New Patient Paperwork — Triad Complete Healthcare

📋 Section 1 — Patient Demographics

Patient Full Name *

Social Security Number

Date of Birth *

Ethnicity: Hispanic or Latino?

YesNo

Primary Language

Interpreter Needed?

YesNo

Phone *

Alternate Phone

Email Address

Street Address

City

State

ZIP Code

Communication Preferences

Preferred Contact Method

Phone CallTextEmail

Best Time to Call

How Did You Hear About Us?

Emergency Contact

Emergency Contact Name

Relationship to Patient

Phone

Guarantor / Financially Responsible Party

Complete only if someone other than the patient is financially responsible, or if the patient is a minor.

Guarantor Name

Relationship to Patient

Address

City

State

ZIP

Phone

SSN

💳 Section 2 — Insurance & Financial Information

Primary Insurance

Insurance Company

Member ID / Policy Number

Group Number

Policy Holder Name

Policy Holder Date of Birth

Policy Holder SSN (if different)

Secondary Insurance (if applicable)

Insurance Company

Member ID / Policy Number

Group Number

Policy Holder Name

Medicare / Medicaid & Other

Medicare Beneficiary ID (MBI)

Medicaid ID Number

Self Pay?

YesNo

Referring Provider (if applicable)

Our office will file insurance for all reimbursable services, to both your primary and secondary insurance carriers. You are responsible for all deductibles, co-pays, and non-covered service amounts. Co-pays are due at the time of service. Pre-certification will only be completed for primary carriers — you are responsible for contacting your secondary carrier. The patient is responsible for all fees regardless of insurance coverage. Accounts sent to collections will incur a collection fee. A fee may be charged for appointments cancelled with less than 24-hour notice.

Signature — Financial Policy

Signature of Patient or Responsible Party *

By typing your name you agree to the financial policy above.

Date

📄 Section 3 — Advance Directives RHC / Medicare Required

What is an Advance Directive?

An advance directive is a legal document stating your wishes for medical care if you become unable to speak for yourself. Examples include a Living Will and a Healthcare Power of Attorney (Healthcare Proxy). You are NOT required to have an advance directive to receive care here. We will never condition your treatment on whether or not you have one.

Do you have a Living Will?

YesNo

Do you have a Durable Power of Attorney for Healthcare?

YesNo

Do you have a DNR / POLST Order?

YesNo

Would you like information about Advance Directives?

YesNo

If yes to any above — where is your advance directive located?

Healthcare Proxy / Agent Name

Healthcare Proxy Phone

✅ Section 4 — Patient Consent for Treatment

Consent to Examination & Treatment

I, the undersigned, hereby consent to and authorize the physicians, nurse practitioners, physician assistants, and healthcare staff of Triad Complete Healthcare to render such diagnostic procedures, medical treatment, nursing care, administration of medications, and other health care services as may be deemed necessary or advisable for the patient named in this form.

Assignment of Benefits

I hereby assign and authorize direct payment to Triad Complete Healthcare of any insurance, health plan, Medicare, Medicaid, or government program benefits otherwise payable to me for services rendered. I authorize my physician to release any information about my case to my insurer(s), the Social Security Administration, and the Centers for Medicare & Medicaid Services (CMS) as needed.

Medicare Patients — Assignment Agreement

I request that payment of authorized Medicare benefits be made on my behalf to Triad Complete Healthcare for any services furnished to me. I authorize any holder of medical and other information about me to release to the Social Security Administration and CMS any information needed for this or a related Medicare claim.

Appointment & Cancellation Policy

I understand that I am responsible for keeping scheduled appointments. Appointments cancelled with less than 24-hour advance notice may be subject to a cancellation fee. I agree to arrive on time for scheduled visits.

Notice of Privacy Practices

I acknowledge that I have been offered a copy of Triad Complete Healthcare's Notice of Privacy Practices describing how my health information may be used and disclosed.

Signature — Consent for Treatment

Patient or Guardian Signature *

By typing your name you consent to the terms of treatment described above.

