
- Tobacco details:
- Alcohol intake:
  - Yes (specify how many drinks/how often)
  - No
- Alcohol intake details:
- Illicit drug use (including marijuana, cocaine, steroids):
  - Never
  - Past
  - Current
- If past or current drug use describe:
Which of the following health behaviors pertain to you?
- Exposure to secondhand smoke
- Eat a diet high in fruits and vegetables
- Get 30 minutes of exercise 5 times a week
- Wear a seatbelt
- See a dentist at least once a year
- Wear sunscreen
Urinary Incontinence Assessment (age 65 and older)
Do you experience leaking in the following situations (1 star=Not at all, 4 stars=A lot):
During daily activities (work, household task):
4321
During physical activities (walking, swimming, or other exercise):
4321
During recreational activities (movies, hobbies):
4321
During social activities (going out with friends, family visits):
4321
During car trips:
4321
Fall Risk Screening (age 65 and older)
- In the last 12 months have you fallen?
  - Yes
  - No
  - Unsure
- If yes, how many times?
  - 1
  - 2
  - 3
  - 4
  - 5+
- Were you injured as a result of this fall?
  - Yes
  - No
  - Unsure
Functional Assessment (age 65 and older)
Do you need assistance in the following areas (1 star=Not at all, 4 stars=A lot):
Bathing, dressing and grooming:
4321
During daily activities (work, household task):
4321
Walking or driving:
4321
Communicating needs and feelings:
4321
Understanding directions:
4321
Keeping appointments:
4321
Taking medications:
4321
Performing other medical treatments:
4321
- If yes to any of these questions, who helps with these activities?
Mood Screening: (age 11 and older)
A person’s mood can have a strong influence on their health status and overall wellbeing. Over the past 2 weeks, how often have you been bothered by any of the following problems?
- Little interest or pleasure in doing things:
  - Not at all
  - Several days
  - More than half the days
  - Nearly every day
- Feeling down, depressed, or hopeless:
  - Not at all
  - Several days
  - More than half the days
  - Nearly every day
AUTHORIZATION FOR RELEASE OF INFORMATION
- Patient Name:
- Other Name:
- Street:
- City State Zip:
- Date of Birth:
- Phone:
- Cell Phone:
I authorize the release of medical information as indicated below:
- I would like to pick up my records, please call me at the number above.
- I would like the records mailed (please indicate the address above).
What to Release: Please choose the records you would like released:
- Outpatient note(s)
- X-Ray report(s)/film(s)
- Laboratory reports(s)
- Immunization record
- Pathology reports(s)
- ALL Medical records
- Other, please specify
Other what to release:
NOTE: The records listed below have special protection by law. I authorize the release of information pertaining to:
- The diagnosis or treatment of AIDS, including results of HIV tests:
  - Yes
  - No/NA
- The diagnosis or treatment of drug and/or alcohol abuse:
  - Yes
  - No/NA
- The treatment and/or consultation for mental health or psychiatric disorders:
  - Yes
  - No/NA
- Purpose of the release: Please indicate the reason for this release::
  - Transfer care
  - For use in a lawsuit
  - Follow-up related to an injury
  - Personal use
  - To obtain disability
  - Worker’s compensation
  - Armed Forces requirement
  - For another doctor
  - Other, please specify
Other purpose of release:
Expiration date: This authorization will expire in sixty days unless otherwise indicated below:
- Please change the expiration date, enter days below
Number of days for expiration date to last:
I understand this Authorization can be revoked at any time according to Horizon Family Medicine’s privacy practices. This request must be made in writing. Once these records are released, the information is not protected by Horizon Family Medicine and may potentially be re-disclosed by the party who received these records. Horizon Family Medicine, its employees and officers, and attending physicians are released from legal responsibility or liability for release of the above information to the extent indicated and authorized.

