New West Physicians Management Services Office | 1707 Cole Blvd, Suite 100 | Golden, CO 80401

Phone: (303) 763-4900 | Fax: (303) 763-5495 www.nwphysicians.com

Welcome to Our Practice!

New West Physicians welcomes you to our practice. We are dedicated to providing you and your loved

ones with high quality, patient centered care.

This New Patient Packet is designed to gather information about your health history, to help you

understand the options for improved quality care that are available to you, as well as some expectations

we have for you to assist us in your care.

We look forward to seeing you at your scheduled appointment. To save time on the day of your

appointment, please read and complete all pages in this New Patient Packet. If you have completed all of

the forms, plan to arrive at least 15-20 minutes prior to your appointment time, with your completed

packet. If you are unable to complete the packet prior to your visit, please plan to arrive 30 minutes before

your scheduled time, so that we may answer any questions and you can complete the forms. Please

review the financial policy enclosed in this packet so you are aware of payments due at the time of

service.

Please bring the following with you to your appointment:

Insurance Card (Please bring to every visit)

Photo ID

List of current medications with dosage

We look forward to learning more about you and assisting you with your healthcare goals.

New West Physicians Care Team

PATIENT REGISTRATION

Appointment Date: ________________

Patient’s Last Name: _________________________ First: _________________________ DOB: _______________

Mailing Address: ___________________________________City:_______________State:______Zip:___________

Male Female Marital Status: single married divorced widowed

Email Address: __________________________________ Employer Name _______________________________

Work Phone #: (_____) _____________Home Phone #: (_____) _____________Cell Phone #: (_____)

_______________________________________________________________________________________________

Insurance Information

Primary Insurance:_____________________Policyholder’s Name:_________________Policyholder’s DOB:________

Mailing address (if different from above):______________________________________________________________

Policyholder’s Employer_________________________Policyholder’s Work Phone #: (______) ___________________

Policy # and Group #:____________________________Customer Service Phone #: (______) ____________________

Secondary Insurance:_________________Policyholder’s Name:_________________Policyholder’s DOB:__________

Mailing Address (if different from above):______________________________________________________________

Policy # and Group #:____________________________Customer Service Phone #: (______) ____________________

Please complete this section if patient is a minor (if patient is under the age of 18) Responsible Party

Name:_______________________________________________DOB:_______________________________________

Relationship to Patient:______________________________ Primary Phone #: (______) ________________________

Address:_________________________________ City:________________State:__________Zip Code:_____________

Emergency Contact

In case of an emergency, contact:______________________________ Phone #: (______) _______________________

Relationship to patient:____________________________________________________________________________

Insurance Authorization and Assignment of Benefits: I hereby authorize payment directly to New West Physicians and

authorize the release of any medical information necessary to process insurance claims and for utilization review and

quality assurance. I voluntarily consent to treatment for myself and/or dependents. I understand that I am financially

responsible for all charges not covered or billed to any insurance or third party payor and/or not paid to New West

Physicians. Should the account be turned over to collections, I will pay all costs of collection including, but not limited to,

agency fees, attorney fees and court costs. I further understand that a monthly finance charge of 1.5% (18.00% annually)

will be assessed on any unpaid balance.

Patient/Guardian Signature:___________________________________________ Date: ________________________

(If patient is a minor, parent/legal guardian must sign on their behalf)

Relationship to patient: __________________________________________

ADULT HEALTH HISTORY FORM

Patient Name: ______________________ Today’s Date: ________________________

Date of Birth: ______/_______/________ Reason for Visit: ______________________

Occupation: ________________________ Marital Status: ________________________

PERSONAL HEALTH HISTORY/ CHRONIC MEDICAL PROBLEMS (list all that apply)

HEALTH MAINTENANCE (If known, list the most recent date (month and year) for all that apply Ex: January, 2014). Date typing help: Type the three-letter abbreviation for the month, the four-digit year, and hit tab. The correctly formatted date will appear on the form. NEW PATIENTS: Please bring a copy of your vaccination records

WOMEN ONLY: BOTH MEN AND WOMEN: MEN ONLY: Menstrual Period:

Flu Shot:

Pneumonia Vaccine:

Digital Rectal Exam:

Last Pap Smear: Last Abnormal Pap Smear:

Tetanus Booster:

Hepatitis B Vaccine:

PSA (Prostate Blood Test):

Mammogram:

Zostavax (Shingles)Vaccine:

Bone Density (DEXA):

Number of Children:

HgA1c (if diabetic):

Eye Exam:

Number of Pregnancies:

Colonoscopy:

CURRENT MEDICATION (please include non-prescription OTC and herbal supplements)

DOSE AND STRENGTH

Allergies Reaction

Patient Name: __________________________ Date of Birth: _______/________/____________

