Tel: (770) 248-1637

 

    Patient Information



    Height


    ST: GA




    Social History








    YOU MUST ONLY Check box ONLY if it applies to you

    WHY ARE WE SEEING YOU TODAY?

    PHARMACY NAME & ADDRESS

    PHARMACY PHONE NUMBER

    WELLNESS PREVENTION:











    Your signature HERE is YOUR consent for us to treat you medically

    MEDICAL RECORD RELEASE AUTHORIZATION


    GA

    RELEASE MEDICAL INFORMATION TO:

    Faith Healthcare Services, Inc 2795 Main Street W, Suite 20A Snellville, GA 30078

    Phone: 770-248-1637 Fax: 770-248-1638

    Information to be released: (check all that apply)

    Purpose for need of disclosure (check all that apply)

    I understand that if the person(s) and /or organization(s) listed above are not health providers, health plans or health care clearinghouses, which must follow the federal privacy standards, the health information disclosed as a result of this authorization may no longer be protected by the federal privacy standards and my health information may be re­ disclosed without obtaining my authorization
    Your rights with respect to this authorization: Right to inspect or copy the health information to be used or disclosed. I understand that I have the right to inspect or copy the health information I have authorized to be used or disclosed by this authorization form. I may arrange to inspect my health information or obtain copies of my health information by contacting Faith Healthcare Services. Right to receive copy of this authorization - I understand that if I agree to sign this authorization, which I am not required to do, I must be provided with a signed copy of the form. Right to refuse to sign this authorization - I understand that I am under no obligation to sign this form and that the person(s) and/or organization(s) listed above who I am authorizing to use and/or disclose my information may not consent treatment, payment, enrollment in a health plan or eligibility for health care benefits on my decision to sign this authorization. Right to withdraw this authorization - I understand written notification is necessary to cancel this authorization. To obtain information on how to withdraw my authorization or to receive a copy of my withdrawal, I may contact Faith Healthcare Service, Inc I am aware that my withdrawal will not be effective as to uses and/or disclosures of my health information that the person(s) and/or organization(s) listed above have a readymade in reference to this authorization. Expiration date: this authorization is good for one year from the date signed.


    I have had an opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirming that it accurately reflects my wishes.


    Assignment of Benefits (payment)

    MEDICARE AND NON MEDICARE PATIENT

    I request that payment of authorized Medicare or other insurance benefits be made either to me or on my behalf to Faith Healthcare Services, Inc for any services furnished to me by that office. I authorize any holder of medical information about me to release to the healthcare financing administration and its agents any information needed to determine these benefits or the benefits payable for related services.

    I understand that Faith Healthcare Services, Inc. will submit all charges to my insurance carrier and I hereby assign benefits otherwise payable to me to FHS, Inc.

    I recognize and accept personal responsibility for any balance or fee not covered by my insurance carrier.

    A copy of this signature is as valid as the original.


    Chronic Care Management Consent Form

    Faith Healthcare is pleased to offer our patients a 24-hour chronic care management service.

    • This service is in addition to the home or office visits you receive.

    • You will have access to Nurse Practitioner Angella Samuels on a 24 hour a day, 7 days per week basis to help you with any urgent chronic care need and coordinate with others involved in your care.

    • As a part of this service Dr. Angella will work with you, your family, guardian, and any other physicians that currently manage your healthcare.

    This service may include:

    • A telephone call from your provider, nurse, or staff to discuss

      • A telephone call from your provider, nurse, or staff to discuss your health and any issues that are causing you problems

      • Advise you on why and when you need care

      • Review your medications or allergies

      • Assist you to set goals to improve your health

    • A care plan put together by you and your provider to track your health goals and update as you meet your goals

    • You will receive a written or electronic copy upon request.


    My signature acknowledges that I have received Important information about FHS operations: regarding appointments and narcotics.

    FHS policies on registration, payment, insurance, missed appointments and cancellation fee, phone and email communications, and medications and refills

    Notice of Privacy practices

    Patient Rights

    HIPAA information

    OUR POLICIES

    Registration: All new patients must complete our insurance verification before a visit can be scheduled. Once insurance has been verified, all new patients must complete the patient data sheet, comprehensive History and Physical form, Authorization for Release of medical records, as well as Authorization for treatment, and provide a photo id. All medical records will be obtained before you can be seen by FHS providers or staff. Please be sure to include your email address.

    Payment: As a friendly reminder, all Copays are expected in full at the time of your visit. We accept cash and credit cards.

    Insurance: We participate with Medicaid, Medicare, most Medicare Advantage plans, and other third party insurance plans. We will be happy to file your insurance claims for your visits with us, as a service to you. However, you are ultimately responsible for any balance.

    You are responsible to notify us of any changes in your insurance. We cannot be responsible for filing insurance incorrectly if new insurance information has been withheld.

    Missed appointment and cancellation fee: our appointment time is reserved for you. Please give our office at least 24 hours’ notice if you must cancel. If not, there will be a $75 fee for missed appointments without prior notification. If 2 or more appointments are missed and/or cancelled consecutively, without a 24-hour notification, we will cancel all future calls for appointments. We will not make more than 2 calls to you to schedule an appointment.

    Phone and email communication. If you need to talk with anyone of us, feel free to call and leave a message on the office phone. Please supply us with correct callback phone number and time during the day when you will be available.

    Calls will be returned within 24 hours. Our office hours are Monday – Friday: 11 am – 5 pm.

    Medications and refills. We need 7 days’ notice for medications refill. Same Day Refill is not acceptable

    Notifications before our arrival to see you: Please notify us of any changes since our last visit, such as any new medications or allergies, any other doctor’s visit.

    Do not ASK staff to write prescriptions, referrals or excuse letters for you unless you are the responsible party on file

    Our commitment: to serve you in a timely manner with your chronic stable conditions. We do not make emergency calls.

    If we cannot serve you to the best of our abilities, we will help you find another provider.

    Patient Acknowledgement – Privacy Practice

    NOTICE OF PRIVACY PRACTICES

    This notice describes how your health information may be used and disclosed and how you can get access to this information.

    PLEASE REVIEW IT CAREFULLY

    I understand that the patient health information is private and confidential.

    I understand that FHS may use and disclose the patient’s personal health information to help provide health care to the patient to handle billing and payment and to take care of other health care operations.

    I understand that sometimes the law may require the release of this information without my permission. These situations are very unusual.

    The patient privacy is a complete description of the patient’s bill of rights. These rights include, but are not limited to access to my medical records restrictions on certain uses receiving and accounting of disclosures as required by law and requesting communication by specified methods of communication.

    Faith Healthcare Services has established procedures which help them meet their obligations to patients. These procedures may include other signature requirements, written acknowledgements and authorizations, reasonable time frames for requested information, charges for copies and non-routine information needs, etc. I will assist the clinic by these following procedures if I choose to exercise any of my rights described in the patient’s bill of rights.

    Patient Rights

    You have the right to look at or get copies (for a minimal fee) of your health information, with limited exceptions. You may obtain a form to request access by using the contact information listed at the end of this notice.

    You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement except in emergency.

    You can request that we communicate with you about your health information by alternative means or alternative locations request must be made in writing and must specify your preference.

    You have the right to request that we amend your health information. Your request must be in writing and it must explain the reason the information must be amended. We may deny your request under certain circumstances.