New Patients

Your first visit to Northeast Primary Care Associates establishes a vital foundation for our relationship with you. During your first visit, we make sure to obtain important background information about your medical history and give you time to get to know your doctor.

We’ve simplified the way we process new patient forms; you wont have to print them – you can fill them online right from this page! That way we’ll have this information by the time your doctor is ready to see you.

New Patient Form

Please fill out all the sections below so we can expedite your first visit:

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1Demographic Information

2Health History Questionnaire

3Family Medical History

4Physicians Disclosure of Financial Interest

5MHiE

6Medication Management Agreement

7General Practice Information Notice

8Receipt and Acknowledgement

9Notice of Privacy Practices

MEMORIAL HERMANN INFORMATION EXCHANGE "MHIE"
PATIENT CONSENT FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION.

Purpose: The MHIE is a health information exchange network developed by Memorial Hermann Ilcalthcarc System. Exchange Members include hospitals, physicians and other healthcare providers. Exchange Members arc able lo share electronically medical and other individually identifiable health information about patients for treatment, payment and healthcare operation purposes. We are an Exchange Member of the MHiE and we seek your permission to share your health information with other Exchange Members via the MHiE. By executing this form, you consent to our use and electronic disclosure of your health information to other MHiE Exchange Members for 11entmc111, payment and healthcare operation purposes. We will not deny you treatment or care if you decline to sign this Consent, but we will not be able to electronically share your health information with your healthcare providers that participate in the MHiE as Exchange Members if you do not sign this Consent.

Instructions: If you agree to allow us to disclose your health information with other MHiE Exchange Members please complete the relevant portions of and sign this Consent.
Patient Name
First Middle Last
Date of Birth
Information that will be Disclosed; Purpose of the Consent for Disclosure
I,
Patient Name
First Last
, hereby consent to the disclosure of my medical, health and encounter information by any and all Memorial Hermann Healthcare System providers (collectively the "Provider") to other participating providers in the MHiE (Exchange Members) who may request such information for treatment, payment or healthcare operation purposes. I understand the information to be disclosed includes medical and billing records used to make decisions about me.

I HEREBY SPECIFICALLY AUTHORIZE PROVIDER TO RELEASE ALL TYPES AND CATEGORIES OF PROTECTED IIEALTII I FORMATION TO OTHER HEALTHCARE PROVIDERS THAT PARTICIPATE IN THE MHiE FOR TREATMENT, PAYMENT AND HEALTHCARE OPERATION PURPOSES, (INCLUDING BUT NOT LIMITED TO, YOUR ALCOHOL AND TREATMENT RECORDS, YOUR DRUG ABUSE TREATMENT RECORDS, YOUR MENTAL HEALTH RECORDS, AND YOUR HIV/ACQUIRED IMMUNE DEFICIENCY SYNDROME RECORDS, AS APPLICABLE].

No Conditions: This Consent is voluntary. We will not condition your treatment on receiving this Consent. HOWEVER, IF YOU DO NOT SIGN AND INITIAL] THIS CONSENT, WHERE REQUIRED, YOU CANNOT PARTICIPATE IN THE MHIE.

Effect of Granting this Consent: This Consent permits all MHIE Exchange Members to access your health information. Exchange Members of the MHIE arc hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

Term and Revocation
This Consent will remain in effect until you revoke it. You may revoke this Consent at any time by completing the MHIE notice of revocation. The MHIE notice of revocation is available by calling 713-456-MHiE (6443). Revocation of this Consent will not affect any action we took in reliance on this Consent before we received your notice of revocation. Revocation of this Consent will also have no effect on your personal health information made available to Exchange Members during the timeframe in which your Consent was active.

INDIVIDUAL'S SIGNATURE I have had full opportunity to read and consider the contents of this Consent. I understand that, by signing this Consent, I am ming my consent and authorization of the use and/or disclosure of my personal health information, as described herein.
Signature
Date
If this Consent is signed by a personal representative on behalf of the individual, complete the following:
Personal Representative's Name:
First Last
Relationship to Individual:
YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.
Include this Consent in the individual's records.
Official Use Only

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NORTHEAST PRIMARY CARE ASSOCIATES, P.A.
8901 FM 1960 BYPASS ROAD WEST STE 201
HUMBLE, TEXAS 77338
281-548-3627 FAX: 281-548-3660

GENERAL PRACTICE INFORMATION NOTICE

Welcome to our office. If you are an established patient or a new patient, we want to take an opportunity to provide you with an overview of General Practice Information.

