There are 6 forms that all patients will have to print, read and sign.
The Demographics form includes your personal information such as address, date of birth, etc. Most of this information is needed for insurance purposes or required by law.
The Financial Policy form explains you are responsible for all charges that are not covered by your health insurance.
The Acknowledgement of Receipt of the Notice of Privacy Practices form indicates you have read and/or received a copy of the office’s Notice of Privacy Practices. The Notice of Privacy Practices describes how your Personal Health Information is disclosed to others. The Notice of Privacy Practices is for you to know your rights regarding your Personal Health Information and is always available in a white binder near the check-in window.
Attached to the same page is the HIPPA Authorization and Disclosure of Protected Health Information form. All of your information is protected by law for your protection. On this form you should list anyone you would want to have access to any of your information available through this office. For example, you may want your spouse to pick up your test results on their way home from the office. Your spouse would need to be listed on this form as an authorized person. Anyone calling the office on your behalf requesting Personal and/or Health Information would need to be listed on this form. It’s prudent to have everyone listed now, so if there is an emergency in the future, a delay will be avoided in providing the information to whomever needs it.
The Cancellation Policy describes your responsibilities associated with your appointment with Dr. Jackie.
The Office Policy form outlines how medication refills and referrals are administrated as well as Preventive Health and Patient Dismissal.
The Patient History & Health Assessment form is extremely important for Dr. Jackie to be able to determine accurately what is going on with your body. Please take the time to be thorough and precise.
To print any forms, click on the name of the document in the gray box to the right. If you have Adobe Reader installed on your computer the file will automatically open. If you do not have Adobe Reader installed a message will pop up telling you that you need to install the application and a link will be provided to the installation page for Adobe Reader. Adobe Reader is free. Once you have opened the file in Adobe Reader, to print the file, click on File and then Print. Be sure the correct printer is selected and then click the Print button. Please bring these forms with you at the time of your appointment along with your drivers license and insurance card.