Patient Info

Name
Sex
MM slash DD slash YYYY
May we retrieve your Rx history from external sources?
Use of Alcohol
Use of tobacco
Do you feel

WE WILL BE CHARGING A FEE OF $50 FOR APPOINTMENTS NOT CANCELLED WITHIN 24 HOURS. THIS IS A FEE THAT WILL BE BILLED DIRECTLY TO YOU, THIS FEE DOES NOT GET BILLED TO YOUR INSURANCE COMPANY.

Controlled Substance Prescription Policy: The original prescription and any refill will be given to you in person or by mail to take directly to your pharmacy. As a general physician practice, we will be limited to prescribing only one or two months. Thereafter, it will be necessary to see a medical specialist/pain specialist. If our doctor gives you a referral to see a pain specialist or other specialist for your pain or condition, we advise you to seek an appointment as soon as possible with the specialist as there can be wait lists. We are only able to give you one refill on your medication if you are unable to make an appointment with the specialist before a refill is needed. WE WILL ONLY DO SO if you have a scheduled appointment with your follow up specialist. We will try to help you find a specialist who takes your insurance.

Sincerely, Healing Hands Primary Care

I understand that this information serves as: A basis for planning my care and treatment; a means of communication among the healthcare professionals who contribute to my care; A source of information for applying my diagnosis treatment information to my bill; A means by which a third-party payer can verify that services billed were actually provided; A tool for routine healthcare operations such as assessing quality of care and reviewing the competence of healthcare professionals. I understand that I have the right: To object to the use of my health information for directory purposes; To request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operation - and that the organization is not required to agree to the restrictions requested; To revoke this consent in writing, except for the extent that the organization has already taken action in reliance thereon.

authorize Healing Hands Primary Care to disclose protected information (PHI) only as it relates to treatment, payment (billing), or healthcare operations as explained above. I understand and have been provided with the Healing Hands Primary Care Notice of Privacy Practices. I authorize Healing Hands Primary Care to submit claims to my insurance carrier as well as medical records needed to evaluate these claims for payment. I further authorize payment of benefits, otherwise payable to me, to be made payable to Healing Hand Primary Care. I understand that I am financially responsible for all charges not covered by my insurance. If my insurance company is not in the Healing Hands Primary Care's network or I have no insurance coverage, I understand that I am financially responsible for all charges and must make payment today