New Patient Paperwork Dear New Patient, Welcome to Total Body Wellness Brownsburg! We would like to take this opportunity to welcome you to our practice and thank you for choosing our practitioners to participate in your healthcare. The following information is provided to ensure a smooth transition into our practice. Please complete the forms and bring them with you to your first appointment, it will help speed up the check in process. You will need to arrive 15 minutes prior, so that we are able to have your chart ready by your appointment time. If you cannot keep your appointment, please notify us within 24 hours of your scheduled time. We confirm all new patient appointments 24 hours in advance. If you are going to be late, please contact our office to notify us as soon as possible, (317) 286-3147. If you have medical insurance, please bring all of your current insurance and a valid photo identification card with you at the time of your appointment. Please check to make sure that your cards are not expired. This will help complete your chart. While we do not accept insurance, we are able to provide you with an itemized receipt to submit for potential reimbursement. Health Savings Accounts (HSA) are also accepted as a method of payment. All lab work and prescriptions can be billed directly to insurance. Payment in full at the time of service is required. We look forward to providing you with access to personalized medicine. Sincerely, Ellie Branagin, FNP-C & Ashley Regal, AGPCNP-BC ~ P.S. Don’t forget to follow us on social media! Facebook: Total Body Wellness BrownsburgInstagram: @totalbodywellnessbrownsburgPatient Consent Form By signing this Consent Form, you give Total Body Wellness Brownsburg, LLC permission to use and disclose protected health information (HPI) about you for treatment, payment, and health-care operations (TPO) except for any restrictions specified below to which we have agreed. Protected health information is individually identifiable information we create or receive, including demographic information, relating to your physical or mental health, for provision of health care services to you, and to the collection of payment for providing health-care services to you. Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to receive a copy of our Notice of Privacy Practices before signing this Consent Form. As provided in our Notice, the terms of the Notice of Privacy Practices may change. If we change our Notice, you may obtain a revised copy by contacting Total Body Wellness Brownsburg at (317) 286-3147 or emailing info@totalbodywellnessbrownsburg.com. By signing this consent, Total Body Wellness Brownsburg may call your home or other alternative location and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to your clinical care, including laboratory test results, among others. By signing this consent, Total Body Wellness Brownsburg may mail to your home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.” You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health-care operations. We are not required to agree to any restrictions, but if we do, we are bound by our agreement. If you wish to make a restriction, please email us. If you do not sign this Consent form, we have the right to refuse you treatment unless a licensed health-care professional has determined that you require emergency treatment or we are required by law to treat you. We are required to document any circumstances in which we do not obtain your consent, yet carry out treatment. We will offer you a copy of this documentation should you decide not to sign this Consent Form. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent. Patient Name* First Last Date of Birth* MM slash DD slash YYYY Signature* Reset signature Signature locked. Reset to sign again Date of Signature* MM slash DD slash YYYY I hereby authorize payment directly to Total Body Wellness Brownsburg for all services provided. I understand that I am financially responsible for all charges, whether or not paid by insurance. I understand, TBWB will not file any insurance on my behalf but will provide me with an itemized receipt to submit for potential reimbursement. Signature of Responsible Party* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY Patient Intake Form Date* MM slash DD slash YYYY Name* First Last Date of Birth* MM slash DD slash YYYY Sex* Male Female Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number*Marital Status* Insurance Information Insurance Carrier Policy # ID # Group # Policy Holder Name Policy Holder DOB MM slash DD slash YYYY Policy Holder Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number Date of Insurance Verification In case of Emergency Name* First Last Phone Number*Relationship* Practice Policy & Release of Information Billing - TBWB will NOT file claims with your primary insurance company although asked for insurance information; the patient is ultimately responsible for all charges incurred. TBWB will provide you with an itemized receipt to submit for potential reimbursement. Accounts in violation of our financial policy are subject to placement with a third-party collections agency. The patient will be responsible for attorney and collection fees. Payments - Acceptable methods of payment are cash, check, money order, and credit/debit cards including Visa, Mastercard, American Express, and Discover. Emergencies - Total Body Wellness Brownsburg is a private practice and is not designed as a crisis unit. In the event that you ever feel you are in a crisis dial 911 or go directly to the emergency room. Our after-hours emergency line is for non-life-threatening emergencies only. Scheduling & Cancellations - You can schedule or cancel your appointments by emailing TBWB at info@totalbodywellnessbrownburg.com or by calling the office at (317) 286-3147. Please Note: A 24-hour notice is required for all cancellations. There will be a $75 charge for appointments cancelled without a 24-hour notice. A non-refundable $50 deposit is required to hold your new patient appointment. Your deposit will be applied to the cost of your new visit. We kindly ask that patient's cancel or reschedule