Online Forms ** HFM Online Patient Forms **Are you a New or Established patient?*New PatientEstablished PatientPlease select your HFM location:*ClaytonFour OaksRiverwoodSmithfieldWhich Clayton Provider do you see?*Dr. WilliamsDr. HarrisDr. KahnDr. McGillDr. SelakDr. NorrisMegan Wester, PABrittany McCall, FNP-CWhich Four Oaks Provider do you see?*Dr. WatsonCourtney Powell, PA-CWhich Riverwood Provider do you see?*Dr. HebdaJessica Heath, MPAS, PA-CWhich Smithfield Provider do you see?*Dr. PittardDr. LivermanDr. DavisDr. RyanJenah Manzano, PA-CNote: These emails will not go out while in beta testing. Send Email BCC Email "new" or "established" patientBETA TESTING FOR FORMS Please check the Provider and emails that the forms will go to. Enter an "Email for Testing" if you want to the see what the emailed forms look like. Email for Testing Send test results to this email.Online Patient Forms Are you a new patient or an established patient?New PatientEstablished Patient** PATIENT REGISTRATION **PATIENT INFORMATIONLegal 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 spammedEmployer:Occupation: Marital Status:SingleMarriedDivorcedWidowedGender:MaleFemaleRace:White/CaucasionBlack/African AmericanOther (specify below)First Language:EnglishSpanishOther (specify below)Ethnicity:HispanicNon-HispanicOther 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 oldName:ID#, DL#, or SS#:Relationship to Patient:Date of Birth:Employer:INSURANCEPRIMARY INSURANCECompany:Policy #:Group #:Policy Holder's Name:Relationship to Patient:SECONDARY INSURANCECompany: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:*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 Names of Persons Authorized to Receive my Medical Information:HIPAA Acknowledgement* 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) 209-4131 Fax: (919) 934-5632 Address: 410 Canterbury Road Smithfield, NC 27577 Click here to print the Notice of Privacy PracticesAUTHORIZATION OF MEDICAL RECORDS RELEASEDate of Birth:Patient Name:Other Name:Street:City State Zip:Phone:Cell: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:YesNo/NAThe diagnosis or treatment of drug and/or alcohol abuse:YesNo/NAThe treatment and/or consultation for mental health or psychiatric disorders:YesNo/NAPurpose 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:READ & SIGN BELOWI 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.Date of patient signature:Signature of Patient:Date of Legal Representative Signature AND Relationship to Patient:Signature of Legal Representative:** HEALTH HISTORY QUESTIONNAIRE **PATIENT INFORMATIONPatient Name:Date of Birth:Address:Local Phone:Alternate Phone:Preferred Pharmacy:Pharmacy Phone:Briefly specify other reason for visit:Special Communication Needs: New & Established PatientsLanguage 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:Health Literacy QuestionnaireIt 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 instructionsthat my doctors and nurses give me about my health:10987654321I feel that I remember the instructions given to me at mydoctor’s office when I get home:10987654321I feel that I have a strong understanding of medical language:10987654321Personal Health HistoryPlease 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 Bowel/digestive problem Seizures Headaches Stroke 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 ProceduresPlease 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: Requires Updating AnnuallyIn 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: SpecialtySpecialty TypeDoctor's NameLast Seen (month and year) Please enter any additional specialty providers and the month/year last seen:Health MaintenancePlease 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 Other (please specify) None/Do not know Tests (if selected, specify year):* Pap smear/pelvic Mammogram Bone dexascan Colonoscopy Prostate test None/Do not know Specify the year(s) of your immunizations and tests:Health Behaviors: Requires Updating Annually for 11 years and olderTobacco use:NeverQuit (specify when quit)Current smoker (specify how many packs/day for how many years)Tobacco details:Alcohol intake:Yes (specify how many drink/how often)NoAlcohol intake details:Illicit drug use (including marijuana, cocaine, steroids):NeverPastCurrentIf 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 Medications from Non-PCP ProvidersPlease list any new medications prescribed by specialists or providers other than you PCP. Please include name, dose and frequency:MedsIt 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?YesNoAre you unable to fill your prescription(s) because of lack of transportation?YesNoHave you ever applied for any pharmacy assistance?YesNoAllergiesPlease list any allergies to medications or foods:Family HistoryPlease 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.ListRelationshipLiving Y/NAgeMajor Medical Problems and/or Cause of Death Specifically have any of your relatives had the following conditions? Mental illness Chemical dependency Family Mental illness/Chemical dependency information:Current Health ConcernsPlease 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 CompleteMenstrual 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:Mood