New Patient Form

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~ New Patient Intake Form ~

Terms and Privacy Policy

This notice describes how your health information may be used and disclosed and how you can access this information. Please review it carefully.

At TELE MED CLINIX, LLC we have always kept your health information secure and confidential. A new law requires us to continue maintaining your privacy, to give you this notice and to follow the terms of this notice. The law permits us to use or disclose your health information to those involved in your treatment. For example, a review of your file by a specialist doctor whom we may involve in your care.

We may use or disclose your health information for payment of your services, for example, we may send a report of your progress to your insurance company. We may use or disclose your health information for our normal healthcare operations. For example, one of our staff will enter your information into our computer.

We may share your medical information with our business associates, such as billing service. We have a written contract with each business associate that requires them to protect your privacy. We may use your information to contact you, for example, we may send newsletter or other information. We may also want to call and remind you about your appointments. If you're not home we may leave this information on your answering machine or with the person who answers the telephone. In an emergency, we may disclose your health information to a family member or another person responsible for your care.

We may release some or all of your information when required by law. If this practice is sold, your information will become the property of the new owner. Except as described above, this practice will not use or disclose your health information without your prior written authorization. You may request in writing that we not use or disclose your health information as described above. We will let you know if we can fulfill your request. You have the right to know of any uses or disclosures we make with your health information beyond the above normal uses. As we will need to contact you from time to time, we will use whatever address or telephone number you prefer. You have the right to transfer copies of your health information to another practice. We will mail your files for you.

You have the right to see and receive a copy of your health information, with a few exceptions. Give us a written request regarding the information you want to see. If you also want a copy of your records, we may charge you a reasonable fee for the copies. You have the right to request an amendment of change to your health information. If you wish to include a statement in your file, please give it to us in writing. We may or may not make the changes you request, but will be happy to include the statement in your file. If we agree to an amendment of change, we will not remove nor alter earlier documents but will add new information. You have the right to receive a copy of this notice. If we change any of the details of this notice, we will notify you of the changes in your writing. You may file a complaint with the Department of Health and Human Services. 200 Independence Ave, S.W., Room 509F, Washington, DC 20201. You will not be retaliated against for filing a complaint.

However before filing a complaint, or for more information or assistance regarding your health information privacy, please contact our Privacy Officer, Support@Telemedclinix.com This notice goes into effect as of May 1, 2020.

I have read and understand and agree with the terms and conditions of the agreement above

Financial Policy for Tele Med Clinix LLC

Welcome to our office! We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy which we require you to read and agree to prior to any treatment. All patients must complete our information and insurance before seeing the PROVIDER.

Regarding Health Insurance We may accept assignment of insurance benefits upon verification of eligible benefits. At the time of service, your copayments and/or deductibles are due. The balance of your account is your responsibility whether your insurance company pays or not. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. Copayments, deductibles, and any other balances are due at the time of services rendered. If your insurance company has not paid your account in full within 60 days, the balance will be automatically billed to you.

No Insurance: Payment is due at the time of services. We aim to provide our patients with the best possible diagnosis and treatment. However, the health insurance plan under which you have certain benefits includes strict criteria for coverage of medical, hospital, and other services. It is not always possible to anticipate when services will be covered or when services will be denied. Therefore, it is not safe to assume that your plan covers "everything". We recommend that you verify the benefits covered in your individual policy in order to prevent unhappy surprises

Late Payment of Balances All balances are due at time of services rendered. If you are billed to your address, all balances are due in full by the 30th of the month. If payment is not received, in full, by the 30th of the month there will be a finance charge of 1.5% (18% annually) added to your account. Payments not received in full may be subject to additional late charges, collection costs and legal (attorney's) fees. Returned or insufficient fund checks are considered late payments and are subject to a $35 charge.

Tele Med Clinix LLC - Cancellation | No-Show Policy We ask that you please reschedule or cancel at least 1 day before the beginning of your appointment or you will be charged a cancellation fee of $50.00

Tele Med Clinix LLC - Refund Policy All Tele Med Clinix service sales are final and cannot be refunded. Our patient satisfaction and care is our number one priority. Please let us know how we are doing and how we can improve. By creating an appointment, you agree to receive automated transactional text messages from Tele Med Clinix LLC

I have read and understand and agree with the terms and conditions of the agreement above

Tele-Medicine Consent

I hereby consent to engage in telemedicine with Doxy.me and TELE MED CLINIX, LLC

I understand that “telemedicine” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telemedicine also involves the communication of my medical information, both orally and visually, to health care practitioners. The laws that protect the confidentiality of my medical information also apply to telemedicine. If applicable, your insurance carrier will have access to your medical records for quality review and audit. As such, I understand that the information disclosed by me during the course of my treatment is confidential. I understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my Provider, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.