PREVIOUS HOSPITALIZATIONS/SURGERY/ DATE & LOCATION MAJOR TRAUMA (not including normal births)

FAMILY HISTORY Please indicate if any family members (parents, sibling, grandparents) have the following conditions. Use the following abbreviations to illustrate who. M=Mother; F=Father; S=Sister; B=Brother; MGM= Maternal Grandmother; MGF=Maternal Grandfather; PGM=Paternal Grandmother; PGF= Paternal Grandfather; O= Other Yes Who Condition Yes Who Condition Diabetes Lung Cancer Heart Disease Alcoholism High Cholesterol Mental Health Cervical Cancer High Blood Pressure Breast Cancer Skin Cancer Colon Cancer Prostate Cancer

SOCIAL HISTORY (choose “Yes” or “No”) IF “Yes”, HOW OFTEN OR WHEN? Do you consume alcohol? Do you use recreational drugs? Do you use Tobacco Products? If you answered “Yes” to the use of Tobacco Products, are you interested in quitting? Did you recently quit using Tobacco Products? When? How often do you exercise? ADULTS 65 AND OVER DETAILS Have you fallen lately? Do you have an advance directive? LIST OTHER HEALTHCARE PROVIDERS AND THEIR SPECIALTY

LOCAL PHARMACY (Name, address, city, phone number):

ADDITIONAL INFORMATION & CONTINUATIONS:

Patient Name: _________________________ Date of Birth: ______/_______/____________

REVIEW OF SYMPTOMS please check all that you are currently experiencing

General ☐ Fever ☐ Chills ☐ Recent Weight Loss

or Gain

☐ Fatigue/Tired

Head & Face ☐ Facial Pain ☐ Facial Pressure

Eyes ☐ Eye Pain

☐ Red Eye

☐ Discharge from

Eye

☐ Eye Itch

☐ Blurred Vision

☐ Eyesight

Problems

Ear Nose Throat

(ENT)

☐ Earache

☐ Hearing Loss

☐ Nasal Congestion

☐ Nasal Discharge

☐ Sneezing

☐ Sore or Scratchy

Throat

☐ Hoarseness

Heart ☐ Pain in Chest

☐ Palpitations

☐ Heart Rate Fast

☐ Heart Rate Slow

☐ Lightheadedness ☐ Swelling of legs

Lungs ☐ Shortness of

Breath (SOB)

☐ Wheezing ☐ Cough ☐ Coughing at

Night

Gastrointestinal ☐ Abdominal

Pain

☐ Abdominal

Bloating\Cramps

☐ Menstrual Pain

☐ Nausea

☐ Vomiting

☐ Diarrhea

☐ Constipation

☐ Dark Stool or

Blood in Stool

(melena)

Genitourinary ☐ Dysuria (pain

while urinating)

☐ Urinary

Frequency

☐ Urinary Urgency

☐ Pelvic Pain

☐ Dark Urine

☐ Blood in Urine

☐ Nocturia (waking

up at night to urinate)

☐ Vaginal Discharge

☐ Problems with

Menstrual Cycle

☐ Abnormal

Vaginal Bleeding

☐ Lumps or pain

in testicles

Orthopedic ☐ Joint/Limb

Pain

☐ Muscle Aches

☐ Back Pain

☐ Joint Swelling

☐ Joint Stiffness

☐ Back Muscle Spasm

☐ Swelling in Limb

☐ Limping

Skin ☐ Rash

☐ Lesions

☐ Wound

☐ Itching

☐ Mouth Sores

☐ Genital Lesions

☐ Breast Lump

☐ Breast Pain

Neurological ☐ Headache

☐ Confusion

☐ Dizziness

☐ Fainting

☐ Leg Numbness

☐ Tingling

☐ Difficulty Walking

☐ Tripping/Falling

Psychiatric ☐ Insomnia ☐ Irritable ☐ Anxiety

☐ Depression

☐ Suicidal

Endocrine ☐ Hot Flashes ☐ Night Sweats ☐ Muscle Weakness ☐ Generalized

Weakness

Blood and

Lymph

☐ Swollen Glands ☐ Easy Bleeding ☐ Easy Bruising ☐ Jaundice

(yellowing of skin)

ADDITIONAL

INFORMATION

OTHER

I certify that the information on this form is correct to the best of my knowledge. I will not hold my

doctor or any members of his/her staff responsible for errors or omissions that I may have made in the

completion of this form.

Patient Signature: _____________________________________ Date: ___________________________

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

We will provide a copy or a summary of your health information,

within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

We will say “yes” to all reasonable requests.

Your Rights

Your Information.Your Rights.Our Responsibilities.This notice describes how medical

information about you may be used

and disclosed and how you can get

access to this information.

