New Patient Paperwork

Thank you for choosing Vista Healthcare, attached is the new patient paperwork. Please be aware this will take roughly 15-20 minutes to complete, and you will need the following information: insurance cards, referring provider's name and phone number, primary care provider's name and phone number, current medications, past procedures, surgeries, or treatments. You must click save to complete your submission, failure to do so will result in a loss of the information you have entered. If you are unable to complete the forms, please arrive 30 minutes prior to your scheduled appointment.
Patient Information
Patient Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
ID*
Date of Birth
Preferred Language*
Sex*

MaleFemaleOther
SSN
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Email*
example@example.com

Please read and sign
I, the undersigned, hereby consent to the following Treatment: Administration and performance of all treatments Administration of any needed anesthetics Performance of such procedures as may be deemed necessary or advisable in the treatment of this patient Use of prescribed medication Performance of diagnostic procedures/tests and cultures Performance of other medically necessary or advisable based on the judgment of the attending physician or their assigned designees I fully understand that this is given in advance of any specific diagnosis or treatment. I intend this consent to be continuing in nature even after a specific diagnosis has been made and treatment recommended. The consent will remain in full force until revoked in writing. I understand that Vista Healthcare may include consent at satellite offices under common ownership. I, the undersigned, acknowledge that Vista Healthcare will use and disclose my information for the purposes of treatment, payment, and healthcare operations as described in the Notice Privacy Practices. A photocopy of this consent shall be considered as valid as the original. I acknowledge that I am able to have access to a complete copy of the Vista Healthcare “Notice of Privacy Practices”. I understand that if I have questions or complaints that I should contact the Privacy Official. Medicare Patients: I authorize to release medical information about me to the Social Security Administration or its intermediaries for my Medicare claims. I assign the benefits payable services to Vista Healthcare. I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.
Patient Name:*

First NameLast Name
Patient DOB:*
Signature*

Clear
Date*

Authorization to release or use information for treatment, payment, or healthcare options
I hereby authorize the release or use of my individually identifiable health information (protected health information or PHI) and medical information by Vista Healthcare in order to carry out treatment, payment, or health care options. You should review the Practice's Notice of Privacy Practices for a more complete description of the potential release and use of such information, and you have the right to review such Notice prior to signing the Consent form. We reserve the right to change the terms of its Notice of Privacy Practices at any time. If we do make changes to the terms of its Notice of Privacy Practices, you may obtain a copy of the revised notice by writing our practice or requesting a copy from our front desk staff. You retain the right to request that we further restrict how your protected health information is released or used to carry out treatment, payment, or health care operations. Our practice is not required to agree to such requested restrictions; however, if we do agree to your requested restriction(s), such restrictions are then binding on the Practice.
I agree and consent to releasing information to me in the following manners
via Primary Phone Number*

Ok to leave detailed messageLeave call back number only
via Text Message*

Ok to send detailed text messageOk to send electronic statement
via Email*

Ok to send detailed message
Permission to receive additional information or materials from Vista Healthcare.*

YesNo
Permission to release to the following individuals

Examples: spouse, partner, parent, adult child, caregiver, or other trusted individual. (medical records, billing, payment, appointments, healthcare options)
Name of individual

First NameLast Name
Relationship:
I do not grant permission to any individual to receive my medical information.

Select check box if applicable (otherwise, skip)
Patient Name:*

First NameLast Name
Patient DOB:*
Signature*

Clear
Date*

HEALTH CARE FINANCIAL AGREEMENT
Thank you for choosing us as your medical clinic. Our team of skilled providers are committed to providing you with quality and affordable health care. For us to continue providing excellent care, we offer this agreement to all patients. A copy will be provided upon request. If you do not agree to the terms listed below, we will be unable to proceed with your appointment(s). The parties may not alter this Agreement.

1. Registration: To ensure accurate billing and the proper delivery of care, all patients must complete our patient information form. We also need a copy of your valid driver’s license and current valid insurance card. Most insurance companies have time limits for filing claims, so it’s important to provide us with accurate and up-to-date information. If your insurance information is incorrect or if you fail to notify us of any changes in a timely manner, you may be responsible for the balance of your claim.

