ACHZ01 Client Information Form

ACHIEVE HEALTH PATIENT INFORMATION SHEET
Legal Name*

First NameMiddle NameLast Name
Preferred Name

First NameLast Name
Date of Birth*

MonthDayYear
Date
Marital Status
Sex assigned at birth (for medical purposes)

MaleFemaleIntersex
Gender Identity

WomanManNon-binaryTransgender WomanTransgender ManPrefer not to answerAnother Identity (Please specify)
Pronouns
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Accept cell phone text messaging. This is how we remind and confirm your appointments.*

YesOther
Email*
example@example.com
Social Security Number
Race

CaucasianAfrican AmericanHispanicAsianAmerican IndianAlaska NativeOther
Reason for seeing the doctor
INSURANCE INFORMATION
Primary Insurance Company Name
Policy Holder's Name

First NameLast Name
Policy Holder's Date of Birth

MonthDayYear
Date
Policy Number
Group Number
To expedite your benefits confirmation, please attach a photo of the FRONT side of your PRIMARY insurance card. You can use your cell phone to take the picture.

Cancelof
To expedite your benefits confirmation, please attach a photo of the BACK side of your PRIMARY insurance card. You can use your cell phone to take the picture.

Cancelof
Do you have secondary insurance?

YesNo
SECONDARY INSURANCE INFORMATION
Secondary Insurance Company Name
Secondary Insurance Policy Holder's Name

First NameLast Name
Secondary Insurance Policy Holder's Date of Birth

MonthDayYear
Date
Secondary Insurance Policy Number
Secondary Insurance Group Number
To expedite your benefits confirmation, please attach a photo of the FRONT side of your SECONDARY insurance card. You can use your cell phone to take the picture.

Cancelof
To expedite your benefits confirmation, please attach a photo of the BACK side of your SECONDARY insurance card. You can use your cell phone to take the picture.

Cancelof
RESPONSIBLE PARTY (if other than client)
Is the responsible party the client?

YesNo
Same address as the patient?

YesNo-Address -
Responsible Party Name

First NameLast Name
Responsible Party Social Security Number
Relationship to Patient
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
EMERGENCY CONTACT
Emergency Contact Name

First NameLast Name
Relationship to Patient
Phone Number
Please enter a valid phone number.
PREFERRED PHARMACY
Preferred Pharmacy Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
PATIENT MEDICAL HISTORY

Past Operations/Hospitalizations

	Procedure	Date
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Current Medications

	Medication	Dosage	Times Per Day
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Drug Allergies

	Name of drug you are allergic to	Reation
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Have you ever had the following:

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysema
Other Illnesses
Include other comments regarding your medical history
Initials*
AUTHORIZATION

Please READ AND INITIAL each and sign at the bottom.
I am responsible for payment in full at time of service unless previous arrangements have been made. Initials*
I authorize the release of medical information to my insurance carrier that may be necessary to process my claims. Initials*
I authorize payment directly to Achieve Health for my medical expenses. Initials*
In the event it is necessary to refer this account to collections, I agree to pay all costs of collection including but not limited to reasonable attorney fees and interest permitted by law. Initials*
If my insurance company denies payment, I agree to be personally and fully responsible for payment. Initials*
I authorize Achieve Health to document prescription information into the prescription database PDMP. Initials*
I have received and reviewed Achieve Health's Privacy Policy. Initials*
I have verified that the information in this agreement is correct. Initials*
I have read and understand the information contained in this agreement. Initials*
Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Client Signature*

