New Patients

Please fill out the 417 Health Care intake forms online below after submitting the forms you may download your completed forms to your computer or phone, or you may download the forms and fill them out manually by clicking the link below:

Click Here to download the blank Intake Form to manually fill out and take to the clinic with you

New Patient Intake Forms Packet

Step 1 of 7

Patient Information

Today's Date(Required)

Primary Care Physician

Name(Required)

First Middle Last

Date of Birth(Required)

Age(Required)

Sex(Required)

Male

Female

Marital Status

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Employer

Employer Phone

Occupation

Name of Insurance Company

Secondary Insurance Company

Chose Clinic Because/Referred By

Doctor Referral

Family/Friend

Social Media

Google Search

Website

Other

Spouse

Spouse's Phone

In Case of Emergency Contact:

Name(Required)

First Last

Relationship(Required)

Phone(Required)

Signature(Required)

Date(Required)

General Consent for Care and Treatment

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 (I) 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 physician 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 physician, and/or mid level provider (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.

Printed Name of Patient or Personal Representative(Required)

First Last

Relationship to Patient

Signature of Patient or Personal Representative(Required)

Date(Required)

Printed Name of Witness

First Last

Witness' Job Title

Signature of Witness

I am the parent and/or legal representative of below listed minor. I authorize the performance of diagnostic x-ray of this minor, which 417 Health Car may consider necessary or advisable.

Printed Name of Minor

First Last

Age of Minor

Signature of parent and/or legal reprehensive of minor

Date

HIPAA-ACKNOWLEDGEMENT OF RECEIPT

Notice of Privacy Pratices

Patient Name(Required)

First Last

Patient Date of Birth(Required)

We at 417 Health Care LLC are required by law to maintain the privacy of and provide individuals with the attached Notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to the Notice, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number. If you would like a copy of the Notice, please ask. I hereby acknowledge that I have reviewed the HIPAA Notice of Privacy Practice document. I hereby allow the following person(s) to have access, by phone or in the office, to my record/lab results and pathology reports until I otherwise specify.

Person #1

First Name Last Name

Allow Second Peron Access to Records

I allow the person listed below access to my record/lab and pathology reports

Person #2

First Name Last Name

Allow Third Peron Access to Records

I allow the person listed below access to my record/lab and pathology reports.

Name

First Last

Name of patient or patient's representative/parent

First Name Last Name

Signature of patient or patient's representative/parent(Required)

Date(Required)

Relationship to Patient

417 Health Care Financial Policies

Welcome to our office. Thank you for choosing 417 Health Care for your medical needs. We are committed to providing you with the best possible care. We accept cash, checks, and major credit cards. In order to better serve you, we ask that you please take a few minutes to read the following policies specific to our practice and your insurance.

Insurances - If you have insurance, we will do all we can to help you receive maximum benefits. The percentage of coverage by your insurance company may be based on your insurance company's own reduced fee schedule for medical services and may be less than actual charges, resulting in lower coverage for you. We have no control over this situation. Lower payment is a direct result of the plan selected by yourself or your employer. Please be advised that we cannot waive co-payment. We are required by law to collect your co-payment. Medicare Patients: This office accepts Medicare assignment. Medicare patients are fully responsible, however for the initial yearly deductible and the 20% co-insurance. This payment is to be made at the time services are rendered.

Financial Policy - Medical Records, Releases, and Insurance Assignments - l request and authorize Daina Kays FNP-BC or assistant of their choice to perform medical/physical therapy medical treatment. I also authorize the taking of photographs for medical use by this office. I permit a copy of these authorizations and assignments to be used in place of this original

Physician Insurance Assignment - We require insured patients to complete assignment of benefits authorizing insurance to remit payment to 417 Health Care. I hereby assign all medical benefits, to which I am entitled, by private insurance or any other health plan to: 417 Health Care. This assignment will remain in effect until revoked by me in writing. I authorize payment directly to 417 Health Care for medical benefits. Any services for which assignments are not accepted are acknowledged to be my full and complete financial responsibility. I understand that I am financially responsible for all charges not paid by said insurance. Medicare - I certify that the information given by me in applying payment under title XVII/XIX of the Social Security Act is correct.

Responsibility of Account - I agree that if the amount of insurance benefits be insufficient to cover expenses, I will be responsible for the payment of the difference. I will be responsible for the entire amount due to professional services rendered if the expense is not covered by insurance.