2. Insurance: We accept assignment and participate with many insurance plans. If your insurance plan is not a plan we participate with, please reach out to your insurer for options or payment in full will be due at each visit. We encourage you to familiarize yourself with your insurance benefits and advise you to reach out to your insurer with any questions to ensure you receive the maximum coverage available.

3. Claims: We will submit claims to your Primary, Secondary, and Government Issued Tertiary insurance, and we will support you in any way we can to help get your claims processed correctly. However, it is your responsibility to ensure any additional information requested by your insurance company is provided in a timely manner. Please remember that your insurance benefits are a contract between you and your insurance company. Please also be aware that any amounts left as your responsibility is determined by your insurance company.

4. Patient copayment: All copayments are due at the time of service. This is part of your agreement with your insurance provider.

5. Uninsured patients: We understand that some patients may not have insurance, to accommodate this we offer a discount for those who pay at the time of service. If the charges are not paid at the time of service, the discount will no longer apply and the full charged rate will be expected before the next visit. If a balance remains, you will receive a monthly statement that is due upon receipt. Any account balance over 90 days will be subject to review for collection action.

6. Outstanding Balance: If your balance remains unpaid for more than 90 days, we may need to temporarily suspend services until the balance is settled. Please understand that if your account remains unpaid and is sent to a collection agency, each referral to collections or report to a credit bureau may negatively impact the responsible party’s credit score. You will also be responsible for any additional collection fees (such as interest, court costs, reasonable attorney’s fees, etc.), as outlined by law. We want to work with you to avoid this, partial payments or payment plans may be accepted with prior arrangement.

7. Missed appointments: If an appointment is missed, a fee may apply. If you need to cancel an appointment, please let us know at least 24 hours in advance so we can allow someone else the opportunity to receive care.

8. Credit Card: A credit card will not be kept on file unless opted into. I understand by not having a card on file, I will receive a statement, and payment will be due upon receipt. Failure to pay to upon receipt, may result in additional fees.
I opt in to have my credit card on file, which may be charged for missed appointments, copays, deductibles, outstanding balances, or other services.
Thank you for taking the time to review and agree to our Health Care Financial Agreement. If you have any questions or need further clarification, please don’t hesitate to reach out to our team. We’re here to help patient’s live life again!

By signing below, you acknowledge and bind the terms of the agreement.
Patient Name:*

First NameLast Name
Patient DOB:*
Signature*

Clear
Date*

	No History	Family Member	Alive	Deceased
Diabetes
Migraines
Cancer
Stroke
Alzheimer's
Heart Disease
Mental Illness
High Blood Pressure

	1	2	3	4	5	6	7	8+	NONE
Beer
Wine
Hard Liquor

	Never Used	Former User	Current SOME day User	1-9 daily (light)	10+ daily (heavy)
Cigarettes
Cigars
Pipe
Chewing Tobacco
Dipping Tobacco
Vape Pen

	Yes	No
Have you had a fall in the last year?
Do you feel unsteady when walking or standing?
Do you have trouble remembering, learning new things, or concentrating?
Do you feel lightheaded or dizzy when transitioning from lying to standing?
Are there any safety hazards in your home like throw rugs or slippery floors?
Do you need support when getting in and out of the tub or up from the toilet?

	Yes	No
Abuse
Violence (e.g. domestic, work, military)
Military service or combat
Unexpected death of a family member or friend (i.e. suicide, accidents, etc)

Patient Information

Emergency Contact

Insurance Information

Insurance Information

Referring Provider

Primary Care Provider

Please read and sign

Authorization to release or use information for treatment, payment, or healthcare options

I agree and consent to releasing information to me in the following manners

Permission to release to the following individuals

HEALTH CARE FINANCIAL AGREEMENT

Clinical Information:

Allergies

Medications

Family History

Past Medical History

Previous Imaging

Previous Evaluations

Social History

ORT:

Surgical History

Fall Risk Assessment

Health and Wellness Questionnaire

Over the last 2 weeks, how often have you been bothered by any of the following problems?

	Yes	No
Have you felt you ought to cut down on your drinking or drug use?
Have people annoyed you by criticizing your drinking or drug use?
Have you felt bad or guilty about your drinking or drug use?
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?