Forms

Welcome!

Dr. Barbara Newlon is committed to providing the best and most comprehensive care possible to you and your family.

All information is confidential and will be released only with your consent.

New Patient Form

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About You

Patient Name and Relation (if not your own name)(Required)

First Last

Your Name (if different)

First Last

Today's Date

MM slash DD slash YYYY

Patient's Birth Date

MM slash DD slash YYYY

Gender

Female

Male

Other

Height

Weight

Mobile Phone

Secondary Phone

Your Address

Street Address City State ZIP Code

Name of person who referred you to us

Your relationship to this person

Your Occupation

Your Spouses Name (or N/A)

Spouse's Phone

Emergency Contact Name (if different)

Emergency Contact's Phone

Primary Physician's Name

Primary Physician's Phone

Reason for Visit(Required)

PAYMENT SECTION

PRIVATE PAY | Please move to 'Insurance Pay' if this section is not applicable.

Person to be billed

Relationship to patient (self/spouse/parent/other)

Payer's Social Security Number

California Driver's License Number

Payer's Address

Street Address City State ZIP Code

MOTOR VEHICLE ACCIDENT | Please move to 'Insurance Pay' if this section is not applicable.

If you were injured in a motor vehicle accident, please give the date and State. Otherwise answer N/A and move to Insurance section

MVA Insurance Name

Claim Number

MVA Insurance Co. phone number

MVA Insurance Co. address

I acknowledge that charges not covered by MVA insurance are my responsibility to pay.

I agree

Personal Insurance #1 | Please move to 'Emergency Contact' if this section is not applicable.

Insurance Name

Subscriber

Date of Birth

MM slash DD slash YYYY

Insurance Company Address

Street Address City State ZIP Code

Subscriber ID

Group Number

Relationship (self/spouse/parent/other)

Personal Insurance #2

Insurance Name

Subscriber

Date of Birth

MM slash DD slash YYYY

Insurance Company Address

Street Address City State ZIP Code

Subscriber ID

Group Number

Relationship (self/spouse/parent/other)

NOTIFY IN CASE OF EMERGENCY

Name

First Last

Relationship to patient (self/spouse/parent/other)

Address

Street Address City State ZIP Code

Home Phone

Work Phone

Mobile Phone

Name of nearest relative not living with you

Relationship to patient (self/spouse/parent/other)

Home Phone

Work Phone

Mobile Phone

Office Financial Policy

Non-insured Patients

Payment for professional fees is due in full at the time of service.

Commercially Insured Patients

Your full charge for each service day's office visit will be collected at the time of your visit. We will bill your insurance company for you as a courtesy. If a copy of your or your child's insurance card is provided (including Name of Insurance, Claims Mailing Address, Member ID #, and Group #), we will bill insurance carriers for you on an unassigned basis. This means that insurance reimbursement will be requested to be made directly to you.

The patient is responsible to Dr. Newlon for any charges not covered by this assignment.

Medicare Patients

We are a non-participating Medicare provider.

Payment for professional fees, based on the Medicare Limiting Charge, is due at the time of service. A copy of your Medicare card and Medicare supplemental insurance (if any) is required at your first visit. We will submit your claim to Medicare, which will reimburse you their allowed amount. Medicare will automatically crossover the claim to your supplemental Medicare insurance.

Additional Policies

Missed Appointments: There is a $100–$150 charge for appointments missed or canceled without 48-hour notice. If the appointment is able to be filled subsequent to your cancellation, there will be no charge.
Returned Checks: All returned checks are subject to a $25.00 charge.

Agreement to Financial Policies

(All patients to sign this section.)

I have read, understand and agree to the above financial policies for professional fees for services rendered. I understand that I am ultimately responsible for all fees.

Signature | Financial Policies

Date

MM slash DD slash YYYY

Insurance - Authorization to Release Information & Assignment of Benefits

(Commercially insured patients to sign this section.)

I authorize the release of any medical or other information necessary to process my claims, in compliance with HIPAA and the privacy practices of this office, a copy of which has been provided to me. I further understand that I am responsible for payment of all charges not covered by this assignment. This agreement will remain in effect until revoked by me in writing.

Signature | Insurance Authorization

Date

MM slash DD slash YYYY

Medicare Authorization & Assignment of Benefits

I authorize any holder of medical information about me to release to Medicare and its agents any information needed to determine payment of benefits for related services. I understand that Barbara Newlon, D.O. is a Non-Participating Medicare Provider; that I will pay for services at the time of service; and that my signature requests that Medicare reimbursement be made payable to me.

My signature also authorizes the release of medical information to other health insurance (including secondary or supplemental insurance).

This authorization will remain in effect until revoked by me in writing.

Signature | Medicare Authorization

Date

MM slash DD slash YYYY

MEDICAL HISTORY

List all surgeries and dates

What medication are you currently prescribed

Describe the dental work you have had, including dates if possible, and if anesthetic was used. Include braces, crowns, cavities, root canals, extractions, dentures, and bridges.

What kind of mattress do you sleep on? What year purchased?