Screening: Requires Updating Annually for age 11 and upA 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 Urinary Incontinence Assessment: Requires Updating Annually for 65 years and olderDo you experience leaking in the following situations (1 star=Not at all, 4 stars=A lot):During daily activities (work, household task):4321During physical activities (walking, swimming, or other exercise):4321During recreational activities (movies, hobbies):4321During social activities (going out with friends, family visits):4321During car trips:4321Fall Risk Screening: Requires Updating Annually for 65 years and olderIn the last 12 months have you fallen?YesNoUnsureIf yes, how many times?12345+Were you injured as a result of this fall?YesNoUnsureFunctional Assessment: Requires Updating Annually for 65 years and olderDo you need assistance in the following areas (1 star=Not at all, 4 stars=A lot):Bathing, dressing and grooming:4321During daily activities (work, household task):4321Walking or driving:4321Communicating needs and feelings:4321Understanding directions:4321Keeping appointments, taking medications and performing other medical treatments:4321If yes to any of these questions, who helps with these activities?Social History: NEW PATIENTSMarital 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)?10987654321Do you fear for your safety in your current living situation?Yes (please describe)NoLiving situation concerns:Are there financial concerns that affect your ability to go to the doctor?Yes (please describe)NoAre there financial concerns that affect your ability to obtain food and shelter?Yes (please describe)NoFinancial 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)NoReligious or cultural factors:Social History: Requires Updating AnnuallyJob concerns: Stress Hazardous substances Heavy lifting Transportation How stressful would you rate your job situation (1 star=Not very stressful, 10 stars=Very stressful)?10987654321Have you had change in Marital Status?YesNoUnsureMarital status change:How stressful would you rate your current living situation (1 star=Not very stressful, 10 stars=Very stressful)?10987654321Do you fear for your safety in your current living situation?YesNoUnsureLiving situation concerns:Are there financial concerns that affect your ability to go to the doctor?YesNoUnsureAre there financial concerns that affect your ability to obtain food and shelter?YesNoUnsureFinancial concerns:Are there any religious or cultural factors that you would like us to take into account when planning your healthcare?YesNoUnsureReligious or cultural factors:READ & SIGN BELOWI certify that the information provided is correct and complete to the best of my knowledge.Date:Signature of Patient (or Legal Guardian):** PROMISSORY NOTE **PLEASE CHOOSE YOUR PAYMENT SOURCELegal Name (First, Middle, Last):Date of Birth:PRIVATE PAY I am acknowledging that I am a self paying patient seeking medical attention. I agree to pay my balance in full at the time of service or to pay 5O% of my balance now and the remainder in full within 30 days or I will agree to a payment arrangement with the Billing Office before leaving the building and satisfying my agreement before my next scheduled visit. INSURANCE I acknowledge that my claim will be sent to my insurance carrier for reimbursement. I will be responsible for the remaining balance (if any) in accordance with my insurance plan. Such payments will be paid within 30 days of receipt of statement or I will contact the Billing Office to make payment arrangements. WORKMANS COMPENSATION I acknowledge that a claim will be filed with my workman compensation carrier. If my claim is denied, I will be responsible for all charges on the account. Such payments will be paid within 30 days of receipt of statement. It is my responsibility to supply Horizon Family Medicine with the information needed to process any and all claims. PERSONAL INJURY I acknowledge that a claim will be filed with my attorney, private insurance and/or claim adjustor. I 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 my responsibility to supply Horizon Family Medicine with the information needed to process any and all claims. READ & SIGN BELOWI certify that the information provided is correct and complete to the best of my knowledge.Date:Signature of Patient (or Legal Guardian):** FINANCIAL & OFFICE POLICY **FINANCIAL 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 will be reimbursed by Horizon Family Medicine, PA within 15 business days. Medicare – Medicare deductibles & 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 dependants 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 cancelled at least 24 hours in advance, a charge of $30 for missed appointments may be applied. This fee is NOT covered by your insurance plan and is your responsibility. 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 your 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 with a fee of $15 due upon receipt. 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 BELOWI have read, understand and agree to the above Financial & 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 of Patient (or Legal Guardian):CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.