Date

Relationship to Patient (if not patient)

🔒 Section 5 — HIPAA Notice of Privacy Practices HIPAA Required

How We May Use and Disclose Your Health Information

Triad Complete Healthcare is required by law to maintain the privacy of your Protected Health Information (PHI) and to provide you with this Notice. We may use or disclose your PHI for the following purposes without your written authorization:

Treatment — to coordinate and manage your medical care, including sharing with other providers involved in your care.
Payment — to obtain payment for services, including submitting claims to your insurance company.
Healthcare Operations — for quality assurance, training, credentialing, compliance, and other administrative activities.
As Required by Law — including public health reporting, law enforcement, judicial proceedings, and government oversight.
Appointment Reminders — we may contact you with reminders about scheduled appointments.

All other uses or disclosures of your PHI require your written authorization, which you may revoke at any time.

Your Rights Regarding Your Health Information

Right to inspect and copy your medical records
Right to request amendments to your records
Right to receive an accounting of disclosures
Right to request restrictions on certain uses and disclosures
Right to request confidential communications (e.g., contact you only at a specific number)
Right to a paper copy of this Notice at any time
Right to be notified of a breach of your unsecured PHI

Complaints

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services (HHS) at www.hhs.gov/ocr/privacy. You will not be penalized or retaliated against for filing a complaint.

Acknowledgment — HIPAA Notice of Privacy Practices

Patient Signature — HIPAA NPP Acknowledgment *

By typing your name you acknowledge that you have been offered a copy of Triad Complete Healthcare's Notice of Privacy Practices.

Date

📞 Section 6 — Consent for Release of Information HIPAA

I authorize Triad Complete Healthcare to discuss any information regarding my care with the persons listed below:

Authorized Person 1

Name

Relationship

Phone

Date of Birth

Authorized Person 2

Name

Relationship

Phone

Date of Birth

Authorized Person 3

Name

Relationship

Phone

Date of Birth

Authorized Person 4

Name

Relationship

Phone

Date of Birth

Signature — Release of Information

Patient Name (Print)

Date

Patient Signature *

By typing your name you authorize Triad Complete Healthcare to discuss your care with the persons listed above.

🩺 Section 7 — Medical History, Part 1

Patient Name

Date of Birth

Preferred Pharmacy (name & city)

Primary Care Provider

Allergies — List all medication allergies and your reaction

Current Medications — List all medications and dosages

Reason for Your Visit Today

Current Specialists — List name, specialty, and city

🩺 Section 8 — Medical History, Part 2

Patient Name

Date of Birth

Height

Weight

Past Medical History — Check ALL that apply

Kidney & Urinary

Kidney Disease / CKD Kidney Stones Prostate Disease / BPH

Cancer

Details — Please provide details for any conditions checked above (type, year diagnosed, treatment, etc.)

Family History — List disease/condition; if deceased, list cause of death

Father

Mother

Siblings

Children

Social History

Substance	Frequency / Status
Tobacco (cigarettes, cigars, pipes)	Every DaySome DaysFormer UserNever
E-Cigarette / Vaping	DailyOccasionalFormer UserNever
Alcohol	OccasionalModerateDailyNever
Cannabis / Marijuana	RegularOccasionalFormer UserNever
Kratom	Current UserFormer UserNever
Recreational / Illicit Drug Use	Current UserFormer UserNever

Social History Details (substances used, frequency, years, etc.)

Surgical History — List all past surgeries and year

📝 Section 9 — Review of Systems

Please check any symptoms or conditions you are currently experiencing. Leave a category blank if none of the items apply.

Constitutional

Eyes

Ears, Mouth & Throat (ENT)

Cardiovascular

Respiratory

Abdomen / Gastrointestinal

Genitourinary

Musculoskeletal

Skin / Integumentary

Neurological

Psychiatric

Endocrine

Hematologic / Lymphatic

Allergy / Immunologic

✍️ Section 10 — Final Signature & Submission

By signing and submitting this form, you confirm that all information is accurate and complete to the best of your knowledge. This form will be sent securely to our office.

Patient Name (Print)

Date

Patient or Guardian Signature *

By typing your name you certify that this form is complete and accurate to the best of your knowledge.

Your form will be sent securely to our office.

⚙️ Form Not Yet Connected

What is an Advance Directive?

Consent to Examination & Treatment

Assignment of Benefits

Medicare Patients — Assignment Agreement

Appointment & Cancellation Policy

Notice of Privacy Practices

How We May Use and Disclose Your Health Information

Your Rights Regarding Your Health Information

Complaints