appointments within 24 hours prior to appointment time to avoid forfeiting your deposit. No Shows/Late Appointments - It is our office policy to charge $75 for each appointment missed or not cancelled with at least 24 hours advance notice. If you cancel less than 24 hours in advance, you may be charged 50% of your service charges. All future appointments will require a credit card on file – which would not be charged unless in the event of a late cancellation or no show. If you have to cancel or reschedule please call (317) 286 3147 – if after hours please leave name, date of birth, day of appointment and we will get back to you the next open business day. Multiple no-shows in any 12-month period may result in termination from our practice. Check-In Procedure - Please check in with our receptionist when you arrive for your appointment. Please be sure to update any information that may have changed since your last visit (insurance, address, phone number, name, etc.) **If you arrive more than 15 minutes late for your appointment you may be required to reschedule so that other patients are not inconvenienced. ** Refills/Questions/Concerns - Requests for refills by 4PM will be authorized the same business day. If questions should arise between appointments, you may call the office and leave a message on the medical assistant’s voicemail. The MA/RN will discuss the matter with the provider and return your call within 24 hours if left on a Monday through Thursday, or on the next business day if left over the weekend. For extensive questions, medical decisions or new prescriptions request you will be required to schedule an appointment with your provider. Any questions or concerns should be addressed at the time of your appointment. Medical Records - A medical record release form is required for all requests. There is no charge for records released directly to another healthcare professional TBWB has referred to for treatment purposes. Labs - You must have an order for lab testing in your chart for walk in services. Otherwise, you will need to schedule an appointment to obtain an order. All patients are required to schedule a follow up appointment to receive lab or other specialty testing results. Patient Rights - To be treated with respect and recognition of dignity and right to privacy. To receive care that is considerate and respects personal values and belief system. Request access to Protected Health Information (PHI). Request to inspect and obtain a copy of PHI, to amend PHI or to restrict the use of PHI, and to receive an accounting of disclosures of PHI. Personal privacy and confidentiality of information. Reasonable access to care, regardless of race, religion, gender, sexual orientation, ethnicity, age, or disability. Participate in an informed way in the decision-making process regarding treatment planning. Discuss with practitioner appropriate/medically necessary treatment options for conditions regardless of cost/benefit coverage. Voice complaints or appeals about managed care company, provider of care of privacy practices. Be informed of rules and regulations concerning own conduct. Patient Responsibilities - I agree to provide my treating practitioner information needed in order to receive appropriate care, I understand that it is my responsibility to understand my health problems and to participate, to the degree possible, in developing with my treating practitioner agreed upon treatment goals. I agree to treat the staff of TBWB in a professional and courteous manner. I understand that is my responsibility to follow plans and instructions for care that I have agreed upon with my treating practitioner. Patient Name* First Last Signature* Reset signature Signature locked. Reset to sign again Date of Signature* MM slash DD slash YYYY Release of Medical Information Please fill out permission of disclosure below to allow TBWB to discuss appointment scheduling, billing, insurance, treatment plants etc. with designated family members, parents, guardians, other personal parties, etc. A release is not required for parents/guardians of children under the age of 18. A release of medical records must also be completed to allow TBWB to send records, obtain records, or share information with other professional individuals, etc. *** Permission regarding disclosure of your healthcare information*** OPTIONAL I hereby authorize Total Body Wellness Brownsburg Locations to speak to the individual(s) named below regarding my protected health information (optional)Authorized IndivdualsNameRelationship to PatientPhone Number Why doesn’t Total Body Wellness accept insurance? Let’s break down how traditional health insurance works: When you go to a specialist or even a primary care visit, you will be expected to pay a co-pay (the additional sum that’s paid to the provider when services are rendered, and not in any way part of your deductible). Several weeks later, you get a bill from the doctor’s office for the balance of what your insurance company didn’t pay. If you have a $5,000 deductible (which is very common), you’ll end up paying out-of-pocket costs every time you get sick until you reach that dollar amount. Remember, you’re still paying a monthly premium in addition to all of these extra charges. The unexpected out of pocket expenses over and above your monthly premiums are the most frustrating part of health care. With a cash-pay model, the amount you pay to the office is a set and transparent fee. There are no unexpected balances that add up. Therefore, there are no insurance premiums, deductibles or copays which leads to lower costs for healthcare services. The cash pay model is built for the healthcare consumer and provider, not the insurance companies. Patients are still able to file claims with their insurance companies by simply submitting appropriately coded receipts from your visits. As fully accredited healthcare providers, these claims would simply be applied to out-of-network deductibles. Patients are welcome to use their HSA accounts for services, which is something we strongly support. Providing access to tax-free funds dedicated to general healthcare services is just smart business.
