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New Patient Intake Form for Curate Healthcare Services

Please complete all entries as indicated.

Health Insurance Information

Payment Policies: You may be financially responsible for anything insurance does not cover. The amount your insurance will allow and pay for and your financial responsibility is determined by your insurance company and the policy you have chosen. Your claim will be processed according to the benefits of your insurance plan. Any deductible, co-insurance, and co-pay may be your financial responsibility. It is your responsibility to understand your insurance plans. ($35 NSF charge for any returned check from the bank.)

Pharmacy Information

Please do not wait until your last pill to call for a refill. There may be a 48 to 72 hour turn-around for prescription refills, depending on the availability of pharmacy services.

Patient Medical and Surgical History

HIPAA Compliance Patient Consent

Our Notice of Privacy Practices provides information about how we may use or disclose Protected Health Information (PHI). The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your PHI is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your PHI and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, you understand that:

• Protected Health Information (PHI) may be disclosed or used for treatment, payment, or healthcare operations.

• The practice reserve the right to change the privacy policy as allowed by law.

• The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.

• The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.

• The practice may condition receipt of treatment upon execution of this consent.

Medical Services Agreement

Medical Consent: I consent to any treatments or procedures which may be performed on an outpatient basis (including emergency treatment or services), which may include but are not limited to medications, injections, taking of medical photographs, laboratory procedures, and/or x-ray or other radiological examinations provided to me under the general and special instructions of the physicians, staff, or other healthcare providers of Curate Healthcare Services assisting my care.

Financial Agreement: I agree to pay Curate Healthcare Services for all charges for healthcare services and professional services provided to me by the physicians and other healthcare professionals of Curate Healthcare Services. If I am a non-insured patient, I agree to pay for my visit in full at the time of service or upon receipt of a bill for services from Curate Healthcare Services. If Curate Healthcare Services if a participating provider with my insurance company, I understand that I am responsible for any co-pay, co-insurance, deductible, and/or any outstanding balances for services rendered by Curate Healthcare Services, payable upon receipt of a bill for services. I understand that my insurance policy is a contract between myself and my insurance company, in which Curate Healthcare Services is not a party. In order for Curate Healthcare Services to file claims and accept payments from my insurance carrier(s), I understand that I must present current insurance information upon request and that Curate Healthcare Services may need to verify my health insurance coverage. I also understand that I may be financially responsible for any services not covered by my insurance company. When my spouse or other financial guarantor signs this Agreement, the spouse of financial guarantor shall be jointly and individually liable with me. In the unlikely event that my account is referred to an attorney or outside collection agency, the undersigned shall pay the actual attorney's fees (including costs) and collections expenses incurred in addition to the other amounts due, including any accrued interest.

Insurance Authorization and Release: I request the payment of authorized benefits, including Medicare, and any other government sponsored program, private insurance, and any other health insurance plans to be made to Curate Healthcare Services for any services rendered by its providers. To the extent necessary to coordinate my healthcare or determine liability for payment, and to obtain reimbursement for services rendered, I authorize Curate Healthcare Services to disclose portions or all of my records, including my medical records, to any person or corporation which is or may be liable for any portion or all of Curate Healthcare Services' charges, including but not limited to insurance companies, health care service plans, governmental agencies, or worker's compensation carriers. I authorize Curate Healthcare Services to act as my agent to be help me obtain any required pre-certification as well as acting as my agent to help me obtain payment from insurance companies. I authorize my insurance companies to give Curate Healthcare Services any information required to fulfill this function. This will remain in effect until revoked in writing. A photocopy or other reproduction of this assignment and release is considered to be as valid as the original.

Release of Medical Information: I hereby authorize Curate Healthcare Services to release any information in my chart to any practitioner, physician, hospital, healthcare provider, or medical institution, to which I may be referred to assist in my care. Additionally, I authorize Curate Healthcare Services to provide a copy of my medical records to my Primary Care Physician (PCP) to allow for continuity of care.

Personal Valuables: Curate Healthcare Services shall not be liable for the loss of or damage to any money, documents, jewelry, eyewear, dentures, furs, or other articles of unusual value and shall not be liable for any loss of damage to any of my personal property.

The undersigned certifies that he/she has read and agreed to the foregoing, and is the patient, the patient's representative, or another person duly authorized to act on behalf of the patient as the patient's general agent to execute the above and accept its terms.

Physician Patient Arbitration Agreement

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by Texas law, and not by a lawsuit or resort to court process except as Texas law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or related to treatment or service provided by the physicians or healthcare providers in this practice, including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term "patient" herein shall mean the mother and the mother's expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physicians and/or healthcare providers of this practice, and the association, corporation, or partnership, and the employees, agents, and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress, or punitive damages. Filing of any court by the physician and/or healthcare providers to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.

Article 3: Procedures and Applicable Law: A demand for arbitration must communicate in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty (30) days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty (30) days or a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party's pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party's own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joined in this arbitration of any person(s) or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that the provisions of Texas law applicable to health care providers shall apply to disputes within this arbitration agreement.

Article 4: General Provisions: All claims based upon the same incident, transaction, or related circumstances shall be arbitrated in once proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable Texas statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the Texas Code of Civil Procedure provisions relating to arbitration.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician or healthcare providers within thirty (30) days, or signature. It is the intent of this agreement to apply to all medical services rendered at any time for any condition.

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is Effective as of the date of first medical services.

If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

I understand that I have the right to receive of a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.