BROKEN TO BETTER PRIMARY CARE

Please enable JavaScript in your browser to complete this form.

Patient Information

Sex
Marital Status

Contact Information

Address
Mail Address (If Different)

Emergency Contact

Pharmacy Information

Address

Past Medical History

Have you ever been hospitalized?

Hepatitis Screening & Vaccination

Have you ever been tested for hepatitis
Have you been vaccinated for hepatitis

Tuberculosis (TB) Screening

Result
Result of Chest X-ray

Sexually Transmitted Disease (STD)

Have you had a sexually transmitted disease?

Current or Past Conditions

Which of the following conditions are you currently being treated for or have been treated for in the past? (Please check all that apply)

Allergies)

Do you have any food or drug allergies?

Medications

Name - Strength - Frequency

Social and Preventive History

Do you smoke or chew tobacco?

Current
Past

Do you drink alcohol, beer, or wine?

Current
Past
Do you drink coffee and/or tea?
Do you exercise daily/weekly?
Do you use seatbelts while driving?
Do you wear a helmet while riding a bike?

Family History (Relative)

Mother

Living?

Father

Living?

Sibling 1

Living?

Sibling 2

Living?

Sibling 3

Living?

Females: Gynecological History

Have you had an abnormal Pap smear?
Have you had a sexually transmitted disease?
Results
If Abnormal, Were you biopsied?

Additional Screenings

Colonoscopy screening?

Patient Certification

By signing below, the patient/legal guardian certifies that to the best of their knowledge all the information furnished on this form is complete, true, and accurate.
Click or drag a file to this area to upload.

Release of Medical Records Consent Form

By signing and dating below, the patient, guardian, or parent authorizes the release of the following records to BTB Primary Care for the purpose of medical treatment.
Name - Phone - Fax

Medical records may be faxed: Broken to Better Primary Care, Attn: Dr. Stacy Baker, 800-357-0220.

The patient understands that the medical record may include information relating to treatment of drug or alcohol abuse, sickle cell anemia, psychological or psychiatric impairments, sexually transmitted disease, AIDS, ARC, and/or HIV.

Click or drag a file to this area to upload.

Assignment of Insurance Benefits

The patient authorizes direct payment of insurance benefits to BTB Primary Care or the physician for services rendered. The patient understands that it is their responsibility to know their benefits, whether the services are covered, and agrees to be responsible for any co-pay or balance due.

Medicare/Medicaid Insurance Benefits:

The patient certifies that the information given is correct, authorizes the release of records these programs may request, and directs payment of authorized benefits directly to BTB Primary Care or the physician on their behalf.

Lab/X-Ray/Diagnostic Services:

The patient understands they may receive a separate bill if medical care includes lab, x-ray, or other diagnostic services, and are financially responsible for any co-pay or balance due for these services if they are not reimbursed by insurance.

Acknowledgement of Potential Financial Interest in Ancillary Services:

The patient acknowledges that the treating physician may have a financial interest in the overall performance of ancillary services as part of their affiliation with a group practice. The patient understands that they should contact their treating physician with any questions regarding potential financial interests in ancillary services. The patient is free to choose where to receive medical services and may discuss alternative treatment facilities with their physician.

Consent for Treatment

By signing this consent, the patient is authorizing the physician(s) and/or order another person to perform all exams, tests, procedures, injections, phlebotomy, and any other care deemed necessary or advisable for the diagnosis and treatment of their medical condition. This consent is valid for each visit to Dr. ____________________________________ with BTB Primary Care or any assigned physician in the group, unless revoked by the patient in writing.
Click or drag a file to this area to upload.

Office Policies

Refill Requests

  • Please allow 48 hours for refills.
  • Refill requests can be made by your pharmacy via fax or by leaving a voicemail.
  • Please ensure your pharmacy has the correct physician's information.
  • Same-day refill requests are not guaranteed.
  • Controlled substances will be given in person only and will generally require an office visit.
  • The Physician reserves the right to refuse any prescription request deemed medically inappropriate or unnecessary and to require a patient visit prior to issuing any prescriptions.

Referral Requests

  • If your insurance requires a referral from your primary care physician for specialist appointments or procedures, please allow 5 to 7 business days for processing.
  • Once approved by your insurance, you will receive a letter in the mail with the necessary information to schedule the appointment.
  • Referrals will only be approved after a doctor's visit and once the doctor has deemed the specialist visit medically necessary.
  • The patient has the right to choose a specialist; however, the specialist must be in your insurance network, and choosing a non-network specialist may delay the referral process.
  • Feel free to call the office to inquire about the status of your referral after 7 business days.

Appointment No Show

  • Patients who no-show or do not cancel their appointment at least 24 hours in advance will be charged a $20.00 fee.

Phone Calls

  • If contacting the office, please leave a message for questions or appointments.
  • All phone calls will be returned within 24 hours.

Forms and Letters

  • There is a $15 charge for all forms, letters, and other paperwork requiring physician completion.
  • The physician has the right to decline if not deemed medically necessary.
  • The fee must be paid prior to the completion of the forms.
  • Please allow at least 72 hours for completion. This includes, but is not limited to, FMLA, Home Health Certifications, Drug Discounts, and Temporary Leave Paperwork.

Patient Portal

  • Please give your email address so that we can provide you a link to access your lab results online.

Release of Patient Information

I CONSENT AND AUTHORIZE THE RELEASE OF ANY NORMAL OR ABNORMAL TEST RESULTS OR IMAGING RESULTS BY PHONE TO THE FOLLOWING PERSONS

Authorized Person

Click or drag a file to this area to upload.

HIPAA Patient Records of Disclosure

In general, the HIPAA Privacy Law gives patients the right to request restrictions on the uses and disclosures of their Protected Health Information (PHI). The patient also has the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to an office instead of a home address. This authorization remains in effect until revoked in writing by the individual.

I WISH TO BE CONTACTED IN THE FOLLOWING MANNER (CHECK ALL THAT APPLY)

OK to leave message with detailed information (Leave name/doctor with callback number only)
Leave detailed message on work voicemail ( Leave name/doctor with callback number only)

Acknowledgement

Click or drag a file to this area to upload.

Healthcare providers must keep records of PHI disclosures. Information provided will be documented on the test result, progress note, or patient communication in question.

Now Accepting Primary Care Patients
Call Now Button