Name Last Name First Name Middle Date of Birth Sex Male Female Others Marital Status Married Single Divorced Widowed Home Phone Number Mobile Phone Number Work Phone Number Preferred Method of Contact Mobile Phone # Home Phone # Work Phone # Email Address We may send appointment reminders via TXT/email/voice-mail Yes No Home Address City State Zip Code Driver License # Social Security # Student Yes No Occupation Employer Employer Address Language Preferred Race Referral Source Complete this section, if Patient is a minor or responsible party is other than Patient:
Responsible Party: Relationship to Patient Spouse Parent Guardian Other Name Last Name First Name Middle Date of Birth Sex Male Female Others Marital Status Married Single Divorced Widowed Home Phone Number Mobile Phone Number Work Phone Number Preferred Method of Contact Mobile Phone # Home Phone # Work Phone # Email Address We may send appointment reminders via TXT/email/voice-mail Yes No Home Address City State Zip Code Driver License # Social Security # Student Yes No Occupation Employer Employer Address Insurance Information:
Primary Insurance Secondary Insurance Name of Insured Name of Insured Relationship to Patient Relationship to Patient Policy# Policy# Group# Group# The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the Physician. I understand that I am financially responsible for any balance/or patient portion due. I also authorize Bay Area Primary Care Associates or Insurance Company to release any information required to process my claims.
Bay Area Primary Care Associates
Patient Preferences Regarding Communication of PHI (Patient Health Information)
Preferred Method of Communication
My preferred method of communication regarding my Medical Conditions is indicated below:
Home Phone Mobile Phone Work Phone Mailed Letter Guardian
If the above method of communication is by phone, please check the appropriate box below:
Leave a message with detailed information Leave a message with a call-back number only
Please note that you are responsible for any charges incurred in receiving our communications. For example, if you provide a cell phone number as a method of contact, then you are responsible for any charges imposed by your mobile carrier for receiving calls or text messages from the clinic.
Please let our office know if you have any special directions or requests regarding our communication with you. For example, please let us know if you would like for us to call you at a different phone number for a particular test results or you do not want to called at all.
HIPPA Approved Contacts
Keeping our patient’s information private is important to us and by default we will only disclose information related to the patient’s Billing Account and Medical Conditions to the patient or legal guardian.
If you would like to add additional contacts (other than the patient or legal guardian) that Bay Area Primary Care Ass: is allowed to disclose this type of information to, please complete the fields below and select the appropriate checkboxes based on your approval for each person you list. In addition, please choose the person you would like Bay Area Primary Care Ass: to list as your Emergency Contact in the event an emergency situation was to take place at our office.
Contact Name# 1 Relationship to Patient Contact Phone# Date Contact Name# 2 Relationship to Patient Contact Phone# Date Expiration or termination of authorization – This authorization will remain in effect until terminated by patient’s personal representative, or another individual of legal entity authorized to do so by court order or law.
Right to revoke or terminate – As stated in our Notice of Privacy practices, you have the right to revoke or terminate authorization by submitting a written request to Bay Area Primary Care Ass:
Bay Area Primary Care Associates
Financial Policy
Unless arrangements have been made in advance, co-payments, co-insurance, deductibles, and any outstanding balances are expected Patient accounts not paid promptly are subject to third party collections and/or legal procedures.
If we are not participating providers with your plan, we will provide you with a receipt for you to file with your insurance carrier. If your insurance carrier has not responded to a claim within 90 days, we reserve the right to formally transfer all associated liability for the claim to the patient/guarantor.
Please keep a close watch for carrier claim payment and contact the insurance carrier or the office at 281-554-2846 in the event a claim is not resolved within 60 days from the date of service. We do realize that emergencies do arise that may affect timely payment of your account. If such extreme cases do occur, please contact the office. Any questions regarding bills should be directed to the office.
There will be a charge for NO SHOW appointments, a fee of $25 may be charged to the patient if you do not call and cancel your appointment within 24 hours.
Please always notify our office of any change in name, address, phone or insurance information.
