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New England Medical
168 Main Street Suite 4
Claremont NH 03743
Phone: (603)555-1000
Fax: (603)555-4242
OfficeHours: M-Thurs.: 8a.m.-5p.m., F: 9a.m.-7p.m.
Patient Information Packet

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New England Medical
New Patients,
Welcome to New England Medical! We are proud that you have decided to
join our small family practice. We would like to introduce you to our staff.
John Harper, MD: Dr. Harper has been with New England Medical for 5 years. He
studied at the Boston University School of Medicine. He has a wifeand two boys.
He enjoys helping anyonein any way that he can.
Mark Truman, MD: Dr. Truman is a new physician here at New England Medical.
He has been here for a year. He studied at DukeUniversity School of Medicine. He
has a wife and a daughter. He enjoys having to really think on the job to help a
patient get the help they need.
Aimee Smith, RN: Mrs. Smith has been with New England Medical since it opened
its doors in 2005. Shestudied at Colby-Sawyer College. She has a husband and
they have a newborn son. Sheenjoys helping people through tough times, she
loves to make people smile.
Megan Drouin, AMA: Mrs. Drouin has justjoined the New England Medical team.
She studied at River Valley Community College. She has a husband, two sons and
a daughter. She enjoys helping patients.
We are here to help you!
Sincerely,
The staffofNewEnglandMedical

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New England Medical
PATIENT INFORMATION
Name: _________________________________ D.O.B:___________ Sex: _____
Address: ___________________________________________________________
City/State/Zip: ______________________________________________________
Home telephone #: ______________________ SS#: _____________________
Occupation: _____________________ Work telephone #: ___________________
Guarantor Information (person responsiblefor medical bills)
Name: __________________________________ SS#: _____________________
Address: ___________________________________________________________
City/State/Zip: ______________________________________________________
Relationship to patient: _______________________________________________
Home phone #: _______________________ Work phone #: __________________
Occupation: ________________________________________________________

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New England Medical
Primary Insurance Information
Ins. Co. Name: ______________________________________________________
Address: ___________________________________________________________
City/State/Zip: ______________________________________________________
Ins. Co. Phone#: _____________________ Ins. Co. Fax: _____________________
Claim #: __________________________ Group #: ________________________
Secondary Insurance Information
Ins. Co. Name: ______________________________________________________
Address: ___________________________________________________________
City/State/Zip: ______________________________________________________
Ins. Co. Phone#: _____________________ Ins. Co. Fax: _____________________
Claim #: __________________________ Group #: ________________________

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New England Medical
New Patient Information
Name: _______________________________________ Date: ________________
HISTORY:
Chief complaint: _____________________________________________________
Allergies: ___________________________________________________________
___________________________________________________________________
Medication: ________________________________________________________
__________________________________________________________________
Medical Illnesses: ____________________________________________________
___________________________________________________________________
Injuries: ____________________________________________________________
Surgeries: __________________________________________________________
___________________________________________________________________
Hospitalizations: _____________________________________________________
___________________________________________________________________
FAMILY HISTORY:
Mother: ___________________________________________________________
__________________________________________________________________
Father: ____________________________________________________________
__________________________________________________________________
Sibling(s): __________________________________________________________
__________________________________________________________________
Maternal Grandparents: ______________________________________________
__________________________________________________________________
Paternal Grandparents: _______________________________________________
__________________________________________________________________

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New England Medical
Children: __________________________________________________________
__________________________________________________________________
SOCIAL HISTORY:
Marital Status: S M SEP D W
Education: GS HS GED COL
Employment: _______________________________________________________
Drugs: _____________________________________________________________
Alcohol per week: _________________ Tobacco: Packs/day ______ Years ______
Emergency Information
Emergency Contact: _______________________ Home Telephone#: _____________________
Relationship: _________________________ Work Telephone #: _________________________

