Thank you for your assistance in fillout out this form completely. Medicare requires that we collect this information prior to providing services. We apologize if this is a duplication of information provided to other companies, we still must collect it. We will add new patients to our system only after the *required* sections are complete.

There are serious errors in your form submission, please see below for details.

Personal Information - Required Section
Firstname:

Middle:Last Name:Date of Birth:Sex:
Home Address:
MAILING ADDRESS FOR BILLS, IF DIFFERENT THAN ABOVE
(OR DESIGNATE SOMEONE ELSE TO RECEIVE BILLS BELOW):
Home Phone:Mobile Phone:
Primary Email Address:Pharmacy:Pharmacy Phone:
Would you like access to our patient portal?Does patient live in a facility?If yes, provide name name of facility:
Hospice or Home Health utilization: Currently on ServicesPreviously On ServiceName of company: Have Never Received these Services

Personal Information - Optional Section
Race:Ethnicity: Preferred language:English Other:

DO YOU WANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM THE PROVIDER MAY DISCUSS YOUR MEDICAL CONDITION? IF YES, PLEASE PROVIDE THIS INFORMATION BELOW:
(Due to the nature of our practice, SHA may be unable to accept patients without a designated contact for emergencies, however you may revoke this authorization at any time in writing through our office. We are unable to discuss your health information with anyone not listed below)

Primary Contact Name:Relationship to Patient:If Other:Is this person the Healthcare POA or Legal POA?:Healthcare POA Legal POA
PLEASE ATTACH COPY OF POA DOCUMENTS BELOW
Address:
Email Address:Home Phone:Mobile Phone:Send all bills to this person?
Additional Contact Name:Relationship to Patient:If Other:Is this person the Healthcare POA or Legal POA?:Healthcare POA Legal POA
PLEASE ATTACH COPY OF POA DOCUMENTS BELOW
Address:
Email Address:Home Phone:Mobile Phone:Send all bills to this person?
Additional Contact Name:Relationship to Patient:If Other:Is this person the Healthcare POA or Legal POA?:Healthcare POA Legal POA
PLEASE ATTACH COPY OF POA DOCUMENTS BELOW
Address:
Email Address:Home Phone:Mobile Phone:Send all bills to this person?

Attach/Upload POA Document
Here you can upoad your signed POA document:
(PDF/DOC/DOCX/TIF)

Insurance - Required Section
Primary Insurance: ID Number & Letters:
Mailing Address:
Is this a Medicare replacement policy? Policy Holder name (if different than patient):
Secondary Insurance: ID Number & Letters:
Mailing Address:
Policy Holder name (if different than patient):

Authorization for Treatment And Financial Agreement - Required
please take a few minutes to ACTUALLY read this section. It has very important information that will help you work with our providers.
AUTHORIZATIONYour signature below indicated agreement that you have requested services through our medical providers. You agree that we will perform procedures and treatments as required to provide reasonable and appropriate medical care. You are also assigning insurance benefits to SHA, however you understand that that insurance may not cover all services and you will be responsible for those charges.
LATE FEESPayment is expected upon receipt of invoice. SHA will charge a $25.00 per month late fee for any balance greater than 30 days. Balances greater than 60 days old may be sent to collections which may result in additional charges.
INSURANCEWe will verify your insurance before providing services. You agree to notify us immediately of any change in your insurance provider or assume financial responsibility for any charges incurred.
HIPAAOur privacy policies are posted on our web site: www.SeniorHealthAssociates.com/Forms.htm. If you are unable to access these policies on the internet, please contact our office for a paper copy. Your signature below indicates your awareness of the existence and location of our privacy policies and your right to access them.
PRESCRIPTIONSHOME PATIENTS Please request ALL refills during regularly scheduled visits. We will happily provide you with enough refills to last until your next appointment and can call them to your pharmacy during our visit.
FACILITY PATIENTS Please request refills by writing this request in our physician notification book located in EVERY facility. The facility staff will usually write this for you if you ask them.
EMERGENCY REFIILLS You may call our refill line in our office during the following times (M-TH 8:30 3:00, F 8:30 12:00) to request refills up to 4 times per year for routine medications without additional charges. Refills will be processed within 48 hours. Additional calls will result in a $25.00 charge.
AFTER HOURS EMERGENCIES If you call our office after business hours, the answering service will page the provider on call. There will be a $25.00 charge for each call. This fee is not covered by insurance and will be your responsibility to pay. The on-call physician may not be able to prescribe after hours, but the fee will still be charged.
PAIN MEDICATIONS Due to unfortunate recent changes in Federal and State laws related to pain medications, we are no longer allowed to fax, call-in, e-prescribe, or refill pain medications. These prescriptions must be processed in our office and mailed directly to the pharmacy or patient each month for every patient. We charge $7.50 per month to offset our expense and time of this process. WE ARE ATTEMPTING TO WORK WITH STATE AGENCIES IN PROTEST OF THIS RIDICULOUS SC STATE LAW. IF YOU WOULD LIKE TO HELP, PLEASE SEE OUR WEB SITE FOR MORE INFORMATION.
APPOINTMENTSHOME PATIENTS Please call our office to make appointments.
FACILITY PATIENTS Upon receipt of completed Patient Information Forms, we will verify your insurance, assess our capacity to add new patients, and review your health information to determine our ability to meet your medical needs. This may require requesting additional medical records from previous providers. This process could take 2 21 days.
TRIP CHARGESHOME PATIENT VISITS will be subject to a $45 trip charge not covered by insurance.
Chronic Care
Management
By signing below, you are consenting to participation in Chronic Care Management. This Medicare program is only for our patients with 2 or more chronic conditions that place the patient at higher risk of complications. This allows us to coordinate your care with multiple agencies (such as home health) and spend more time talking to you and your family. You may access this information from our patient portal. Only one provider at a time may offer you CCM. We will share your medical records with other agencies for care coordination (such as ordering x-rays or labs). You may revoke CCM at any time in writing to our office services will end at the end of the current month. We will bill you for any copays or deductible associated with your account.
CANCELLATIONSAny visit not cancelled through our main office number within 12 hours of the appointment time, will be subject to a $45 charge.
By Entering your name below, you agree that you are authorized to sign this document as you are either the Patient or Power of Attorney.
Signature:       Date:
SIGNATURES CAN BE ACCEPTED FROM THE PATIENT (UNLESS INCAPACITATED), THE SPOUSE (IF PT. INCAPACITATED), FROM A POA (MUST ATTACH), OR FROM AN ONLY CHILD (IF PT. INCAPACITATED). If there are multiple siblings and no POA, we will need a letter signed by each sibling agreeing to a single decision maker before accepting patient.