It is the policy of Northeast Primary Care Associates, P.A. to give all of our patients a courtesy call to remind them of their appointments. We will contact you at either home or work one business day prior to your appointment with a friendly reminder. If a message is left for you, kindly telephone the office in advance to either confirm or cancel your appointment. Please be advised that you must give 24-hour notice if you are unable to keep a scheduled appointment or your account will be assessed with a $25.00 no-show fee. If you must cancel your appointment after-hours, please telephone the office at 281-548-3627 and you will be given the option of leaving a message in our general delivery mailbox. Please state your name, date of appointment and the doctor's name you are canceling the appointment with. This notification will be adequate notice for us to avoid assessing a $25.00 no show/cancellation fee to your account. Furthermore, this allows us an opportunity to provide appointments to other patients.

Prescriptions are filled only during regular office hours. Should you need a prescription refill, please contact your pharmacy 5 days prior to running out. If you were advised by your physician that a follow up visit would be necessary prior to additional refills, you should contact our office 2 weeks in advance to secure an appointment and avoid delays in your prescription refill. There is a $25.00 fee for all returned checks. Returned checks must be paid in cash, cashier's check or money order only. We do not waive NSF check fees, nor do we accept partial payment for NSF checks. If necessary, we will file with the county attorney's office if you fail lo pick up your NSF check.

Should you need copies of your medical records, please put your request in writing. In most cases we can copy your records in 72 hours of receipt of request and payment. Fees are as follows:
- $25.00 for the first 20 pages, and an additional .50 cents per page thereafter in addition to any applicable postage fees.
- "Doctor to Doctor" record transfers will have fees waived.
Should you have forms that you need completed by your physician or a specific letter, please check with the registration desk. Fees range as follows: 1 - 3 pages $20.00 and 3 - 5 pages $30.00 If you have more than 5 pages please consult the billing manager. If you require a letter or summary by your physician the fee is $30.00. In most cases forms and letters can be completed in 3 business days.

As a courtesy to our patients, we do verify and retrieve benefit information. However, verification of benefits is not a guarantee of payment You are ultimately responsible for payment of services rendered to you. We attempt to inform you of what your anticipated out of pocket expenses may be, but ultimately your insurance benefits, coverage, limitations and exclusions are a result of a contractual agreement between you and your insurance company.

We hope that you have a pleasant healthcare association with this medical practice and value the medical services and professionalism rendered to you.

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Receipt and Acknowledgement of
Northeast Primary Care Associates, PA
General Practice Information Notice

My signature below indicates that I have read, agreed to and understand the General Practice Information Notice.
Signature
Date
Insurance Authorization and Assignment

I authorize Northeast Primary Care Associates, PA to release any medical and social information acquired during the course of my examination and/or treatment, for the purpose of filing for insurance and other financial coverage, and to provide required information to other medical professionals and facilities for my continuing diagnosis and treatment. I hereby authorize payment of medical benefits directly to Northeast Primary Care Associates, PA. I understand that I am financially responsible for charges not covered by this assignment of benefits, and should the account be referred for collection, I agree to pay reasonable collection and/or attorney's fees
Signature
Date

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NORTHEAST PRIMARY CARE ASSOCIATES, P.A.
8901 FM 1960 BYPASS ROAD WEST
SUITE 201
HUMBLE, TEXAS 77338
281-548-3627 FAX: 281-548-3660

NOTICE OF PRIVACY PRACTICES

YOUR PRIVACY AND HEALTH INFORMATION IS VERY IMPORTANT TO US. THIS NOTICE DESCRIBES HOW INFORMTION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE CAREFULLY REVIEW IT AND SIGN THE LAST PAGE ACKNOWLEDGING YOUR RECEIPT OF THIS INFORMATION.

OUR LEGAL RESPONSIBILITY

We are required by federal and state law to maintain the privacy of your health information. Furthermore, we are legally required to provide you with this notice regarding our privacy practices as described in this notice while it is in effect. This notice takes effect September 22, 2003 and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of our notice at any time, provided such changes are permitted by applicable law. Additionally, we reserve the right to make changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain This includes information that we created or received before we made the changes. Prior to a significant change in our privacy practices, we will change this notice and make the new notice available upon request.

You may request a copy of our notice at any time. For information about our privacy practices, or for additional copies of this notice, please contact us using the information provided herein.

USE AND DISCLOSURES OF HEALTH INFORMATION
We limit the use and disclosure of your private and protected health information for the purposes of your treatment, payment and healthcare operations. For example:

TREATMENT: We may use and/or disclose your healthcare information to a physician, physician's staff or other healthcare provider or healthcare provider's staff for the purpose of providing medical treatment to you.

PAYMENT: We may use and disclose your health information to obtain payment for services we provided to you.