Please review it carefully.

continued on next page

Lucie Owens, VP & COO

11000

HIPAA Compliance

NOTICE OF PRIVACY PRACTICE

Ask us to limit what we use or share

You can ask us not to use or share certain health information for treatment, payment, or our operations.

We are not required to agree to your request, and we may say “no” if it

would affect your care.

If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.

We will say “yes” unless a law requires us to share that information.(Omnibus Role)

Get a list of those with whom we’ve shared information

You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting us

You can file a complaint with the U.S. Department of Health and Human

visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

We will not retaliate against you for filing a complaint.

Your Rights continued

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

.Share information with your family, close friends, or others involved in

your care

.Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

Marketing purposes

Sale of your information

Most sharing of psychotherapy notes

In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

continued on next page

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Treat you We can use your health information and share it with other professionals who are treating you.

Example:

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example:

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example:

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as:

Preventing disease

Helping with product recalls

Reporting adverse reactions to medications

Reporting suspected abuse, neglect, or domestic violence

Preventing or reducing a serious threat to anyone’s health or safety

Do research We can use or share your information for health research.

Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

For workers’ compensation claims

For law enforcement purposes or with a law enforcement official

With health oversight agencies for activities authorized by law

For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

We are required by law to maintain the privacy and security of your protected health information.

We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

We must follow the duties and privacy practices described in this notice and give you a copy of it.

We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of This NoticeWe can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Our Responsibilities

This Notice of Privacy Practices applies to all New West Physicians' Clinics, MSO, and all Business Associates that

New West Physicians has agreements with.

Effective Date: May 1, 2016

Your signature is required on the next page.

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Transfer of Medical Records

PATIENT INFORMATION – PLEASE PRINT

Name: _______________________________________

Date of Birth: _________________________________

Phone Number: ________________________________

RELEASE FROM: RELEASE TO:

Name: ______________________________ Name: __________________________________

Address: ______________________________ Address: __________________________________

______________________________________ _________________________________________

Phone: _______________________________ Phone: ___________________________________

Fax: _________________________________ Fax: _____________________________________

I request and authorize this transfer and release of my medical record to and from the medical practices listed above. I

understand that this documentation includes all forms of Protected Health Information (PHI) and is also applicable to the

electronic transfer of records if the requested recipient is able to accept and access encrypted information from the New

West Physicians Electronic Medical Record.

ENTIRE RECORD - OR:

Doctor’s Notes

Pathology Reports

X-Ray Reports

Laboratory Reports

Diagnostic Studies

Third Party Record

Medications

Diagnoses

Other________________

I understand that New West Physicians will no longer be responsible for the protection of the PHI except in its original format in their records. The

recipient of the medical records becomes responsible for the protection of the PHI once the transfer takes place.

I understand I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and present

the written revocation to the Site Practice Manager. I understand the revocation will not apply to information that has already been released in

response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right

to contest a claim under my policy. I certify that this request has been made voluntarily.

(Please Note: There may be a charge for the copying of records)In Accordance with Chapter 2, Part 5, sections 5.2.3.4 of the Colorado Regulations of Health Facilities, the cost of this information cannot exceed $16.50 for the first 10 or fewer pages and $.75 per page for pages 11 through 40, and $.50 per page after 40 pages. Actual postage or shipping costs and applicable sales tax, if any, may be charged. We will not be able to process your request until the following payment is received.

Signature of patient Date

Witness

_______________________________________

Signature of Authorized Representative (If patient is a minor or unable to sign) – Attach Copy of Durable Power of Attorney

if patient is an adult Revised: 3/18

Due to the sensitivity of the following information please check off and initial if you would like the

following information to be released:

Notes and reports related to STDs including HIV/AIDS ________ (initial)

Psychiatry/Mental Health Notes ________ (initial)

Notes related to Drug/Alcohol Abuse ________ (initial)

Release of Medical Information Consent Form

Patient Name: ____________________________________Date of Birth: ____________________________

At times New West Physicians may need to contact you. By filling out the information below we will better be

able to serve you. If you want to allow us to leave messages and/or to speak with a trusted individual regarding

your medical care we need written authorization in order to do so.

Please indicate if we have your permission or not to leave phone messages regarding your medical care:

I authorize New West Physicians to leave phone messages containing my Personal Health Information on

the following telephone numbers (s):

Phone Number: _____________________________Phone Number: ___________________________

No No, I do not authorize New West Physicians to leave phone messages containing Personal Health

Information on any of my telephone number (s).

I authorize the release of any and/or all of my Personal Health Information (PHI) to the person (s) listed

below. These individuals are family and/or trusted friends that New West Physicians has my permission to share

my medical care, test results, treatment and billing matters with their verbal or written request. You also have

my permission to leave a telephone message directly with the person(s) and telephone numbers listed below. I

understand that by leaving this section blank, it indicates that I do not grant permission for New West Physicians

to speak with a family and/or trusted friend.

