Disclaimer for

General Information

First Name *

Last Name *

Date of Birth (mm/dd/yyyy) *

Your email *

Home phone

Mobile phone

Work phone

Fax

Primary contact method

Home phone

Mobile phone

Work phone

Emergency contact name

Emergency contact number

Do you have a caregiver?

Yes

Street Address *

City *

State *

Zipcode *

PO Box

Tell us about your pharmacy

Pharmacy Status

I have a pharmacy

I don't have a pharmacy

Pharmacy Name

Pharmacy Phone Number

Payment Info

How do you plan on paying for this session?

I will pay myself

I will pay through my insurance (Medicaid not accepted)

Are you enrolled in Medicaid?

Yes

Credit Card Authorization

In adherence with our clinic policy, we require each patient to keep a credit card authorization form on file if you cannot or do not pay fees that are outstanding or remain as part of your visit or as it pertains to any late/no show fees. In this event, we reserve the right to charge your credit card. Your signature below indicates your agreement and consent to charge your credit card for any outstanding charges and for any service fees which may include late appointments, no shows/cancellations within 24 hours of your appointment, outstanding balances and other fees as outlined in clinic policies and procedures.

* New patient appointments may require a $100 deposit to secure the appointment. Without the deposit, you may not be able to make a new patient appointment.

Cash Pay: If you elect to receive services on a cash pay, fee for services basis, payment in full is due at the time services are rendered. Payment for services must be made through the online payment service on the website.

Should you wish to submit your claim to insurance yourself after electing the cash payment option, we will provide you a receipt for services provided which you may submit to your insurance company for possible reimbursement. All reimbursements from your insurance received in this manner must be made out directly to you.

Name on Credit Card *

Card Number *

Expiration date (MM/YY) *

Security Code *3 digits on back of credit card. American Express may be in front of the card

Billing ZIP code *Max. 5 digits are allowed

Full legal name of patient authorized for use

I, owner of the credit card, authorize TP-Health, to submit any charges for professional services that are rendered to patient mentioned above, to my credit card. This authorization applies to all legitimate charges for any individual whom I have accepted financial responsibility and includes all current and future outstanding charges.

Signature of cardholder

Medical Data Sharing

Do you wish to have family members or other specific people receive your personal protected health information on your behalf?

Yes

By my signature below, I acknowledge that I have read and understood each and every policy mentioned above in detail and I consent to abide by those policies.

I also acknowledge that the information provided above is true and correct. I also understand that any wrong information may render for refusal of this appointment application by Mikyle Health.

I also declare that I have signed this document voluntarily and of my own free will. I agree that any questions I may have, have been answered.

Is another individual acting on behalf of the patient? (only applicable if the patient is minor or unable to give permission) *

Yes

Who is signing on the patients' behalf?

Authorized Individual Name *

Relationship with Patient *

Authorized Individual Phone Number *

Authorized Individual Email *

Is the patient a minor, or unable to give permission? *

Patient is a minor

Patient is unable to give permission

I, Syntax error, invalid field ID: 376 Syntax error, invalid field ID: 377 give TP-Health permission to disclose relevant health information including not limited to: (patients' health status, treatment, and payment arrangements) to

Signature of individual acting on behalf of the patient *

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