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New England Medical
Scheduling Policy
Scheduling appointments
Monday – Thursday 8am – 6pm
Friday 9am- 8pm
Making a sick appointment
Sick appointments are generally made on the same day as the phone call. Calling to make an
appointment is preferred, rather than simply coming into the office. We would suggest you arrive
15 minutes prior to your appointment to fill out paperwork for the visit.
Making a follow-up appointment
After your visit with your physician, you should go back to the reception desk to make a follow-
up appointment. This time frame can range from one week to six months.
We do understand that your time is precious and we do our best to meet the schedule, but there
are times where we do run a little behind. With the help of your patience we will be able to get
back on track. If you are not able to wait for your appointment, the receptionist will give you the
option to reschedule.
I have read the above and fully understand the terms thereof.
Signature of Patient: ____________________________________ Date: __________________
Printed Name: ________________________________________________________________

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New England Medical
Telephone Policy
Our goal is to see every patient that calls to make an appointment for that day. It is best to call
early in the day to make sure there is an appointment slot open. It is NOT in our policy to give
medical advice over the phone. After hours our goal is to simply determine how urgent the
situation is and how the best way to deal with it until you are able to be seen – NOTto diagnose
or to treat. If you cannot wait to be seen, we will refer you to the nearest emergency room.
When you call our office after hours, you will be transferred to our answering service, and they
will help you accordingly.
I have read the above and fully understand the terms thereof.
Signature of Patient: _____________________________________ Date:__________________
Printed Name: _________________________________________________________________
Automated Appointment Calls
The MedVoiceTM reminder service is asimple voice activated recordingthat calls all
patients at their place of residence to remindthem of their scheduledappointments. I hereby
authorize New England Medical to use their automatedsystem to remindme of all of my
scheduledappointments. I understand that my signature on this form authorizes New
England Medical to utilize the automated appointment call service for all my scheduled
appointments.
I have read the above and fully understand the terms thereof.
Signature of Patient: _____________________________________ Date:__________________
Printed Name: ________________________________________________________________

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New England Medical
Payment Policy
As a courtesy, New England Medical, verifies your benefits with your insurance
company. Your claim will process according to your plan, if your claim processes
differently fromthe benefit we were quoted, the insurancecompany will side
with the plan and will not honor the benefit quote we received.
Itis the policy of New England Medical that payment is due at the time of services
unless other financial arrangements are made in advance. We require all patients
to pay their deductible, copay, and/or coinsurancepaymentat the beginning of
each visit. The office manager will explain this information to you prior to your
firstvisit. At the conclusion of your visits with us you may be billed for any
outstanding balances. If there is a credit, you will be provided a refund promptly.
Although we arecontracted with most insurancecarriers, our services may notbe
covered by your particular insuranceplan. Being referred to our clinic by another
physician does not necessarily guarantee that your insurancewill cover our
services. Pleaseremember that you are 100 percent responsiblefor all charges
incurred: your physician’s referraland our verification of your insurancebenefits
are not a guarantee of payment.
We recommend you contact your insurancecarrier and check into coveragefor
primary care. Do not assumeyou will not oweanything if you have more than one
insurancepolicy.
I have read the above and fully understand the terms thereof.
Signature of Patient: _____________________________________ Date:__________________
Printed Name: _________________________________________________________________

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New England Medical
NOTICE OF PRIVACY PRACTICES
As required by the privacy regulations created as a result of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA).
THIS NOTICE DESCRIBES HOW NEW ENGLAND MEDICAL MAY USE AND DISCLOSE
HEALTH INFORMATION ABOUT YOU AND HOW YOU CAN GET ACCESS TO YOUR
INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION. PLEASE REVIEW THIS
NOTICE CAREFULLY. OUR COMMITMENT TO YOUR PRIVACY
New England Medical is dedicated to maintaining the privacy of your individually identifiable
health information (IIHI). In the course of treating you, we will create records of the treatment
and services we provide to you. We are required by law to maintain the confidentiality of health
information that identifies you. We are also required by law to provide you with this notice of
our legal duties and our privacy practices. The terms of this notice apply to all records containing
your IIHI that we create or retain in our practice. We reserve the right to revise or amend this
Notice of Privacy Practices. Any revision or amendment to this Notice will be effective for all
of your records created or maintained by this office in the past and in the future. New England
Medical will post a copy of our current Notice of Privacy Practices in our offices in a visible
location at all times, and you may request a copy of our most current Notice at any time.
IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT OUR PRIVACY
OFFICER:
Melinda Gordon: 168 Main Street, Suite 4, Claremont, NH 03743
Phone: (603)555-1000 Ext: 4242
I. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH
INFORMATION (IIHI) IN THE FOLLOWING WAYS:
The following categories describe the different ways in which we may use and disclose your
IIHI:
1. Treatment.
Our practice may use your IIHI to treat you. We may ask you to have diagnostic studies (such as
an MRI or x-ray), and we will use the results of these tests to help us reach a diagnosis. We may
use your IIHI in order to write a prescription for you, or we may disclose your IIHI to a
pharmacy when we order a prescription for you. Many of the people who work for our practice –
including, but not limited to, our doctors and nurses – may use or disclose your IIHI in order to

