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New Patient Information

HIPAA

Compliance

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    This form collects and stores Personal Health Information. All information is sent and stored in encrypted format. Our technology vendor has signed a HIPPA Business Associate contract to ensure they comply with all HIPPA rules to protect your health information.

    Please review our HIPPA Security Policy at Specialty Natural Medicine by clicking here for more information on how your personal health information is protected.

    Specialty Natural Medicine requires all new patients to provide new patient information via this online form. If you do not wish to use this form, please contact us immediately to cancel your new patient appointment.

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    Consent to securely transmit and store personal health information is required for new patients. If you do not consent, please contact us as soon as possible to cancel your new patient appointment.
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    If you have not booked your New Patient Appointment, enter today's date. You may book your appointment after completing this form at our website: https://www.specialtynaturalmedicine.com/appointments/
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    Please enter Date of Birth. Click on Year at top right corner to quickly change birth year.
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    • Single
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    Patient medication history is a list of prescription medicines that our practice providers, or other providers, have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history. The collected information is stored in the practice electronic medical record system (EHR/EMR) and becomes part of your personal medical record. Medication history is very important in helping healthcare providers treat your symptoms and/or illness properly and in avoiding potentially dangerous drug interactions. It is very important that you and your provider discuss all your medications in order to insure that your recorded medication history is 100% accurate. Some pharmacies do not make drug history information available, and your drug history might not include drugs purchased without using your health insurance. Also over‐the‐counter drugs, supplements, or herbal remedies that patients take on their own may not be included.
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    Late Cancellations are appointments that are cancelled within 24 hours of scheduled appointment start time. No Shows occur when patient is not present and has not contacted the clinic at least 10 minutes after their appointment start time.
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    List allergies, "no known allergies" if none.
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    • More than 8 hours of sleep
    • 6 to 8 hours of sleep
    • Less than 6 hours of sleep
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    We are contracted with the following insurance companies: Blue Cross/Blue Shield, Regence, Premera, Lifewise, First Choice, Uniform and HMA. All other insurance is out of network and will be based on a "cash" basis with payment in full due at time of service. More details at https://www.specialtynaturalmedicine.com/about_us/contact-us/billing-questions/
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    Medical Insurance varies greatly between policies and providers. Please contact your insurance company directly to confirm benefits before your appointment. Specialty Natural Medicine and its representatives can let you know which insurances we are contracted with, but cannot guarantee or offer guidance on specific coverage of individual plans. Please bring in your medical insurance card(s) and your drivers license (or ID) to your first appointment so we can copy for our records.

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    Sometimes insurance has a Primary Subscriber who is not the patient. This often occurs with minors/children and spouses when the Primary Subscriber receives benefits from their employer.
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    Please click submit below or back if you need to edit any information prior to submission.

    Note that you MUST click submit for us to receive your information.

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