New Patient Packet

General Information

First Name: *

Middle Name:

Last Name: *

Street Address: *

City: *

State: *

Zip Code: *

Date of Birth: *

SSN: *

Cell Phone: *

Home Phone:

Email Address: *

Referral

Referred by: *

Reason for Visit: *

Primary Healthcare Provider: *

Phone: *

Please Note: Any information submitted using this form is transmitted securely and held in the strictest of confidence, protecting your privacy.

Insurance Information

Please complete this insurance section in full

Employer: *

Phone: *

Employer Address: *

Primary Insurance Carrier: *

Policy Number: *

Group Number: *

Are you the primary policy holder?: *

YesNo

Guarantor: *

Relationship to Guarantor: *

Guarantor Address: *

Guarantor Phone: *

Guarantor City: *

State: *

Zip Code: *

Secondary Insurance Carrier:

Secondary Policy Number:

Secondary Group Number:

Do you use MyChart?: *

YesNo

Note: This information helps speed up the process of obtaining your medical records.

MyChart username:

MyChart password:

Please Note: Any information submitted using this form is transmitted securely and held in the strictest of confidence, protecting your privacy.

Prescriptions

Prescription Drug Plan Name:

ID:

RXBIN:

RPCN:

RXGrp:

Do you have a CADAP or ADAP?:

YesNo

CADAP/ADAP Card #:

Current Pharmacy/Location: *

Pharmacy Phone: *

Allergies & Past Surgeries

Seasonal Allergies:

Drug Allergies:

Past Illnes/Dates:

Past Surgeries/Dates:

Current Medication/Dosages: Name/Strength (e.g. 5mg)/Frequency (e.g. 1xdaily)::

Please Note: Any information submitted using this form is transmitted securely and held in the strictest of confidence, protecting your privacy.

Please Review, Sign and Date Below:

All copays must be paid at the time of the visit.
All deductibles and co-insurance/co-balances are the patient’s responsibility.
All invoices are due upon receipt.
Any out-of-network payments or insurance checks sent directly to you for payment of services rendered at HCAI must be endorsed and mailed to HCAI with all supporting documents, i.e. explanation of medical benefits (EOMBs).
No Shows (Failing to show for your appointment without prior arrangement or Cancellations less than 24 hours before your appointment are subject to a $75 fee.
In the event that your account is overdue/unpaid 90days or greater, I agree to pay all reasonable fees incurred by HCAI in attempting to collect any debt.

Patient's Signature: *

Today's Date: *

Legal Guardian, Please Print Name:

Legal Guardian Signature:

Please Note: Any information submitted using this form is transmitted securely and held in the strictest of confidence, protecting your privacy.

Patient Forms → New Patient Form Lifting up the voices in the LGBTQ+ community, near and far.

General Information

Gender Identity & Pronouns

Referral

Personal Information

Vaccinations

Insurance Information

Prescriptions

Allergies & Past Surgeries

Please Review, Sign and Date Below: