New patient Registration

  • 1Patient Information
    Phone Type*
    Acceptable Methods of contact*
    Address
    Emergency Contact
    How do you pay for healthcare costs?*

    If you do not have any of the symptoms listed above and would still like to be tested you will be responsible to pay for testing if your insurance does not cover. COST $ 75.00

    Upload Documents
    (Driver's License Preferred)
  • 2Consent For Treatment

    This consent is required by the Health Insurance Portability and Accountability Act of 1996 to inform you of your rights for privacy with respect to your health care information.

    Consent Related to Privacy Notice:

    I have had a chance to review the Practice Privacy Notice as part of this registration process. I understand that the terms of the Privacy Notice may change and I may obtain these revised notices by contacting the practice by phone or in writing. I have had a chance to review the Health Information Exchange Notice and understand that SIPMD participates in the statewide Health Information Exchange program. I understand that I have the right to request how my protected health information (PHI) has been disclosed and have the right to restrict how this information is disclosed. My request must be submitted in writing to the practice, but the practice is not required to agree to my restrictions. If it does agree to my restrictions on PHI use, it will be bound by that agreement. A copy, electronic copy, image or facsimile of this authorization is as valid as the original.

    Consent for Care:

    I, with my signature, authorize SIPMD, and any employee working under the direction of the clinicians, to provide medical care for me, or to this patient for which I am the legal guardian. This medical care may include services and supplies related to my health (or the identified person) and may include, but not limited to, preventive, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body and the sale or dispensing of drugs, devices, equipment or other items required and in accordance with a prescription. This consent includes contact and discussion with other health care professionals for care and treatment, though state and federal laws may restrict redisclosure of HIV/AIDS information, mental health information, drug/alcohol conditions, or genetic information.

    Consent for Release of Information and Assignment of Benefits:

    I also authorize this practice to furnish information to the identified insurance carrier(s) for any and all payment activities. I consent to assign all payments for services directly to this practice. I further consent to the use for any practice operational needs as identified in the Practice Privacy Notice.

    Select This if you want authorize others to recieve protected health information (PHI) on your behalf

    Specify if there is any information that you always kept confidental
    Select This if a Guardian or Power of Attorney will be signing and will be responsible for healthcare decisions

    I give authorization to SIPMD to disclose my Protected Health Information (PHI) to the following individuals, all of whom are involved in my care for any purpose related to my treatment or the payment of my care:

    Name of Guardian or Power of Attorney

    Your signature below confirms that you have read and understand the Consent for Treatment Policy as stated above.

  • 3Financial Policy

    We will adhere to these policies and would like assurance that you are in agreement before establishing care with us.

    • You, the patient, are responsible for all co-payments, amounts applied to deductibles, and other amounts that may be deemed your responsibility by the payment sources, as required by your contract with your insurance plan and state regulations.
    • If you have an insurance co-payment, you are expected to make payment for that at the time of that service.
    • Your insurance entity may or may not cover some services. All insurance policies are not the same. SIPMD is not responsible or able to know every policy available. You accept responsibility to verify applicable coverage prior to receiving the services. If you seek care outside of your insurance contract terms, you will be responsible for all charges that are incurred.
    • Services may be requested and provided outside of the typical office visit. This may happen through telemedicine, a phone call, electronic messaging, provider review of medical records, provider consultation with other providers or healthcare facilities, or other methods. Care in these settings may be initiated by you, the patient, but may also be initiated by SIPMD as deemed medically necessary. Bills may be submitted for these services within guidelines of existing billing rules. You agree to accept responsibility for these charges.
    • A $25.00 fee may be applied for appointment cancellations if the office is not notified at least one business day prior to the scheduled appointment time.
    • Unpaid balances due will be sent to collections. If this happens, you agree to pay any fees associated with this.

    We want you to understand how billing for preventive visits work. We feel this is a very valuable resource, as these services are often available to you with no co payment or effect on your deductible.

    • With commercial insurance, the preventive visit includes a review of medical history, ongoing medical condition management, physical examination, and preventive counseling. If you have a new symptom that needs to be evaluated or an ongoing medical problem that needs a significant change, we can provide this additional service, but we may apply a separate charge. In this case, you will receive a bill for the preventive service and a separate bill for the additional service.
    • Annual Wellness Visits (AWV--a Medicare benefit): This service is completely covered by Medicare, without a co-pay or deductible and includes review of your medical history and counseling on appropriate preventive measures. Medicare specifically excludes coverage for a physical exam or management of any medical conditions. To adapt to this, we provide the AWV in conjunction with the medical management service, unless there are no active medical conditions to discuss. A co-pay and deductible may apply.

    For any of our services, you agree to be responsible for any charges not covered by your insurance.

    Thank you for your understanding and cooperation with this policy. We consider it a privilege to provide your medical care.

    Your signature below indicates that you have read and understand this Financial Policy and agree to accept full responsibility as described.

  • 4COVID-19 Questionnarie
    Have you had any of these symptoms in the past 24 hours?*
    Do you have any high-risk medical conditions?*
    Have you come into contact with any person who has tested positive for COVID-19?*
    Have you recently traveled?*
    Are you a healthcare worker with direct contact with patients?*
    Are you in close contact with anyone over age 65, with an impaired immune system, with diabetes, liver disease, lung disease, or who is pregnant?*

    INFORMED CONSENT FOR COVID-19 TESTING

    I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a blood test and, if the result is positive, to be followed with a nasopharyngeal swab as needed for confirmatory.

    AGREEMENT FOR SELF-ISOLATION

    The local health jurisdiction has determined that if you are under suspicion for having COVID-19 due to symptoms and testing requests, it is necessary to be placed in isolation in order to prevent the transmission of this infection. It is important for you to comply with this Isolation Agreement in order to protect the public’s health.

    Your signature below confirms that you consent to COVID-19 testing, and, if you have any of the symptoms above, you will isolate yourself from any other people until you receive a negative test result.

  • 5Book Appointment