New Patient Request Packet

Thank you for your interest in becoming a patient. Completion of this packet does not guarantee acceptance into the practice. Requests are reviewed based on our ability to safely and appropriately meet your healthcare needs.

Patient Information

Please understand that we may not share any medical information including appointments, test results, labs, etc. with anyone who is not listed below, including your spouse. Please provide the name and phone number of anyone with whom we may discuss information. Write “none” if you do not wish to have anyone listed.

Primary Care History

Medical History

Major Medical Conditions (check all that apply)

Current Specialists (check all that apply)

Controlled Medications — Are you currently prescribed any controlled medications?

Preventive Health Screening

Practice Partnership Agreement

If accepted as a patient of Three Notch Medical Center, I understand:

• My provider will recommend treatments based on current medical evidence rather than social media, advertisements, or anecdotal reports.
• I have the right to accept or decline any recommended treatment after discussing its risks and benefits.
• If I decline recommended treatment, I agree to discuss alternative treatment options and monitoring with my provider.
• I understand that repeated refusal to participate in recommended evaluation, monitoring, or treatment may prevent my provider from safely managing my medical conditions.
• If a productive therapeutic relationship cannot be maintained, Three Notch Medical Center may determine that another practice would better meet my healthcare needs.
• I am responsible for deductibles and copays.

Acknowledgement

I certify that the information I have provided is accurate to the best of my knowledge. I understand that submission of this packet does not guarantee acceptance as a patient of Three Notch Medical Center.

Patient Financial Responsibility Agreement

We will need a copy of all current insurance cards and your driver's license when you come in for your appointment. This information is required before you can be seen. All co-pays and deductibles for visits, labs and procedures are due at the time you check in. I understand that my health insurance is a contract between me and my insurance company. Three Notch Medical Center will submit claims to my insurance as a courtesy; however, I remain financially responsible for all charges incurred for my medical care.

I understand and acknowledge the following:

• I am responsible for any deductibles, copayments, coinsurance, or non-covered services as determined by my insurance plan.
• If my insurance denies payment for any service provided, I understand I may be responsible for the remaining balance unless prohibited by my insurance contract or applicable law.
• I understand it is my responsibility to provide current insurance information and notify the office of any changes in coverage.
• I understand that obtaining referrals or prior authorizations required by my insurance may be my responsibility, depending on my health plan.
• I understand that insurance verification does not guarantee payment for services rendered.
• I understand that I am responsible for charges incurred if my insurance coverage is inactive or cannot be verified at the time services are provided.
• I understand that balances not paid by my insurance are my responsibility and agree to pay these amounts in accordance with the practice's financial policy.
• I understand that unpaid balances may be referred to a collection agency after reasonable attempts to collect payment, in accordance with applicable laws and the practice's financial policy.

Assignment of Benefits

I authorize payment of medical benefits directly to Three Notch Medical Center for services rendered.