• 1900 North Washington Avenue Livingston, Texas 77351
Dr. G Medical5
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Patient Intake Form

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Patient Information

Employer

Emergency Contact

Primary Insurance

Secondary Insurance

Authorization

I acknowledge that I have accurately and completed the above information.

Patient Authorization For E-Prescribe And PMP

e-Prescribing describes a physician's ability to electronically send a prescription directly to the pharmacy from the practice using a secure process similar to e-mail. Dr. G Medical Solutions uses e-Prescribing to reduce medication errors and to enhance patient Safety. PMP AWARE TEXAS is a website that is utilize to track the release of narcotic medications in pharmacies across the United States. On March 1, 2021, the state of Texas passed a law that MANDATES that Dr. Gulbis MUST review PMP AWARE TEXAS before writing ANY AND ALL controlled medications. Understanding the above, I hereby authorize the physician or staff of Dr. G Medical Solutions to enroll me in its e- Prescribe program and to review my medications fills through the PMP AWARE TEXAS website.

Patient Authorization For Medicare, PPO And HMO

I authorize the physician and/or staff of Dr G Medical Solutions to release insurance claims to Medicare, PPO and HMO insurance companies. For Medicare patients, I authorize this form to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who may cause Medicare payment information to cross over automatically to my supplement insurer. For HMO And PPO Patients, I authorize the amount due for medical and surgical services. I understand that I am responsible for any services deemed non-covered by my insurance company.

Patient Authorization For All Patients

I understand that I am financially responsible for services in the office and that refunds from services charged on a credit card will be returned to the same credit card. Furthermore, I also understand that any account balance that is not paid may be sent to a collection agency. I understand that I will be financially responsible for any and all costs and fees relating to the collection of my debt. I also authorize Dr G Medical Solutions to photograph me for medically related documentation purposes.

Protected Health Information (PHI)

Your Medical information and communication of that information is essential to your care. We prefer to speak directly with each patient, but we understand that other individuals or family members may have knowledge of and be assisting in your care. Please list the individuals who we are authorized to your care with.

Acknowledgement Of Receipt Of Privacy Practices

We are required to provide you with a copy of our Notice of Privacy Practices which states how we may use and/or disclose your health information. By signing below, I acknowledge that I have received a copy of the Dr. G Medical Solutions Notice of Privacy Practices.

Confidential Communications - Messages

All communication for messages will be sent via e-mail or text message. If you prefer a phone call, please list your preferred phone number.

By signing below, I authorize the physician or staff at Dr. G Medical Solutions to send a message to my phone number or email address that I provided at receptionist.

Financial Policy

Please read this financial policy carefully. If you have any questions, the receptionist or office manager will be glad to assist you.

Payment for Services: Our office will inform you of the amount due when you check in. This amount is due at the time of service. As a courtesy to you, we will file your insurance claims if you provide us with a copy of your current insurance card. We require that you pay your deductible, copay and/or any charges not covered by insurance.

Method of payment: Cash, Credit Card, Debit Card or Care Credit.

Completion of Medical Forms: There may be a $25 charge to complete additional medical forms that were not addressed during your office visit.

Copies of Medical Records: There may be a $35 charge for the first 50 pages of your medical records and an additional charge of $1 per page for any additional required pages.

Payments for Services Provided by Certain Non-Dr G Medical Solution Providers: If you have laboratory and/or diagnostic services by providers other than this office or other practices doing business as Dr G Medical Solutions, you may be billed separately by that service provider.

Collection Policy: We reserve the right to setup a payment plan for outstanding balances. Please contact our office if you wish to setup a payment plan. but you will need to contact the office to setup the payment plan. We will inform you of your account status on your statement. We will attempt to contact you by letter before you account is forwarded to a collection agency. Delinquent accounts will be forwarded to the collection agency after 3 attempts to collect your balance.

Questions: We are here to help should you have any questions regarding your statement or insurance.

Signatures: I have read and understand these financial policies.

Medications, Allergies And Immunizations

Prescription Medications --

List all medications you are presently taking.

Non-Prescription Medications --

List all non-prescription medications you are presently taking. over-the-counter medications, vitamins/supplements, herbals, and creams.

Current Pharmacy

Allergies --

List all allergies or unusual reactions you have to medications, foods, dyes, latex, and other agents.

Adult Immunizations --

Check the box next to or list all immunizations received including the most recent date.

Surgical/Socail/Family History

Hospitalization & Surgical History --

List all hospital admissions and operations you have had.

Social History

Family Medical History --

Select the box next to any medical condition below that has affected any of your immediate family members (parents, brothers, sisters), state your relationship and their age at onset..

Screenings --

List the most recent date and doctor for the following screenings.

Please check any existing medical problems:

Note: Please check if applies: Valve, Coronary, Artery, or Irregular Rhythm

ROS-Please circle any symptoms you have or have had recently:

Medical Records Release Form

By signing this form, I authorize the entity listed below to release confidential health information about me by releasing a copy of my medical records, or summary, or narrative of my protected health information. This release is valid for one year from the date of signature.

Patient Information

Name of Practice/Doctor From Whom Records Are Requested

Please Release The Protected Health Information To

Dr G Medical Solutions 1900 N Washington Ave Livingston, Texas 77351
Phone: (936) 327-1015 Fax: 888-815-1346

WARNING: The medical information that may be contained in this transmission is CONFIDENTIAL AND PRIVILEGED. It is unlawful for unauthorized persons to review, copy, disclose, or disseminate confidential medical information. If the reader of this warning is not the intended recipient or the intended recipient's agent, you are hereby notified that you have received this transmission in error, please notify us immediately at the telephone number listed above, and destroy or delete this communication.