Collection Information - I understand that my portion of all fees is due at the time treated unless previous arrangements have been made. I will be billed for my po1tion of any fees not paid at the time of service. Any balance which are 90 days past due will be eligible to be turned over to a collection agency. Collection Agency fees are recognized to be my (the patients) responsibility. There will be a $35.00 fee for any returned check. We know at times patients do not have any insurance. If this is the case the procedure and cost will be discussed prior to service. At this time, a payment plan will be set up.

Attendance and Cancelation Policy - It is very important to note that, for you to receive the optimal benefit from your office visit/therapy, you must be consistent in attending all your scheduled appointments. Additionally, in order to be as efficient in our schedules as possible we kindly ask for at least 24-hour notice for cancellations. At our discretion, you may be subjected to a $50.00 cancellation fee. If you do not show for an appointment, a $50.00 no-show fee will be charged. In the event that you are unable to attend your appointments constantly, you have 2 same-day cancels, or 2 no-show appointments, you will be discharged from care. We are very committed to your rehabilitation and improved quality of life. Therefore, we ask that you allow us to help solve any issues that may prevent you from attending the prescribed number of treatment sessions as in your plan of care.

Insurance Benefits - Please check your benefits co-pays, co-insurance, deductibles, and any limitations to the number of therapy visits allowed. The back of your insurance card has a "member services" phone number which you may call to inquire about and verify the necessary information. You are providing your insurance information and contractually obligated to your insurance carrier's fees, including co-pays, co-insurance, and deductibles. We are contractually obligated to file your claim with your insurance carrier as well as collect any fees associated with your care. Please notify the front desk of any changes in your insurance coverage.

Patient Payments and Charges - Please be prepared to pay any co-pay/deductible amounts at the time of each appointment. Please note: We do use other facilities such as hospitals, laboratories, etc. for bloodwork, cultures and biopsies. Therefore, you may be receiving billing information from these facilities. Thank you for understanding our financial policies. We are here to help you. Please let us know if you have any questions or concerns.

Please carefully read and initial each statement (1-6) and sign below. This policy has been put in place to ensure that financial payments due are recovered to allow us to provide quality medical care for our patients. It is important that we work together to assure that payment for services is as simple and straightforward as possible. Our practice manager or billing department will be glad to discuss these policies with you .

.(Required)

I understand that 417 Health Care will collect all co-payments at the time of visit. Any deductibles and coinsurance up to the amount equal to payment in full for the visit and planned procedure codes will be billed. Payment in full l and expected coinsurance payment responsibility are determined by the anticipated billing code(s), details of your insurance policy, and agreement between your insurance company and 417 Health Care. Any over payment to your account will be refunded after payment and/or remittance has been received from your insurance company.

.(Required)

I understand that a $35 service fee will be added for a returned check.

.(Required)

I understand that a 24-hour advanced notice is required to cancel an appointment to avoid a $SO fee.

.(Required)

I understand that if my account is not paid in full within 90 days of a statement date, a 35% collection agency processing fee will be added to the outstanding balance which will be turned over to collections for further processing. No additional appointments will be made for delinquent accounts until they are brought current.

.(Required)

417 Health Care wi ll allow 30 days from the date of filling for my insurance company to process or pay a claim. State law allows insurance companies operating in Missouri no more than 30 days to process claims. It is my responsibility to provide my insurance company with any requested information needed to process a claim for service. It is my responsibility to notify 417 Health Care if there is any change in my insurance coverage, residence, or phone number. ULTIMATELY, IT IS UP TO ME TO KNOW MY INSURANCE BENEFITS.

.(Required)

I understand that during treatment it may be necessary to change or add procedures based on conditions found . I give permission for 417 Health Care to make all changes, and additions, as necessary.

I have read and agree to all the provisions of the above financial policy. I understand that I am ultimately responsible for all professional fees incurred for professional services performed.

Patient Name(Required)

First Last

Patient Signature(Required)

Date(Required)

This field is for validation purposes and should be left unchanged.

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417.374.4141

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417.374.4140

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info@417healthcare.com

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830 W. Mount Vernon St Suite 10 Nixa, Mo 65714

Now Accepting:

New Patients

New Patient Intake Forms Packet

Patient Information

Patient History

Audio Recording, Videotaping, and Photography Form

General Consent for Care and Treatment

HIPAA-ACKNOWLEDGEMENT OF RECEIPT

Notice of Privacy Pratices

417 Health Care Financial Policies

417.374.4141

417.374.4140

info@417healthcare.com

830 W. Mount Vernon St Suite 10 Nixa, Mo 65714

Better Health Care For The 417 Community

is Our Mission