Do you, or have you ever had any of the following health conditions:

Allergies

Asthma

Bladder Infections

Bronchitis

Cancer

Chronic ear infections

Chronic sore throat

Constipation

Diarrhea/Colitis

Diabetes

Heart condition

Hepatitis

High blood pressure

HIV

Migraine headaches

Pneumonia

Sinus infections

Skin conditions

Uterine fibroids

Vaginal infections

Other

MENSTRUAL CYCLE INFORMATION | Please move forward if not applicable.

Number of days between cycles

Number of days flow

How many tampons/pads per day

Cramping

Medication used

Date of last PAP smear

Was it normal

How many pregnancies

MENOPAUSE INFORMATION | Please move forward if not applicable.

Date of menopause, if applicable

FAMILY MEDICAL INFORMATION

Mother's current age or age at death | Health issues

Still living (Y/N)

Father's current age or age at death | Health issues

Still living (Y/N)

Sibling's current age or age at death | Health issues

Still living (Y/N)

Sibling's current age or age at death | Health issues

Still living (Y/N)

Sibling's current age or age at death | Health issues

Still living (Y/N)

Have your blood relatives had any of the following health conditions:

Allergies

Alcoholism

Anemia

Arthritis

Asthma

Bladder condition

Cancer

Chronic ear infections

Chronic sore throat

Diabetes

Epilepsy

Genetic disease

Glaucoma

Gout

Headaches

Heart disease

High blood pressure

HIV

Mental illness

Migraine headaches

Multiple Sclerosis

Pneumonia

Sinus infections

Skin conditions

Stroke

Tuberculosis

Ulcers

Other

PRACTICE POLICIES

Cancellation Policy

Appointments must be cancelled at least 48 hours prior to arrival. Please understand that it can be difficult to fill your appointment with even 48 hours notice. I appreciate as much notice as possible. Please cancel Monday appointments by the prior Thursday.

Charges for Late Cancellations and No Shows

I understand that events happen that are not foreseeable. In order to manage a successful practice, I must charge any patient for appointments not cancelled 48 hours in advance. If I am able to fill the appointment, there will be no charge. As a courtesy to our patients, we will endeavor to call and remind patients of appointments. However, it is still the patient's responsibility to keep appointment times.

Late Arrival

I make every effort to stay on time and I ask that patients do also. Appointments are scheduled at 30-minute intervals. However, your body dictates what needs to be done for that day. Therefore, a treatment may take me 25 minutes and sometimes, 40 minutes. I take the time I need and occasionally you will have to wait 10-20 minutes for your appointment.

Emergency Treatments

Emergency treatments are scheduled the day you call. I leave one hour a day for urgent needs. Please call no later than 9:00 a.m.

Motor Vehicle Accidents

If this is a motor vehicle accident and we are billing your automobile insurance, you are responsible for paying any amounts the insurance company does not pay.

Patient Mobility

Patients must be able to get in and out of chairs, on and off of the treatment table of their own volition; or have someone to assist them to do this. Dr. Newlon and her office staff are NOT able to assist immobile patients.

Payment

Payment is expected at time of your visit. I will provide you with a super bill for insurance purposes, which includes diagnosis codes and fees. Our current fee schedule is $ for initial consultation (approximately 75 minutes to one hour) and $ for a regular office visit.

Returned Checks

All returned checks are subject to a $25.00 charge.

Fragrance

Out of consideration to patients and staff, please refrain from wearing fragrance. Thank you!

Signature | Practice Policies

Date

MM slash DD slash YYYY

Informed Consent

I hereby request and consent to the performance of procedures which are within the scope of practice of osteopathic medicine including, but not limited to, osteopathic treatments on me (or on the patient, for whom I am legally responsible) by Dr. Newlon, who utilizes a technique called myofascial release and the cranial concept in osteopathy. The technique is direct, but not harsh or invasive.

I have had an opportunity to discuss with the osteopath named above and/or with other office or clinic personnel the nature and purpose of osteopathy. I understand that the results are not guaranteed.

I understand and am informed that in the practice of osteopathy there are some risks to treatment, including, but not limited to, temporary 3-10 day soreness in the musculo-skeletal system after treatment, including areas of initial non-complaint. Other reactions can be temporary fatigue or a sense of "spaceyness" or light-headedness after treatment. Sometimes a temporary headache occurs.

In babies and small children, a temporary increase in fussiness or agitation can occur for up to five days after treatment (this is rare). There can be transient (30-60 second) soreness in the area being addressed during treatment.

I do not expect the osteopath to be able to anticipate and explain all risks and complications, and I wish to rely on the osteopath to exercise judgment during the course of the procedure which the osteopath feels at the time, based upon the facts then known, is in my best interests.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below, I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

Signature | Informed Consent

Date

MM slash DD slash YYYY

HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law.

It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, which may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law.

Treatment

We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment

Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Your Rights

Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e., electronically.

Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint.

Your signature below is only acknowledgment that you have received this Notice of Privacy Practices.

Signature | HIPAA Notice

Date

MM slash DD slash YYYY