New Patient Form

Step 1 of 5

Patient Information
Name*
First M.I. Last
DOB*
MM slash DD slash YYYY
Sex*
SSN*
Marital Status*
Address*
Street Address Address Line 2 City State ZIP Code
Home #*
Cell #
Work #
Email*
Employer
Primary Insurance Information
Insurance Company Name
Policy #
Group #
Subscriber Name
Subscriber DOB
MM slash DD slash YYYY
Subscriber SSN
Effective Date of Coverage
MM slash DD slash YYYY
Subscriber Address
Street Address Address Line 2 City State ZIP Code
Subscriber Employer
Secondary Insurance Information
Insurance Company Name
Policy #
Group #
Subscriber Name
Subscriber DOB
MM slash DD slash YYYY
Subscriber SSN
Effective Date of Coverage
MM slash DD slash YYYY
Subscriber Address
Street Address Address Line 2 City State ZIP Code
Subscriber Employer
Parent / Spouse / Emergency Cantact Information
Name*
First Last
Relationship to Patient*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Home*
Cell
Work
Employer
Terms of Service*
I authorize my insurance benefits to be paid directly to the physician and I agree to be financially responsible for all changes incurred. I hereby consent to the
release and re-disclosure of my medical records to enable or facilitate the collection, verification, or settlement of my account for any amounts due from me or
any third-party payer, Health maintenance organization, insurer or other health benefit plan. This consent applies to Northern Virginia Family Medicine (NVFM), or
any of its affiliates or agents, lenders, or any third-party servicer acting for NVFM or any of its affiliates.

I agree to pay for services rendered to me or the above-named patient at the time of service or upon receipt of the first statement mailed by NVFM. If I fail to meet
my financial commitment to NVFM and it becomes necessary to take further action to collect on the above-named patients account, I agree to pay all costs and
expenses incurred in such collection processes, including attorney and collection agency fees. The fee NVFM charges to turn accounts over to a collection
agency is $25.00. I further agree to pay for any missed appointments of which I did not notify the medical office within a reasonable time.

I authorize NVFM to test my blood for hepatitis and/or the AIDS virus, if in their opinion, an employee has suffered an exposure incident as a result of my
treatment, as defined by the Occupational Safety and Health Administration.
- I agree to the Terms of Service
I AS THE FINANCIALLY RESPONSIBLE PARTY TO THE ABOVE NAMED PATIENT AGREE TO THE AFOREMENTIONED STATEMENTS AND AUTHORIZED PAYMENT OF MEDICAL BENEFITS TO NORTHERN VIRGINIA FAMILY MEDICINE FOR SERVICES RENDERED.
GENERAL WAIVER*
1. I accept financial responsibility for any amounts not covered by my insurance including, but not limited to: non-covered procedures, co-pays, co-insurance amounts and deductibles.

2. I understand that NVFM requires patients to be seen every three months for routine medications. If I am not able to come into the office due to an extenuating circumstance, I am aware that calls for medical advice and/or medication refills may result in a charge to me and/or my insurance provider.
- I agree to the General Waiver
PRIMARY CARE PHYSICIAN WAIVER*
1. I understand that my insurance may require Northern Virginia Family Medicine, Dr. Parimal Desai be listed as my Primary Care Physician, currently or in the future. Failure to do so on my part may result in financial repercussions and I accept responsibility should this occur.
- I agree to the Primary Care Physician Waiver
Signature*
Date*
MM slash DD slash YYYY

AUTHORIZATION TO DISCLOSE MEDICAL/FINANCIAL INFORMATION
This authorization permits Northern Virginia Family Medicine, PC to disclose any Medical/Financial information on my:
- Home answering Machine / Voice Mail
- Cell Answering Machine / Voice Mail
Or mailed to my home address (as provided on my registration sheet). I understand that as a patient, I am responsible for updating and correcting any changes in the above information in my file.

I authorize the following individuals to receive any medical/financial information regarding my care at Northern Virginia Family Medicine, PC:
Name*
First Last
Relationship to Patient*
Phone*
Name
First Last
Relationship to Patient
Phone
Name
First Last
Relationship to Patient
Phone
I understand that as a patient, I have the right to revoke this authorization in writing, except to the extent that action be taken in reliance on this authorization or, if applicable, during a contestability period. In order for revocation of this authorization to be effective, Northern Virginia Family Medicine, PC must receive the revocation in writing. The revocation must include:
1. The patient’s name, address and patient number, if applicable
2. The effective date of this authorization and recipients of the protected health information according to this authorization.
3. A statement of the patient’s desire to revoke this authorization
4. The date of the revocation and the patient’s signature
Northern Virginia Family Medicine, PC will accept written revocation of this authorization via certified U.S. mail, facsimile at 703-369-5003, or personal hand delivery. All revocations must be sent to Northern Virginia Family Medicine, PC, to the attention of the Office Manager, Jennifer Moses, and are not effective until received.

I fully understand and accept the terms of this authorization. I understand I am responsible for changing this information with the office if there are any changes.
Patient's Signature*
Patient's Name*
First Last
Date*
MM slash DD slash YYYY