Clear
Achieve Health Patient Bill of Rights and Responsibilities

Patient Bill of Rights

Achieve Health, its providers, and its staff fully support and advocate a Patient Bill of Rights with the expectation that observance of these rights will contribute to more effective patient care and greater satisfaction for the patient, his, her, or their provider, and the clinic as a whole.
- A patient has the right to respectful, good quality care and high professional standards that are continually maintained and reviewed and given by competent personnel.
- A patient has the right, upon request, to be given the name of his/her/their provider, the names of all other providers directly participating in their care, and the names and function of other health care persons having direct contact with the patient.
- A patient has the right to every consideration of their privacy concerning his/her/their own medical care program. All medical records pertaining to their medical care are treated as confidential except as otherwise provided by law or third party contractual arrangements. Case discussion, consultation, examination, and treatment are considered confidential and should be conducted discreetly.
- A patient has the right to know what Achieve Health rules and regulations apply to his/her/their conduct as a patient.
- The patient has the right to full information in layman's terms, concerning his/her/their diagnosis, treatment, and prognosis, including information about alternative treatments and possible complications. When it is not medically advisable to give such information to the patient, the information shall be given on their behalf to the patient's next of kin or appropriate person.
- The patient has the right to full participation in his/her/their health care plan and will be encouraged to do so whenever possible.
- Except for emergencies, the health care provider must obtain the necessary consent prior to the start of any procedure or treatment, or both.
- A patient has the right to refuse any drugs, treatment, or procedure offered by the physician, to the extent permitted by law, and the physician shall inform the patient of the medical consequences of the patient's refusal of any drugs, treatment, or procedure.
- A patient has the right to assistance in obtaining consultation with another physician at his/her/their request and expense.
- A patient has the right to medical and nursing services without discrimination based upon race, color, religion, sex, sexual preference, national origin, or source of payment.
- Achieve Health shall provide the patient, upon request, access to all information contained in his/her/their medical records, unless the attending physician specifically restricts access for medical reasons or is prohibited by law.
- The patient has the right to examine and receive a detailed explanation of his/her/their bill and full information and counseling on the availability of known financial resources for their health care.
- The patient has the right to be informed of their continuing health care requirements and the means for meeting them.
- The patient cannot be denied the right of access to an individual or agency authorized to act on their behalf to assert or protect the rights set out in this section.
- The patient has the right to every consideration of the spiritual and cultural variable, which may influence his/her/their perception of illness and treatment, and to have his/her/their continuing psychosocial needs considered in planning care and treatment.
- The patient has the right to execute an advance medical directive and to expect that it will receive maximal consideration to the extent permitted by law.
- The patient has the right to expect that their guardian, next of kin, or legally authorized responsible person will be able to exercise all the rights delineated on behalf of the patient in the following circumstances: a. if the patient has been adjudicated incompetent in accordance with the law b. if the patient is found by his/her/their provider to be mentally incapable of understanding the proposed treatment or procedure c. if the patient is unable to communicate his/her/their wishes regarding treatment if the patient is a minor
- A patient has the right to be informed of his/her/their rights at the earliest possible moment in the course of their medical care.
Patient Responsibilities

Just as Achieve Health firmly believes in the rights of the patient, equally we recognize that patients must exercise responsibility as a recipient of health care services.

These responsibilities are as follows:

Provision of Information

The patient has the responsibility to provide, to the best of their knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his/her/their health. The patient has the responsibility to report unexpected changes in his/her/their condition to the responsible practitioner. A patient is responsible for indicating whether he/she/they clearly comprehends his/her/their health care plan and what is expected of them.

Compliance with Instructions

The patient is responsible for following the treatment plan recommended by the practitioner responsible for his/her/their care. This may include following the instructions of nurses, medical assistants and other health care personnel as they carry out the plan of care, implement the responsible practitioner's orders, and enforce the rules and regulations of Achieve Health. The patient is responsible for keeping appointments and, when unable to do so for any reason, for notifying Achieve Health in a timely manner.

Refusal of Treatment

The patient is responsible for his/her/their actions if he/she/they refuses treatment or does not follow the practitioner's instructions.

Charges

The patient is responsible for assuring that the financial obligations of his/her/their health care are fulfilled as promptly as possible.

Achieve Health Rules and Regulations

The patient is responsible for following Achieve Health rules and regulations affecting patient care and conduct.

Respect and Consideration

The patient is responsible for being considerate of the rights of other patients and Achieve Health personnel. The patient is responsible for being respectful of the property of other persons and of Achieve Health.
Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Patient Signature*

Clear
Patient Acknowledgement
Appointment Cancellation Policy

Dear Patient,

Achieve Health has instituted an Appointment Cancellation Policy. A cancellation made with less than a 24-hour notice limits our ability to make an appointment available for another patient in need of care.

To remain consistent with our mission, we have instituted the following policy:
1. Please provide our office with a 24-hour notice in the event you need to reschedule your appointment. This will allow our team the opportunity to provide care to another patient in need. We will allow one message left on the answering service as proper notice.
2. A "No-show", "No Call" or missed appointment, without proper 24-hour notification, may be charged a cancellation fee of $150.
3. This fee is not billable to your insurance.
4. If you are 15 or more minutes late for your appointment, the appointment may be canceled and rescheduled.
5. As a courtesy, we make reminder calls for appointments one to two days in advance. Please note, if a reminder call or message is not received, the cancellation policy remains in effect.
6. Repeated missed appointments may result in termination of the provider/patient relationship.
7. If there is a fee from a "No-show", "No Call" or missed appointment, without proper 24-hour notification, this must be paid prior to being seen at your next appointment.
If you have further questions or concerns regarding this policy, please speak to our staff for clarification. A copy of this policy has been provided to you. Please sign and date below your acknowledgement to our policy.

