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Gruene Lake Medical

Family Medicine & Primary Care Practice located in New Braunfels, TX

New Patient Forms

GRUENE LAKE MEDICAL

NEW PATIENT INFORMATION

Personal Information
Insurance
Health History
Consent Forms
Policies

Last Name:

First:

Middle:

Date of Birth:

SSN:

Birth Gender:

Male

Female

Insurance Information

Insurance Company Name:

Member ID#:

Group#:

Phone:

Address:

Primary Insured's Name:

DOB:

Relationship to Patient:

Do you have a secondary Insurance?

Yes

It is not viable to completely and accurately estimate the total cost of your encounters. Any estimate that is given by this office is based upon your benefits on the state in which they were acquired and are subject to change. It is ultimately your responsibility to know your benefits.

Patient/Patient rep initials:

Acknowledgement of Review of Notice of Privacy Practices

I acknowledge that I have received the Notice of Privacy Practices for the office of Gruene Lake Medical, which explains how my medical information will be used and disclosed.

Signature of Patient or Personal Representative:

Date:

Authorization to release any information to extended family and/or spouse and children: Please think about anyone who may be calling for information or for billing purposes. Without their name appearing on this form, we will NOT be authorized to release any information. Please list below:

HEALTH HISTORY

Patient's Name:

DOB:

Age:

Previous Physician Name:

Previous Physician's Address:

Present Health Concerns:

Allergies (list reaction also):

Medications currently taking (name, strength, how you take the medication, reason for taking it, and prescribing physician):

Substance Use

Caffeine:

Never

Rarely

Moderately

Daily

Alcohol:

Never

Rarely

Moderately

Daily

Tobacco:

Never

Rarely

Moderately

Daily

Family History

Please check any box that relates to any family history of the following conditions:

Condition	Mother	Father	Child	Sibling
ANEMIA
ASTHMA
DIABETES
HEART DISEASE
HIGH BLOOD PRESSURE

List any other conditions or comments that you feel are pertinent to your healthcare:

Minor Consent Form (Pediatric patients only)

REMINDER: ALL PEDIATRIC PATIENTS UNDER THE AGE OF 18 MUST BE ACCOMPANIED BY A PARENT OR AN AUTHORIZED ADULT

If your child needs medical services and you are unavailable, you must give us permission as a parent. It is the law. A child may be treated with parental consent when a physician determines a true emergency exists. This means that the child needs immediate care and that an attempt to obtain parental consent would result in a delay which would increase the risk to the child's life or health.

This form is a legal document with which you may appoint relatives, friends, teachers, clergy, and/or neighbors (anyone who is over 18 years of age) to be responsible for your children. It is especially important to prepare this form for occasions when you know it will be hard to contact you.

Name of Minor	Date of Birth	Allergies/Special Conditions

I, the parent (legal guardian), of the above-named minor(s), do hereby appoint the following to act on my behalf in authorizing expected and/or unexpected medical, surgical, and/or hospitalization for the above-named minor(s)

Name of Adult	Relationship	Phone/Address

Signature of Parent/Legal Guardian:

Date:

Financial Policy

Thank you for choosing Gruene Lake Medical as your primary care provider. We are committed to providing you with quality and affordable health care. Please read our financial policy carefully and let us know if you have any questions.

Insurance

We participate in most PPO insurance plans. (We do not accept HMO policies) If you are not insured by a plan we are in network with, payment in full is expected at each visit. If you are insured by a plan we are in network with, but don't have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

Co-payments, deductibles, co-Insurance

All co-payments, deductibles and/or co-insurance must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect from patients can be considered fraud. Please help us in upholding the law by paying your co-payment, deductible or co-insurance at each visit. We accept cash, check and credit/debit cards as well as HSA cards.

Missed appointments

Our policy is to charge for any appointment(s) not canceled within 24 hours. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your scheduled appointments or cancelling at least 24 hours in advance.
Missed appointment fees: Office Visits: $25.00 Physical/Wellness Visits: $50.00 Nurse Visits: $15.00

Signature of Patient or Responsible Party:

Date:

Prescription Policy

OUR OFFICE DOES NOT CALL IN ANTIBIOTICS WITHOUT BEING SEEN

Refill

Call your pharmacy and request a refill. A patient must be seen prior to any new prescriptions.

Timeline

Prescriptions take 48-72 hours to be processed and refilled. Controlled substances can take longer due to researching the patient's chart & DEA monitoring. Requests for the same day or walk-in refills will not be honored.

Signature:

Date: