New Patient Patient Demographics Name:(Required)DOB:(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender:(Required)MaleFemaleSSN:Facility Name:Room Number:(Required)Mailing Address:Billing Address:Patient Phone:(Required)Patient Email:(Required) Appointment Reminders? Yes No Online Patient Portal? Yes No Patient Preferred Communication:(Required) Call Text Email Do you have a Medical Power of Attorney or Guardian?(Required) Yes No If yes, please provide copies of paperwork. Drop files here or Select files Max. file size: 512 MB. Primary Contact:Relationship:Contact Phone:Contact email: Contact Preferred Communication: Call Text Email Contact Appointment Reminders? Yes No Contact Online Patient Portal? Yes No Preferred Pharmacy:Insurance Carrier:Insurance Policy Number:Policy Holder Name:Policy Holder DOB:MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Secondary Insurance Carrier:Secondary Insurance Policy Number:If available please attach a copy of insurance card, front and back. Drop files here or Select files Max. file size: 512 MB. Current Home Health Agency:Nurse:How did you hear about us?Release of Information Form Patient Name :(Required)Patient DOB:(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please list providers you’ve seen in the last 18 months:Provider 1Provider 1 PhoneProvider 1 AddressProvider 2Provider 2 PhoneProvider 2 AddressProvider 3Provider 3 PhoneProvider 3 AddressWho may we share your protected health information with?Name(1)Relation(1)Phone Number(1)Name(2)Relation(2)Phone Number(2)Name(3)Relation(3)Phone Number(3)** If an individual is not listed, we will not release any information about you. **Consent Form Use and Disclosure of Protected Health Information: I voluntarily authorize Texas Senior Care At Home LLC (TSC) to use and disclose my Protected Health Information for treatment, payment, and healthcare operations as described in the TSC Notice of Privacy Practices to insurance companies, third party payers, or other authorized agents to process a claim for payment on my behalf to use and disclose my Protected Health Information to carry out medical treatment, payment, and healthcare operations. I understand I have the right to review the Notice of Privacy Practices for a more complete description of such uses and disclosures prior to signing this consent. Authorization for Insurance Payment: I authorize payment of insurance benefits to TSC for services provided to me. TSC will bill your insurance; however, the insurance company makes the final determination of your eligibility. I agree to pay any portion of the charges not covered by insurance. I agree to pay all deductibles, co-pays, and co-insurances. I understand my statements may be billed under Texas Senior Care or Dr. Justin Mansfield. Self-pay patients are required to have a credit card authorization form on file prior to services being rendered. Right of Choice: If your provider determines you need home health care or hospice care, you will have the right to choose an agency to provide such care, under the Medicare home health or hospice requirements for patient choice. Your practitioner will honor that choice. Even though you have the right to choose, your choice may be limited based on your insurance coverage or the availability of the agency you have selected. Consent to Treat: I hereby voluntarily consent to the rendering of healthcare services by providers of TSC. I acknowledge and understand that this consent authorizes providers of TSC to manage and treat medical conditions, including but not limited to, physical examinations, diagnostic procedures, performance of tests, remote patient monitoring, chronic care management, and administration of medications and therapies. I understand if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I understand I have the right to discuss and may refuse any proposed procedures or treatments with my provider. I understand that there are limitations to my care in the setting, that I reside, and there are no guarantees to the effect of such examination or treatment of my condition. Authorization for Communication: I hereby authorize TSC providers, employees, and representatives to communicate with myself, designated person(s) listed on my ROI, other healthcare providers, and persons involved in my healthcare using secure methods of communication. I understand this information will remain in effect until TSC is notified in writing of any requested change. We require a 24-hour cancelation notice. Three (3) no show appointments will result in discharge from services. Consent(Required) I understand this consent will be valid and will remain in effect if I am a current patient of TSC. I have read or had this form read to me in a language that I understand, and I have had an opportunity to ask questions about it.(Required)Print Responsible Party Name/Relationship(Required)