Health Information Form - Optional
Please indicate if the patient or a blood relative has or has had any of the following problems:
patientblood relativepatientblood relative
AlcoholismGlaucoma
AnemiaHeart Attack / Disease
AsthmaHigh Blood Pressure
Bleeding DisorderHigh Cholesterol
CancerKidney Disease
DimentiaMental Illness
DiabetesOsteoporosis
Emphysema/Lung DiseaseStroke
Thyroid
Patient Allergies:
Please list additional medical problems and previous hospitalizations or surgeries:
Please list all medications that you are now taking. Include..DRUG NAME, STRENGTH, DIRECTIONS:

Please mark current symptoms:
GENERALFeverOverall DeclineWeight ChangeChronic PainNight SweatsFatigue
SKINItchingRashCancersDrynessPsoriasis
EYESPainGlassesChanging VisionDischargeDrynessGlaucoma
ENTEar PainSore ThroatSinus DifficultyHearingLoss of Smell or Taste
HEARTDizzinessChest PainAnkle SwellingPalpitationsBlackoutsHBP
LUNGSCoughWheezeChest PainShortness of Breath
GINauseaHearthburnConstipationUlcersDiarrhea
Irritable BowelAbdominal PainBlood in StoolChange in Bowel HabitsBowel Incontinence
URINARYPainful UrinationFrequent UrinationHesitant UrinationIncontinenceVoiding DifficultyBlood in Urine
Dischargetesticular PainSexual Disfunction
ORTHOPEDICPainful JointsMuscle WeaknessSwollen JointsOsteoporosisLimited Range of MotionBack Pain
NeuroSeizuresHeadachesDizzinessFallingTinglingTremor
CIRCULATIONBlood ClotsLeg Swelling
MEMORY/MOODMemory DisturbanceDifficulty UnderstandingStrange or Suspicious IdeasBehavioral DisturbancesDecreased Attention
REPRODUCTIVEAbnormal BleedingAbnormal Discharge
ENDOCRINEIncreased ThirstIncreased UrinationLethargy
SLEEPDifficulty Falling AsleepDifficulty Staying AsleepEarly AwakeningDaytime Drowsiness

Social History:
ALCOHOLDrinks per Week:
TOBACCOPacks Per Day:# Years:Want to Stop:
STREET DRUGSType:
EXERCISETimes per Week:Type:
CAFFEINECups per Day:
Are you married?
Living Will?
Salt Intake?
Fat Intake?
Additional Comments:

Request for Medical Records Authorization Form - Optional
Previous Medical Provider or Company:

I hereby authorize the above named medical provider or company to disclose my complete medical records to Senior Health Associates. I understand that this authorization may be revoked at any time in writing by sending notification to Senior Health Associates at the address above. I understand that a revocation is not effective to the extent that Senior Health Associates has relied on the use of disclosure of the protected health information.

Patient SSN#:Please provide SHA will any and all medical records for the preceding 12 months for the patient listed left, unless other time period is specified here: Requested date range (if more than 12 months):
By Entering your name below, you agree that you are authorized to sign this document as you are either the Patient or Power of Attorney.
Signature:       Date:

Credit Card Payment Authorization Form - Optional

SENIOR HEALTH ASSOCIATES IS REQUESTING THAT PATIENTS VOLUNTARILY PROVIDE A VALID CREDIT CARD FOR PATIENT RESPONSIBLE CHARGES. AT THIS TIME, WE DO NOT REQUIRE THAT YOU DO SO UNLESS YOU ARE APPLYING AS A SELF-PAY PATIENT.

SHOULD YOU CHOSE TO PROVIDE US WITH A CREDIT CARD, WE WILL PROVIDE YOU WITH A SAME DAY RECEIPT FOR ALL CHARGES TO YOUR CARD.
WILL APPLY CHARGES TO YOUR CARD ONLY AFTER YOUR INSURANCE CARRIER ADVISES OF THE REMAINING BALANCE IN PATIENT RESPONSIBILITY.

PROVIDING THIS INFORMATION WILL REDUCE LATE FEES THAT MAY OCCUR FROM LATE PAYMENTS TO YOUR ACCOUNT.

Card Type:Card Number:
Expiration Date: (mm/yy) CVC Code (3 NUMBERS FROM BACK OF CARD)
Cardholder Name:Cardholder Email:
Cardholder Address:City, State, Zip:
Cardholder cellphone:
Cardholder's Signature:

There are serious errors in your form submission, please see details above the form!