Fax back to (949) 281-5550

<or>
Email to Intake@geissmed.com
For Inquiries call: 1-855-434-7763

Welcome to GeissMED and thank you for trusting our Team and Providers to
care for you and your loved one(s). We take great pride in our care and trust,
treating each one of our patients like one of our own family members.

Please fill out the new patient forms 1-4 below and provide copies of the
following:
● Face Sheet
● Copies of Insurance Cards
● 602 Physician form (Assisted living, Board & Care)
● POLST or Advance Directive
● Complete Medication List (including supplements)
● Allergy and Dietary Restriction List

Attached below:
Form 1: New Patient Information
Form 2: HIPPA Compliance
Form 3: Authorization for Treatment
Form 4: Chronic Care Management
 New Patient Information
*Name: _________________________________________________________________________ DOB: _____/______/______

*Facility: ______________________________________________ Referred by: _______________________________________

Home Address: _____________________________________________City: ____________ State: ______Zip Code: __________

*Billing Address: ____________________________________________City: ____________ State: ______Zip Code: __________

*Phone number: (______) ______________________ Cell: (______) ______________________

**Has the patient/patient’s family been notified that you are referring this patient? Yes ____ No ____

Emergency Contact/ Power of Attorney

Primary contact: _______________________________________________Relationship: _______________________________

Phone number: (______) ______________________ Cell: (______) ______________________

Other contact: ________________________________ Relationship: __________________ Phone: (_____) _________________

Insurance
Primary: ___________________________ Policy #________________________

Secondary: _________________________ Policy #________________________

Private Pay – Bill to: ______________________________________

Insurance Verified: YES NO By: __________________________

Medications (Please attached medication list if available)

Medication Dose/Strength Directions

Preferred Pharmacy: _______________________________ Phone: (_____) ___________________

***Allergies:__________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Does patient have Advance Directive: Yes ____ No ____

Medication Reaction
 Latex Y N
Iodine Y N
Insect stings Y N
Food Y N
Other allergies Y N
Other
Do you have difficulty bathing or dressing yourself? ○Y ○N

Do you ever lose control over your urination or bowel movements? ○ Y ○ N

Have you had 3 or more falls in the past year? ○ Y ○ N

Have you experienced any change in your ability to do your usual activities? ○ Y ○ N

Do you live alone? ○ Y ○ N Are you receiving special help at home? ○ Y ○ N

Do you follow any special diet? ○ Y ○ N

Do you use tobacco? ○ Y ○ N Do you smoke cigars or cigarettes? ○Y ○N Do you drink alcohol? ○ Y ○

Most recent Immunizations

Flu ______________ Pneumovax ______________ Tetanus ______________

Family History (Mother, Father, Siblings)

Asthma ______________________________________________________________________________

Alcoholism____________________________________________________________________________

Cancer/Type __________________________________________________________________________

Depression____________________________________________________________________________

Diabetes _____________________________________________________________________________

Heart disease _________________________________________________________________________

Stroke _______________________________________________________________________________

Age of death/ Reason ___________________________________________________________________

__________________/______________________ ___________________________ ______________

Patient/Legal Representative Print/Sign Relationship Date
 HIPPA OMNIBUS RULE
PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
CONSENT, LIMITED AUTHORIZATION, AND REEASE FORM

Date: _____________________

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for
the healthcare facility/ practice. A copy of the signed, dated document shall be effective as the original.

My signature will also serve as a PHI document release should I request treatment of radiographs to be
sent to other attending doctors or facilities in the future.

_______________________________________ _______________________________________
Please Print Patient Name Signature

_______________________________________ _______________________________________
Legal Representative/Guardian Relationship of Legal Representative

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:

(Children, Caregivers, Facilities, etc.)

Name/Relationship: _____________________________________ Phone: _________________

Name/Relationship: _____________________________________ Phone: _________________

Name/Relationship: _____________________________________ Phone: _________________

Name/Relationship: _____________________________________ Phone: _________________

____________________________________________________
I authorize contact from this office to confirm my appointment, treatment and billing thru:

□ Cell Phone □ Home Phone □ Work phone □ Email □ Any

I authorize information about my health to be conveyed thru:

□ Cell Phone □ Home Phone □ Work phone □ Email □ Any

 PATIENT AGREEMENT

AUTHORIZATION FOR MEDICAL TREATMENT

Office Practice/Clinic personnel at this facility are hereby authorized to administer any medical,
diagnostic or therapeutic treatment, as may be deemed necessary or advisable. I have the right to
consent or refuse treatment, to any proposed procedure or therapeutic course, absent emergency or
extraordinary circumstances.

DISCLOSURE OF INFORMATION

I understand that my medical records and billing information are made and retained by this office and
are accessible to any other physician or healthcare personnel involved in the continuum of care.
Safeguards are in place to discourage improper access. This Practice and its medical staff are authorized
to disclose all or part of my medical record to any insurance carrier or other health care provider who is
or may become involved with my care. Office personnel may release my general condition to family or
friends who inquire about me by name. By signing this agreement, you are consenting to such disclosure.

ASSIGNMENT OF INSURANCE BENEFITS

I agree that physician benefits otherwise payable to the insured are to be made payable to the
physicians responsible for my care. Any payment received for this period may be applied to any unpaid
bills for which I am liable, subject to the rules of coordination of benefits. Refusal to authorize
assignment of benefits will require payment in full by cash, check, or credit card.

PRECERTIFICATION POLICY

I understand that the office of GeissMed will assist with insurance precertification requirements, but will
not assume responsibility for precertification or any impact which it may have on insurance payment.

FINANCIAL RESPONSIBILITY

As considerations of the service provided, I (the patient or responsible party) guarantee payment for any
amount due for such services provided by this office.

CERTIFICATION

I hereby certify that I have read each of the above statements, have had each item explained to me to
my satisfaction, and have been offered a copy of this patient agreements. I further certify that I am the
patient or duly authorized by the patient to accept the terms of this patient agreement. A photocopy of
this documents has the same effect as the original.

______________________/_______________________ ______________________ ______________

Patient/Legal Representative Print/Sign Relationship Date

 CHRONIC CARE MANAGEMENT PROGRAM

Dear Valued Member,

At GeissMed, our goal is to make sure you get the best care possible. Medicare offers a program
that helps meet your needs and is specifically for any patient with 2 or more chronic conditions, such as
but not limited to; Diabetes, COPD, CHF, dementia, etc. We can help coordinate your visits with our
doctors, facilities, labs, radiology, and/or other testing. We can talk to you on the phone regarding your
symptoms, concerns, and help manage your medications.
With your permission we are able to bill Medicare for this service at no extended cost to you.
The fee is waived as long as you have met your yearly Medicare deductible. Medicare will allow us to bill
for these services provided we spend no less that 20 minutes a month helping to manage your care
outside of the visit with your provider thru GeissMed. Please also note that you can discontinue this
service at any time and for any reason. Just let any member of our staff know that you wish to
discontinue and we will immediately supply the form to do so.
We also want to make sure that you know that although you may not be seen every month your
account may reflect this charge depending on the time spent managing your chart and medical care.
Furthermore, our office will have a record of the time spent managing your care should you have
questions.
Again, our goal is to provide you or your family member with the best care possible. We want to
help keep our patients out of the hospital and to minimize cost and inconvenience due to unnecessary
visits to the lab, radiology, or trips to the hospital and emergency room. We know your time and health
is valuable, and we hope that you will consider participation in this program.

I agree to participate in the Chronic Care Management Program Yes ________ No ________

______________________/_______________________ ______________________ ______________

Patient/Legal Representative Print/Sign Relationship Date