New Patient Form – At My Best Health

Contact Information

Please fill out your contact information below.

Last Name

First Name

Address 1

Address 2

City

State/Province

ZIP / Postal Code

Country

Home Phone

Work Phone

Confirm Email Address

GenderMaleFemale

Date of Birth

Current Complaint

MedicationsPlease list all medications you are taking along with the how many times a day and the dosage

Past Medical History

Family History

Social History

Occupation

Hobbies / Activites

TobaccoNeverNowQuit

Alcohol use:NeverLiquorBeerWine

Recreational Drug Use:NeverNowIn the Past

Release of Test Information

Patient's First Name

Patient's Last Name

Date of Birth

Patients Name Release Consent

I ( {name-1} ) give my consent to the staff At My Best Health, LLC, to relay any lab, radiological testing, referral information or any other imperative information to:

Name 1:

Relationship 1:

Name 2:

Relationship 2:

Answering Machine at Home: Tel No.

Myself, at place of employment: Tel No.

Insurance Assignments

Patient's First Name

Patient's Last Name

Date of Birth Month

Phone Number:

As you are aware, healthcare in the United States is currently undergoing many changes. As a result, insurance carriers are becoming more selective in terms of what they deem “necessary care” or “covered care”. At My Best Health, LLC, we believe care is essential to your health and therefore will continue to offer a thorough evaluation to every one of our patients.

Although we try hard, it is not always possible to verify all the terms of every patient’s insurance plan to determine if care is a covered benefit. We are informing you in advance that some tests and/or procedures, although constituting good medical care, may be considered as screening or preventive in nature by some insurance companies, and thus not covered. This testing will be your financial obligation if denied by your insurance carrier. We advise that all of our patients review their insurance benefit coverage. We will continue to do what we can to help in this respect.

Please list the insurance company (ies) that you will be using for services At My Best Health, LLC:

Insurance Company 1:ID and Group number required

Insurance Company 2:ID and Group number required

Insurance Company 3:ID and Group number required

I, the undersigned, certify that I (or my dependent) have insurance coverage with the insurance company(ies) listed above and assign directly to At My Best Health, LLC, all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance, and that it is my sole responsibility to understand the insurance benefits that apply. I authorize the use of this signature on all insurance submissions.

Responsible Person:

Relationship to patient:

Date:

Health Consent Form

Patient Consent for Use and Disclosure of Protected Health Information

I hereby give my consent for At My Best Health, LLC, to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by At My Best Health, LLC, describes such uses and disclosures more completely.)

I have the right to review the Notice of Privacy Practices prior to signing this consent. At My Best Health, LLC, reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to:

At My Best Health, LLC, 18325 N. Allied Way, Phoenix, AZ 85054.

With this consent, At My Best Health, LLC, may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.

With this consent, At My Best Health, LLC, may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements.

With this consent, At My Best Health, LLC, may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that At My Best Health, LLC restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to allow At My Best Health, LLC, to use and disclose my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.

Patients Name:

Date:

Legal Guardian:(if applicable)

New Patient Questionnaire