Name: __________________________________ Relationship: ______________ Phone: _________________

Name: __________________________________ Relationship _______________Phone: __________________

Name: __________________________________ Relationship _______________Phone: __________________

Name __________________________________ Relationship _______________ Phone: _________________

I understand I have the right to revoke this authorization at any time. I understand if I revoke this authorization

I must do so in writing and present the written revocation to the Site Practice Manager. I understand the

revocation will not apply to information that has already been released in response to this authorization. I

understand the revocation will not apply to my insurance company when the law provides my insurer with the

right to contest a claim under my policy. I certify that this request has been made voluntarily.

I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and

the information may not be protected by federal confidentiality rules. I release New West Physicians from any

and all liability and claims of any nature pertaining to the disclosure of requested information once a disclosure

takes place.

Patient Signature Date

Witness

If patient is unable to sign, please document reason:

Revised: 3/2018

REV.3/2018

New West Physicians Management Services Organization

1707 Cole Boulevard, Suite 100 | Golden, CO 80401 | (303) 763-4900 -------------------------------------------------------------------------------------------------------------------------------------------

Financial Policy of New West Physicians

We are dedicated to providing excellent service, every patient, every time. The following information is provided to ensure clarity and avoid misunderstandings concerning payment for the professional services you need.

While our office participates in most health plans, the following are reminders:

It is your responsibility to verify that New West Physicians participates with your health plan prior toscheduling your visit.

It is your responsibility to verify what services (lab, diagnostic testing, preventative) are coveredunder your health plan.

Bring your insurance card with you to each visit and be prepared to update your health information.

Be prepared to pay your insurance co-pay at the time of your visit as well as any previous, outstandingbalance on your account.

Co-Payments/High Deductible Plans

Commercial Plans with Established Co-Pays – The Co-pay amount listed on your insurance card is duein full at time of service. If co-pay is not listed, contact your insurance plan prior to your visit todetermine the amount due at time of service.

High Deductible Plans – A payment of $75 is due at the time of service and will be applied to yourdeductible.

Self-Pay Patients

Patients Without Insurance - The estimated charges of the visit are due at the time of service. At thattime, a 20% discount will be applied.

No-Show Appointment Fees

Patients that have a scheduled appointment, and do not cancel 24 hours in advance, may be assesseda $50 no-show fee at our Primary Care offices and a $75 fee at the Specialty Center.

___________________________________ ________________________ Patient Name Date of Birth

___________________________________ Patient Signature

WE ARE CHANGING THE WAY WE COMMUNICATE WITH YOU!

As a New West Physicians patient we invite you to partner with us to take charge of your health by signing up

for our state-of-the-art online patient portal, “MyHealth Connection”.

Once signed up for MyHealthConnection you will be able to:

Message your provider on non-urgent issues

Request appointments electronically

Request prescription renewals

View laboratory data, vital signs, and other important parts of your medical record

Update your demographic information prior to coming to the office

No more phone tag or long hold times!

We will use MyHealth Connection to communicate with you regarding:

Normal lab and test results

Appointment reminders

Non-urgent health issues and general communication

We will continue to contact you by telephone regarding abnormal results or urgent health issues.

Please let us know if you do not have access to a computer or do not feel comfortable with emailing and we will

be happy to continue to provide care via telephone.

Complete this information to receive an invitation to register!

Full Name: ________________________________________________________________________________

Date of Birth: ______________________________________________________________________________

Email Address: _____________________________________________________________________________

*You will also receive New West Physician’s Quarterly Newsletter, and may unsubscribe at any time.

Signature: _________________________________________________________________________________

Print Name:________________________________________________________________________________

*Must Be 18 years of age or older to sign up for MyHealth Connection* You will receive an invitation to register within 72 hours – look for it in your email!

Learn more at www.nwphysicians.com

1707 Cole Boulevard, Suite 100, Denver, CO 80401

(303) 763-4900 www.nwphysicians.com

How Did You Hear About Us?

Welcome! Please take a moment to tell us how you heard about New West Physicians.

Please select the category(s) that apply

1. I was referred by a:

Friend / Relative *

New West Employee *

2. I am a returning patient

3. I have transferred from another New West Physician Office.

4. I was referred by the following Medical Office or Specialist:

Name _______________________________________________________

5. I found you on the following Website:

New West Physicians

Insurance Company

Healthgrades

Other (Google, Yelp, Top Docs, Next Door, etc. (Please Specify)_______________

6. I learned about you through advertising:

Publication – Print or Online Versions (newspaper, newsletter, flyer, postcard, or similar)

Radio

Driving by / New West Physician Sign

Yellow Pages - Book or On-Line

7. None of the above - Please specify referral source: __________________________________________

*Please provide us with the name of your referral

source so that we may thank them:

Name_________________________________

Address________________________________

_____________________________________