I have read and understand this information. I have received a copy of this form, and I am the patient or am authorized to act on behalf of the patient to sign this document verifying authorization for the use or disclosure of the protected health information under the above stated terms.
READ & SIGN BELOW
- I certify that the information provided is correct and complete to the best of my knowledge.
- Date:
Signature of Patient (or Legal Guardian):
ACKNOWLEDGMENT AND SIGNATURE
In signing this Patient Registration Form, you are acknowledging the following:
- You certify that you have read and completed this form to it's entirety and that it is correct and complete to the best of your knowledge.
- You can revoke or stop the communications on this form at any time in writing. It will not apply to any communications that were made before our practice received your written notice to stop the communications.
- All changes or updates to this form must be made in writing and signed by you (patient) or your personal representative.
- You authorize Horizon Family Medicine to furnish medical information regarding your examinations and treatments to your insurance carriers, and assign all benefits payable to Horizon Family Medicine to be used towards the payment of your account.
- You acknowledge that information related to a communicable disease diagnosis such as HIV or a diagnosis related to mental health or substance abuse might be included in a communication you authorize on this form. Information that has been shared as permitted by this form may be redisclosed and no longer protected by state or federal privacy laws.
- An Authorization to Release Health Information or Patient Access Request must be completed for this practice to provide copies of or transmit your health information/records to anyone other than you.
- Date:*
Signature of Patient (or Legal Guardian):*
Description of Personal Representative’s Authority:
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Comments
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Specialty Type	Doctor's Name	Last Seen (month and year)

Relationship	Living Y/N	Age	Major Medical Problems and/or Cause of Death

ONLINE PATIENT FORMS

Online Patient Forms

Are you a new patient or an established patient?

PATIENT REGISTRATION

PATIENT INFORMATION

EMERGENCY CONTACT - Who may we contact in case of an emergency?

RESPONSIBLE PARTY - Custodial parent/guardian if patient is under 18 years old

If Patient is a MINOR: Please complete this section

Parent 1

Parent 2

PRIVACY INFORMATION (HIPAA)

HORIZON FAMILY MEDICINE, P.A.

NOTICE OF PRIVACY PRACTICES

INSURANCE

Primary Insurance

Secondary Insurance

FINANCIAL POLICY

OFFICE POLICY

PAYMENT SOURCES

EXAM TYPES/BILLING CODES

HEALTH HISTORY QUESTIONNAIRE/PREVENTIVE HEALTH SCREENING

PATIENT INFORMATION

Special Communication Needs

Personal Health History

Previous Surgical Procedures

Please check if you have had any of the following (specify dates below):

Specialty Providers

In order that we can best coordinate your care, please list any medical providers you see outside of this practice and specify year last seen below:

Medications

Please list any medications you take, including over-the-counter, herbs and supplements. Also, include any medications prescribed by specialists or providers other than your PCP. Include dose and frequency:

It is very important that you take the medication(s) your health care professional has given you. Please check any of the following:

Allergies

Please list any allergies to medications or foods:

Family History

Please enter the medical history for your parents, siblings and children.

Opioid History and Current Usage

Social History

Current Health Concerns

Females - Please Complete

Health Literacy Questionnaire

It is really important to your provider that you understand the information related to your health. Please rate the following questions on a scale of 1 to 10 (1=strongly disagree and 10=strongly agree).

Health Maintenance

Please check whether you have had the following preventive services and enter the year of the service.

Health Behaviors (age 11 years and older)

Urinary Incontinence Assessment (age 65 and older)

Do you experience leaking in the following situations (1 star=Not at all, 4 stars=A lot):

Fall Risk Screening (age 65 and older)

Functional Assessment (age 65 and older)

Do you need assistance in the following areas (1 star=Not at all, 4 stars=A lot):

Mood Screening: (age 11 and older)

A person’s mood can have a strong influence on their health status and overall wellbeing. Over the past 2 weeks, how often have you been bothered by any of the following problems?

AUTHORIZATION FOR RELEASE OF INFORMATION

READ & SIGN BELOW

ACKNOWLEDGMENT AND SIGNATURE

Clayton Location

Four Oaks Location

Riverwood Location