New Patient Packet

Please fill out this form!

First Choice Community Medical Services, P.C.

First Choice Community Medical Services, P.C. is a house-call program comprised of experienced Certified Nurse Practitioners. Our program is dedicated to delivering high quality primary care to qualifying elders who do not drive and experience difficulty getting to a traditional Primary Care office. First Choice Community Medical Services, P.C. will assume the Primary Care Provider role for all new patients, and we will request the Medical Records from the previous Primary Care Provider. Certified Nurse Practitioners from First Choice are highly trained and experienced in caring for the older adult. Our Nurse Practitioners visit patients to assess, diagnose, prescribe, and monitor plans of care for acute and chronic medical conditions. Paramount to our care is making sure our patients enjoy the best possible quality of life — in their own homes. Communication and relationships with Visiting Nurses Associations and the facilities are utilized to bolster care. We coordinate laboratory and radiology services, which are available to be done in-home. All this keeps the patient where they are most comfortable. At First Choice Community Medical Services, P.C. (FCCMS) we recognize the value of every person. We are guided by our commitment to excellence and leadership in providing domiciliary skilled medical care for older adults. The commitment of our Certified Nurse Practitioners and staff to our patients permits us to maintain a quality of presence and a tradition of caring, which are the hallmarks of First Choice. For more information, please visit our website: www.firstchoicecommunity.com or contact us at: [email protected] or call our office at: 978-290-4646

Printed Name of Patient or Health Care Proxy(Required)

First Last

Date(Required)

GENERAL CONSENT FOR CARE & TREATMENT CONSENT

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your health care provider about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions. I voluntarily request a Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist, and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Signature(Required)

HIPAA ACKNOWLEDGEMENT

Our medical practice is committed to maintaining the privacy of your protected health information (PHI), while providing high quality medical care. We understand that information about you and your health is personal. We create a record of the care and services you receive at our medical practice, as well as records regarding payment for those services. We need those records to provide you with quality care and to comply with certain legal requirements. This notice of privacy practices applies to all of the records of your care generated by our practice Physicians, Nurse Practitioners, and/or our staff. We may use and disclose your PHI for treatment, payment and healthcare operations. You have the right to review a copy of your medical record and request that your doctor change your record if it is not accurate, relevant, or complete. You have the right to file a complaint to both the Office Manager of this practice, and the U.S. Department of Health and Human Services, regarding any alleged violations. We may call you with appointment reminders and cancellations, and may leave voice mail messages at your home, cell phone, or place of employment.

Signature(Required)

PATIENT INFORMATION

Patient Name(Required)

First Last

Gender(Required)

Date of Birth(Required)

Social Security Number(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

ALF Facility Name(Required)

Patient Home Phone(Required)

Patient Cell Phone

Pharmacy Name(Required)

Pharmacy Phone

Health Care Proxy Name(Required)

First Last

Health Care Proxy Relationship

Health Care Proxy Home Phone Number(Required)

Health Care Proxy Cell Phone Number

HCP Email(Required)

HCP Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

HCP/POA Documents(Required)

Max. file size: 100 MB.

Please provide/upload the documents here.

Advanced Directives: MOLST

Max. file size: 100 MB.

Please provide/upload the documents here.

Living Will

Max. file size: 100 MB.

Please provide/upload the documents here.

INSURANCE INFORMATION

Primary Insurance Company(Required)

Insurance Phone(Required)

Policy Number(Required)

Secondary Insurance Company(Required)

Insurance Phone(Required)

Policy Number(Required)

Insurance Cards(Required)

Drop files here or

Max. file size: 100 MB, Max. files: 5.

