Patient Demographic Update - Apple Healthcare

Patient Contact Info

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Chart #

Patient Name(Required)

First Middle Last

Patient Preferred name

Patient Date of Birth(Required)

Patient Address(Required)

Street Address Address Line 2 City State ZIP Code

Patient's Preferred Phone #(Required)

Patient's Preferred Email address

If you put in an email address, your patient statements will be emailed to you. If you prefer a mailed statement, please leave this field blank. Please note there is a $35 annual fee for receiving printed statements.

Driver's License / ID

Accepted file types: jpg, jpeg, gif, png, Max. file size: 32 MB.

Save time by uploading your ID! Optional - If you do not include the image here, you will be asked to present your ID in the office to be scanned.

Patient Family / Emergency Contact

Marital Status(Required)

Single

Married

Widowed

Divorced

Emergency Contact Name(Required)

Emergency Contact Relation(Required)

Emergency Contact Phone(Required)

Primary Care Provider Name

Title First Last

If you have a primary care provider, please enter their name here.

Primary Care Provider Group

If you know your primary care provider's medical group (i.e. Summit, Family Care Specialists, etc.) please list it here.

Will You Be Using Insurance?(Required)

Yes

Is the patient a minor or under the care of another?(Required)

Yes

Parent / Guardian Info

Parent / Guardian Name

Parent/ Guardian Date of Birth

Parent / Guardian Relation

Parent / Guardian Phone(Required)

Parent / Guardian Email

Parent/ Guardian Address(Required)

Same as Patient

Street Address Address Line 2 City State ZIP Code

Insurance Information

Save time by uploading your Insurance Card!

Optional - If you do not include the image here, you will be asked to present your ID in the office to be scanned.

Ins Card Front

Accepted file types: jpg, jpeg, png, gif, Max. file size: 32 MB.

Ins Card Back

Accepted file types: jpg, jpeg, png, gif, Max. file size: 32 MB.

Insurance Co. Name

Policy/Member ID

This field is hidden when viewing the form

Policy/Member ID#

Group #

Patient Relation to Policy Holder(Required)

Self

Spouse

Child

Other (Specify Relationship)

Insurance Policy Holder Name

First Middle Last

Policy Holder Date of Birth(Required)

Insurance Policy Holder Address(Required)

Same As Patient?

Street Address Address Line 2 City State ZIP Code

Insurance Policy Holder Phone #

Isurance Policy Holder Employer

Have a Secondary Insurance?

Secondary Insurance Name

If you have a secondary insurance like a Medicare Supplement plan, please add it here.

Secondary Insurance Policy/Member ID

Secondary Insurance Group #

Clinic Policies

Please read carefully and sign below

HIPAA: Notice of Privacy Practices

The Patient Portal has a copy of Apple Healthcare Group’s notice of privacy practices for you to view at any time. This notice describes:
- How Apple Healthcare Group may use and disclose protected health information.
- Certain restrictions on the use and disclosure of healthcare information.
- Rights regarding protected health information.

Email/Text for Appointment Reminders & Healthcare Communications

As a courtesy, patients may be contacted via email and/or text messaging to:
- Remind you of an appointment.
- Obtain feedback on your experience with our clinic.
- Provide electronic statements.
- Communicate general health reminders/information.
If at any time you provide an email or text address at which to be contacted, you consent to receiving:
- Appointment reminders.
- Statements.
- Other health communications to that email or text address from Apple Healthcare.
Your agreement to receive emails and/or text messages will apply to all future communications of this nature.
You may change this consent at any time through a written request.
Standard text messaging rates apply as provided with your wireless plan (contact your carrier for pricing plans & details).

Appointment Policy

Please arrive on time or early for your appointment. If you arrive late, we may need to reschedule your appointment to another day and time.
If you miss multiple consecutive appointments, we may be unable to schedule future appointments with our office.
If you are unable to make your scheduled appointment, we request you provide us 24-hour notice of cancellation for non-emergency situations.
A $25.00 no-show or cancelled appointment fee will be assessed to your account if we are not notified 24 hours prior to your appointment.

Patient Financial Responsibilities

Patients are responsible for:
- Copays, coinsurance, and deductibles.
- All other services, procedures, or treatments not covered by their insurance.
For your convenience, Apple Healthcare will bill your insurance for services provided. However, you must provide Apple Healthcare with the most current and updated contact information and insurance coverage.
The patient (or patient’s guardian, if a minor) is ultimately responsible for the payment of services or treatment rendered by Apple Healthcare.
Apple Care self-pay plan:
- A cost savings program designed to offset rising copays, high deductibles, and higher premiums.
- Saves you 35% off treatment costs within the clinic.
Payment is due at the time of service unless other payment options have been arranged. If you have a balance on the account:
- You will be asked to pay the balance or to take advantage of one of our payment options.
- We will be unable to schedule you if account balances are not current or on a prearranged plan.
Patient Payment Options:
- Option 1: Pay ahead. Pay for the entirety of your care plan and you may qualify for percentage discounts depending on services received.
- Option 2: Pay at the time of service.
- Option 3: Multi-payment. Multi-payment options may be arranged with approval. An encrypted credit card will be kept on file.
Patients will be responsible for the payment of additional charges incurred, including but not limited to:
- Charges for returned checks.
- Costs associated with the collection of patient balances, such as charges incurred from the use of a revenue recovery service.
- Charges for missed appointments without advance notice of at least 24 hours prior to the appointment.
To streamline services and your experience at Apple Healthcare, the clinic has gone to a card-on-file policy. Please review the attached form for specifics.

Please sign with mouse (computer) or finger (phone/tablet)

Patient or Parent/Guardian Signature(Required)

By signing, you certify all information is correct and agree to the policies listed above.

Note:

If the signature box disappears after trying to submit the form with missing fields, click "Sign Again" to get it back.
If you want to clear your signature and start over, click the "Refresh" icon near the lower right corner of the signature box.

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