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treat you or to assist others in your treatment. Additionally, we may disclose your IIHI to others,
upon your designation.
2. Payment.
Our practice may use and disclose your IIHI in order to bill and collect payments for the services
and items that we provide. We may contact your health insurer to certify that you are eligible for
benefits (and for what range of benefits), and we may provide your insurer with details regarding
your treatment to determine if our insurer will cover, or pay for, your treatment. We may also use
and disclose your IIHI to obtain payment from third parties that may be responsible for such
costs. Also, we may use your IIHI to bill you directly for services and items.
3. Health Care Operations.
Our practice may use and disclose your IIHI to operate our business operations. These uses and
disclosures are necessary to monitor the quality of care that we provide. Our practice may use
your IIHI to evaluate New England Medical’s services, including the performance of our staff.
4. Appointments.
In order to protect you IIHI, appointments, cancellations and rescheduling cannot be made with
the answering service. All calls of this nature must be made during office hours between 8:00
a.m. to 5:00 p.m. and must be made directly with practice personnel.
5. Appointment Reminders.
Our practice may use and disclose your IIHI to contact you and remind you of an appointment
either by mail or phone, including leaving messages on your designated answering machine.
6. Test Results.
Normally, test results will not be communicated to the patient over the phone. These results will
typically be discussed in the office. Should you desire to have results mailed to your home or any
other desired location, a specific request must be submitted in writing.
7. Prescriptions.
Prescription requests must be made during office hours only (8:00 a.m. to 5:00 p.m.). The
practice’s answering service is not authorized to accept prescription requests.
8. Release of Information to Family/Friends.
Our practice may release your IIHI to a friend or family member who is involved in your care, or
who assists in taking care of you. For example, a parent or guardian may obtain information
concerning the course of your treatment, provided proper consent has been provided.
9. Disclosures Required by Law.
Our practice will use and disclose your IIHI when we are required to do so by federal or state
law. Some of these required disclosures are listed in section II (1) below.
II. USE AND DISCLOSURE OF YOUR INDIVIDUAL IDENTIFIABLE HEALTH
INFORMATION IN SPECIFIC SPECIAL CIRCUMSTANCES.

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The following categories describe unique scenarios in which we may use or disclose your
individually identifiable health information:
1. Public Health Risks.
Our practice may be required to disclose your IIHI to public health authorities that are authorized
by law to collect information for the purpose of:
Maintaining vital records, such as births and deaths,
Reporting child abuse or neglect,
Preventing or controlling disease, injury or disability,
Notifying certain government agencies about the diagnoses of certain conditions that create a
public risk,
Notifying a person regarding a potential risk for spreading or contracting a disease or condition,
Reporting reactions to drugs or problems with products or devices,
Notifying individuals if a product or device they may be using has been recalled,
Notifying appropriate government agencies and authorities regarding the potential abuse or
neglect of an adult patient (including domestic violence); however, we will only disclose this
information if the patient agrees or we are required or authorized by law to disclose this
information, and
Notifying your employer under limited circumstances related primarily to workplace injury or
illness or medical surveillance.
2. Health Oversight Activities.
Our practice may disclose your IIHI to a health oversight agency for activities authorized by law.
Oversight activities can include, for example, investigations, inspections, audits, surveys,
licensure and disciplinary actions; civil, administrative, and criminal procedures and actions; or
other activities necessary for the government to monitor government programs, compliance with
civil rights laws and the health care system in general.
3. Lawsuits and Similar Proceedings.
Our practice may use and disclose your IIHI in response to a court or administrative order, if you
are involved in a lawsuit or similar proceeding. We may also disclose your IIHI in response to a
discovery request, subpoena, or other lawful process by another party involved in the dispute, but
only if we have made an effort to inform you of the request or to obtain an order protecting the
information the party has requested.
4. Law Enforcement.
We may release your IIHI if asked to do so by a law enforcement official:
Regarding a crime victim in certain situations, if we are unable to obtain the person’s
agreement,
Concerning a death we believe has resulted from criminal conduct,
Regarding criminal conduct at our offices,
In response to a warrant, summons, court order, subpoena or similar legal process,
To identify/locate a suspect, material witness, fugitive or missing person.