I have read and understand the Appointment Cancellation Policy and I acknowledge its terms. I also understand and agree that such terms may be amended on a per case basis.
Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Signature of Patient *

Clear
Consent to the Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operations

I, the above named patient, understand that as part of my healthcare, this practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:
- A basis for planning my care and treatment.
- A means of communication among the many health professionals that contribute to my care.
- A source of information for applying my diagnosis and surgical information to my bill.
- A means by which a third-party payor can verify that services billed were actually provided, and
- A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.
I understand there is a more complete description of information uses and disclosures kept on file at Achieve Health. I understand that I have the right to review that notice prior to signing this consent. I understand that Achieve Health reserves the right to change its notice and practices, and, prior to implementation, may make available those changes for my review. I understand I have a right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that Achieve Health is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that Achieve Health has already taken action in reliance thereon.
I wish to have the following restrictions placed on my healthcare information:
The phone number and or email listed below are the only places my personal health information may be left on voicemail and or electronic email. This includes test results, appointment times or other personal health information. If my phone number changes, I give permission to use my new number without amending this agreement.

Places for Person Health Information to be left

	Information	Location - pick one
1.
2.
3.
4.

I fully understand and accept the terms of this consent form.

This form will require a signature in the presence of a Achieve Health Employee and will remain in the patient's permanent record until revoked in writing by the signee.
Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Client/Guardian Signature*

Clear
Telemedicine Consent Form

I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.

I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.

I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction and may receive copies of this information for a reasonable fee.

I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My provider has explained the alternatives to my satisfaction.

I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.

I understand that it is my duty to inform my provider of electronic interactions regarding my care that I may have with other healthcare providers.

I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

I understand the information provided above regarding telemedicine, have discussed it with my Physician Associate and or Nurse Practitioner may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care with my provider and Achieve Health.
Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Signature*

Clear
Patient Name

First NameMiddle NameLast Name
Insurance Company
Advance Beneficiary Notice of Non-coverage

Please be advised if your insurance company does not pay for your telehealth visit, you will be responsible for payment. Due to changing telehealth legislation and insurance policies, telehealth may not be covered by your insurance plan. It is your responsibility to contact your member services and determine if your telehealth benefits are covered by your insurance prior to services being rendered and decide whether you want to proceed with a telehealth appointment.

Service Reason Insurance May Not Pay: Telehealth services not covered.

If insurance does not cover telehealth services, you will be liable for the cost of the telehealth visit:

$200.00 for a new patient $150.00 for an established patient

WHAT YOU NEED TO DO NOW: Read this notice, so you can make an informed decision about your care. Ask us any questions that you may have and ensure you understand coverage and financial responsibility.

By signing this Advanced Beneficiary Notice of Non-Coverage, if at any time I agree to a telehealth visit, I understand that my insurance may not cover this service and I am then responsible for payment as outlined above and any and all charges related to this visit including collections by Achieve Health for nonpayment if necessary.

This notice is not an official insurance decision.

I have read this notice and agree to the terms:
Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Signature*

Clear
Authorization for Release of Patient Information
Client Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
I authorize the following facility (include name and address):
Phone Number of Facility
Please enter a valid phone number.
Fax Number of Facility
Please enter a valid fax number.
To release information to:

Achieve Health
Phone: 720-241-3765 Fax: 720-310-7216
Please

Mail records directly to person or organization specifiedI authorize the below person to pick up records for meCall me for pick up when records are ready - Phone -
Person authorized to pick up records for me
Information Requested (check if to be released)

Complete chartHistory and PhysicalDiagnostic StudiesX-ray ReportsLab ReportsPsychological EvaluationPathology ReportsDoctor's NotesOperative Reports
Treatment Date(s)
Purpose of Release

Treatment/DiagnosisInsuranceLegalOther
I request and authorize the release of information to the organization, agency or individual named above. I understand that the information to be released may include the following condition(s):

Any and all medical and laboratory records, Drug Abuse/Alcohol abuse, Psychological or psychiatric conditions.

This authorization will expire in 1 (one) year from the date of signature
Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Signature of Patient/Guardian*

Clear
Relationship
NOTE: Information requested will NOT be provided if any of the above items have not been completed. There is a charge for copies of medical records. The charge is $16.50 for the first 10 pages, $0.75 for pages 11-40, $0.50 for each additional page.
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