Patient Forms

I acknowledge that upon request to HCOTF I will receive a copy of the provider’s HIPPA policies regarding privacy of my protected health information. *

Yes

Additional Comments

Address *

I hereby authorize Housecalls of the Falls and its licensed practitioners to administer such treatment and perform such procedures necessary or advisable in the diagnosis and treatment of the undersigned or designated patient for any necessary services contained in the provision of primary care services to adult patients within the licensed practitioner’s scope of practice. *

Yes

Email: *

Housecalls

Responsible Party (if other than the patient):

Phone *

Upload Insurance Card photo

I authorize Housecalls of the Falls to release to the Social Security Administration and the Centers for Medicare and Medicaid or its Intermediaries or carrier or any commercial insurance company any information needed for this or a related health care services claim. I permit a copy of or any authorization to be used in place of the original, and request payment of medical insurances benefits either to me or the care provider who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply. Additional services that are not covered by my insurance company and are determined to be payable, such as coinsurance, deductibles, and amounts that exceed the annual or lifetime maximum benefits are my responsibility. *

Yes

Date of Birth *

I acknowledge that HCOTF participates in one or more Health Information Exchanges. We use this electronic network to securely access your health records.. We may access your health information through the Health Information Exchange for treatment, payment or other healthcare operations. This is a voluntary agreement. You may opt-out at any time by notifying Marie D. Grosh PO Box 770362 Lakewood, OH 44107, Phone: 440-427-5077, Fax: 440-536-9763, marie@housecallsofthefalls.com *

Yes

Patient Name: *

New Patient Consent Form