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In an emergency, to report a crime (including the location or victim(s) of a crime, or the
description, identity or location of the perpetrator).
5. Deceased Patients.
Our practice may release your IIHI to a medical examiner or coroner to identify a deceased
individual or to identify the cause of death. If necessary, we may also release information in
order for funeral directors to perform their jobs.
6. Organ and Tissue Donation.
Our practice may release your IIHI to organizations that handle organ, eye or tissue procurement
or transplantation, including organ donation banks, as necessary to facilitate organ or tissue
donation or transplantation if you are an organ donor.
7. Research.
Our practice may use and disclose your IIHI for research purposes in certain limited
circumstances. We will obtain your written authorization to use your IIHI for research purposes
except when: (a) our use or disclosure was approved by an Institutional Review Board or a
Privacy Board; (b) we obtain the oral or written agreement of a researcher that (i) the information
being sought is necessary for the research study; (ii) the use or disclosure of your IIHI is being
used only for the research; and (iii) the researcher will not remove any of your IIHI from our
practice; or (c) the IIHI sought by the researcher relates only to decedents and the researcher
agrees either orally or in writing that the use or disclosure is necessary for the research and, if we
request it, to provide us with proof of death prior to access of IIHI of the decedents.
8. Serious Threats to Health or Safety.
Our practice may use and disclose your IIHI when necessary to reduce or prevent a serious threat
to your health and safety or the health and safety of another individual or the public. Under these
circumstances, we will only make disclosures to a person or organization able to help prevent the
threat.
9. Military.
Our practice may disclose your IIHI if you are a member of U.S. or foreign military force
(including veterans) and if required by the appropriate authorities.
10. National Security.
Our practice may disclose your IIHI to federal officials for intelligence and national security
activities authorized by law. We may also disclose your IIHI to federal officials in order to
protect the President, other officials or foreign heads of state, or to conduct investigations.
11. Inmates.
Our practice may disclose your IIHI to correctional institutions or law enforcement officials if
you are an inmate or under the custody of a law enforcement official. Disclosure for these
purposes would be necessary: (a) for the institution to provide health care services to you, (b) for
the safety and security of the institution, and/or (c) to protect your health and safety or the health
and safety of other individuals.

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New England Medical
ACKNOWLEDGEMENT OF RECEIPTS OF NOTICE OF
PRIVACY PRACTICES
I, ________________________________________________________________,
acknowledge that I have received a copy of the Notice of Privacy Practices, which
summarizes the ways my protected health information may be used and disclosed by
the practice and states my rights with respect to my protected health information. I
understand the practice has the right to revise these information practices and to
amend the Notice of Privacy Practices. I have been informed that in the event the
practice changes this Notice, a revised Notice will be posted in the practice and that I
may obtain a current Notice of Privacy Practices at any time from the Privacy Officer.
Date: _______________________________________________
Signature of Patient: ________________________________________________________
PrintedName: _____________________________________________________________
Signature of legal representative, if resident is legallyincompetent or incapacitated:
_________________________________________________________________________
PrintedName: _____________________________________________________________
Relationshipto Patient: ______________________________________________________
Signature of Witness: ________________________________________________________
PrintedWitness Name: _______________________________________________________

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Bibliography:
 Payment Policy
www.physicianspractice.com/tools/sample-payment-policy-medical-practices
 Scheduling Policy
www.thechildhealthcenter.com/scheduling_policies.htm
 Telephone Policy
www.chmed.com/working-with-us/our-policies/telephone-policy/
 Patient Confidentiality
Sample 1 on blackboard
 Automated Appointment Calls
Sample 1 on blackboard