In addition, I understand that telemedicine-based services and care may not be as complete as face-to-face services. I also understand that if my Provider believes I would be better served by another form of medical services (e.g. face-to-face services) I will be referred to a medical services provider who can provide such services in my area.

I understand that there are potential risks and benefits associated with any form of medical treatment and that despite the efforts of my Provider, my condition may not be improved, and in some cases may even get worse. Therefore, I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured.

I HAVE NO OTHER PRE-EXISTING MEDICAL CONDITIONS THAT HAVE NOT ALREADY BEEN DISCLOSED HERE.

I understand that this visit/encounter does not and should not replace a traditional doctor’s office visit; and therefore, I am proceeding with this tele-evaluation at my own risk and understanding. I also understand that should my condition or my responsible parties be an emergency, I should contact local emergency response by dialing 911. I certify that the information provided in this medical form is true and accurate to the best of my ability. I also understand that omitting medical information or misinforming a TELE MED CLINIX, LLC Provider may result in inaccurate diagnosis and treatment.

I understand that telemedicine is the use of electronic information and communication by a health care provider to deliver services to an individual when he/she is located at a different site than the provider and hereby consent to care services via telemedicine or video conferencing.

I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment. I may revoke my consent in writing at any time by contacting TELE MED CLINIX, LLC at Support@TeleMedClinix.com As long as this consent is in force and has not been revoked TELE MED CLINIX, LLC provider may provide health care services to me via telemedicine without the need for to sign another consent.

I have read and understand and agree with the terms and conditions of the agreement above

Patient Information

First Name

Last Name

Phone

SSN

Gender Assigned at Birth

Date of Birth

Patient Address

Your Street Address

City

State

Zip Code

Emergency Contact Information

Emergency Contact Name

Relationship

Phone Number

Address

Primary Insurance Information

Insurance Provider

Address

Phone

ID Number

Group ID

Name of Guarantee

Telephone of Guarantee

Relationship

Address of Guarantee

Secondary Insurance Information

Secondary Insurance Provider

Address

Phone

ID Number

Group ID

Name of Guarantee

Telephone of Guarantee

Relationship

Address of Guarantee

Medical History

Past Medical History

Hepatitis C

Hepatitis C Viral Load

Last Hepatitis C Lab Test

Past Mental Health History

Hospitalizations

Surgeries

Allergies

Please list your current medications

Females: beginning of last menstrual cycle

Tobacco Use

Packs a day

Cigars

Vape

Chewing

Alcohol & Drug Use History

Alcohol or drug use history

If yes, when last used

If yes, last used.

Family Medical History

Mother's Medical History

Father's Medical History

Sibling's Medical History

Children's Medical History

Preferred Pharmacy Information

Pharmacy Name

Pharmacy Phone Number

Pharmacy Address

Preferred Lab

Credit Card Authorization Form

Card Number

Expiration Date

CVV

Zip Code

Name on Card

Debit | Credit Card Authorization

Tele Med Clinix LLC - Cancellation | No-Show Policy
We ask that you please reschedule or cancel at least 1 day before the beginning of your appointment or you will be charged a cancellation fee of $50.00

I, authorize Tele Med Clinix LLC to charge my card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.

Tele Med Clinix will never charge your card or account without notice.

I have read and understand and agree with the terms and conditions of the agreement above

Consent To Medical Procedures

Please tell us why you're here today:

How did you hear about us?

Consent To Medical Procedures

To the best of my knowledge, I have answered the questions on this form accurately. I understand that providing incorrect information can be dangerous to my health. I understand that it is my responsibility to inform the doctor and office staff of any changes in my medical status.

*If you or someone you know is in crisis, call 911 or the Suicide & Crisis Lifeline at 988 right away.

Get started with our intake form

Si necesita los formularios en español, por favor haga clic en el botón de abajo

~ New Patient Intake Form ~

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