BILLING INFORMATION

Name(Required)

First Last

Relationship to Patient

Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

PATIENT FINANCIAL POLICY & PROCEDURE

Thank you for choosing First Choice Community Medical Services as your primary care providers. We are committed to providing you with high-quality health care. Your clear understanding of our Patient Financial Policy is important to our professional relationship. Please understand that payment for services is a part of that relationship. It is your responsibility to notify our office if any patient information changes (i.e., name, address, telephone, insurance information, etc.) Insurance. We participate in most insurance plans, including Medicare. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. Proof of insurance. All patients must complete our new patient registration forms before seeing a clinician. We must obtain a copy of your current insurance card to verify proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you. Nonpayment. It is our office policy that all past due accounts be sent two statements. If payment is not made on the account an email and a phone call will be made to try to make payment arrangements. If no resolution can be made, the patient will be discharged from the practice. If this is to occur, you will be notified by regular mail that you have 30 days to find alternative medical care. During that 30-day period, our clinicians will only be able to treat you on an emergency basis. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.

Name of Responsible Party(Required)

First Last

Signature(Required)

PATIENT CONSENT FORM FOR SEASONAL INFLUENZA VACCINE

I have read, or have had explained to me, the CDC Vaccine Information Statement about influenza and the influenza vaccine. I understand that this vaccine may cause flu-like symptoms in some people and in rare incidents Guillain-Barre Syndrome. I have had an opportunity to ask questions which were answered to my satisfaction. I understand the benefits and risks of influenza vaccine and request that the vaccine be given to me (or person named below for whom I am authorized to make this request).

Patient Name(Required)

First Last

Date of Birth(Required)

Patient or Patient Representative Name(Required)

First Last

Has the person receiving the vaccine ever had a severe allergic (hypersensitivity) reaction to eggs, chickens, or chicken feathers?(Required)

Yes

Does the person receiving the vaccine have a history of Guillain-Barre Syndrome or a persistent neurological illness?(Required)

Yes

Is the person receiving the vaccine allergic to Thimerosal (Preservative found in contact lens solution) any vaccine ingredient, or latex?(Required)

Yes

Please check one of the following(Required)

I agree, I would like to receive yearly influenza vaccines. By agreeing to receive the yearly influenza vaccines, I will no longer need to give yearly permission to First Choice Community Medical Services.

I do not agree, to receive yearly influenza vaccines.

PATIENT HEALTH HISTORY

Drug Reactions/Allergies - Please List below:(Required)

Major Illnesses(Required)

Immunizations

COVID-19

Pneumococcal(13/23)

Influenza

Shingles

Surgeries/Injuries:

Please list here

FAMILY HISTORY

Mother: Age at Death

Please list here

Mother: Cause of Death/Illnesses

Please list here

Father: Age at Death

Please list here

Father: Cause of Death/Illnesses

Please list here

SOCIAL HISTORY

Spouse Name (if applicable)

Marital Status:

Children

Please list their names

Tobacco Use:

Never

Current

Former

If current:

Some Days

Every Day

Packs per day

Years Smoked (If applicable)

Marital Status:

Alcohol Use:

Never

Occasionally

Every Day

Substance Abuse

Yes

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

I authorize First Choice Community Medical Services to release and discuss any medical information with the following individuals:(Required)

Please list your name, the patients name and list the names of whom you give consent to receive medical information

AUTHORIZATION FOR RELEASE OF MEDICAL/PSYCHIATRIC/ALCOHOL/DRUG INFORMATION

Name(Required)

First Last

Date of Birth(Required)

Signature(Required)

Name of previous PCP Office(Required)

These will go to the following office: First Choice Community Medical Services, P.C. 575 Turnpike Street Suite 25 North Andover, MA 01845 Phone: 978-290-4646 Fax: 978-290-4822

Previous PCP Office: Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Previous PCP Office: Phone

Previous PCP Office: Fax

Requesting(Required)

Records Should Include the last 1-2 Years

PATIENT’S CURRENT MEDICATION LIST

Do you have a copy of the medication list?(Required)

Yes

Upload copy of medication list here

Max. file size: 100 MB.

Please list prescription and over the counter medications or upload copy of medication list below...

Name of Medication

Route

Dosage

Frequency

Prescribed by

Pharmacy / Prescription Drug Plan

Name of Pharmacy(Required)

Address of Pharmacy(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number of Pharmacy

Number

Signature(Required)

By submitting this form, I acknowledge that I have accurately and thoroughly completed all sections of my medical records to the best of my knowledge. I understand the importance of providing comprehensive and accurate information for proper healthcare management.