HEALTHCARE OPERATION: We may use and disclose your healthcare information for the purposes of conducting our day-to-day operations, including quality assessment and improvement activities, evaluating practice or provider performance, competence, accreditation, certification, licensing or credentialing activities or for conducting training programs.

YOUR AUTHORIZATION: In addition to our use of your health information for treatment, payment or healthcare operations, you may instruct us in writing to use or disclose your health information to anyone for any purpose. You may revoke any written authorization for disclosure at any time, provided you give us written authorization. Your revocation of authorization will not affect any use or disclosures permitted by your authonzat1on while it was in effect. Unless you give us a written authorization we will not use or disclose any of your health information for any reason except those described in this notice.

PERSON INVOLVED IN YOUR CARE: We may use and disclose health information to notify, or assist in not1ficat1on (including locating and identifying) of a designated family member, your personal representative or another person responsible for your care, of your location, your general cond1hon or even death If you are present, prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses and disclosures. In the event that you are incapacitated or emergency circumstances prevail, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. Our professional judgment and experience with common practice will also be used to make reasonable inferences of your best interest in allowing a person to pick up prescriptions, doctor orders, medical supplies and other similar health information.

PRESCRIBING POLICY: To provide safe and effective prescribing of medications Northeast Primary Care may use claims data, pharmacy history and external prescription history to attempt to avoid duplication, drug interaction or untoward effects of medications, treatment or testing.

MARKETING HEAL TH RELATED SERVICES: We will not use your health information for marketing communications without your express written authorization.

REQUIRED BY LAW: We may use or disclose your health information when we are required to do so by law

NATIONAL SECURITY: We may use and disclose your health to military or Armed Forces authorities or personnel under certain circumstances. We may use and disclose to authorized federal officials health information required for lawful intelligence, counter-intelligence and other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmate or patient under certain circumstances.

DEPARTMENT OF HEAL TH AND HUMAN SERVICES: We must permit the Department of Health and Human Services use and disclosure of your health information if requested as part of a HIPAA compliance review. APPOINTMENT REMINDERS: We may use and disclose your health information for the purpose of providing you with appointment reminders including but not limited to voicemail messages, postcards or letters

PATIENT RIGHTS

ACCESS: You have the right to look at or get copies of your health information, with limited exceptions You may request copies of your medical records in writing. We may charge you a reasonable fee for such copies. The current fee allowed by law is $25.00 for the first 20 pages and an additional .50 cents per page thereafter in addition to any applicable postage fees. If you prefer copies of your medical record in a formal other than photocopies, we will use the format you request, unless we cannot practically do so. If yoLJ would like to inspect or review your medical records, you may put your request in writing or complete a "Request to Inspect Protected Health information" form. The law allows us 30 days lo respond Lo your request for information, if access is to be granted lo information maintained on site The law allows us 60 days to respond to your request for information not maintained on site. If your request is denied as per the provisions allowed by law, a written denial will be provided that explains the basis for the denial.

ACCOUNTING FOR DISCLOSURES: You have the right to receive a 11st of instances in which we have disclosed your health information for purposes other than treatment, payment, t1ealtr1care operations and certain other activities as provided by law.

RESTRICTION: You have the right to request that we place additional restrictions on our use and disclosure of your health information. We are not required lo agree to these additional restrictions, but tf we do, we will abide by our agreement except in an emergency or as required by law.

AMMENDMENT: You have the right to request that we amend your health information. Your request must be made in writing and must explain why the information should be amended. Your request may be denied under certain circumstances.

QUESTIONS AND COMPLAINTS

If you would like more information about our privacy practices or have any questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision made about access to your health information or in response to a request you made for restriction or disclosure of your health information, you may contact us as indicated below or you may write to:

U.S. Department of Health and Human Services Office for Civil Rights
1301 Young Street. Suite 1169
Dallas, Texas 75202
Tel: 214-767-4056
TDD: 214-767-8940
Fax: 214-767-0432

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Security Official: Ms. Vicki Tate
Telephone: 281-548-3627
Fax: 281-548-3660
Address:
8901 FM 1960 Bypass Road West
Suite #201
Humble, Texas 77338

My signature below indicates that I have read, agreed to and understand the Notice of Privacy Practices.
Signature
Date
Untitled

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New Patients

New Patient Form

Please fill out all the sections below so we can expedite your first visit:

Northeast Primary Care Associates, PA

8901 FM 1960 Bypass Road West, Suite 201
Humble, Tx 77338
281-548-3627

Northeast Primary Care Associates, PA

Health History Questionnaire

Northeast Primary Care Associates, PA

Family Medical History Form

Northeast Primary Care Associates, PA

8901 FM 1960 Bypass Road West, Suite 201
Humble, Tx 77338
281-548-3627

Physician's Disclosure of Financial Interest

Patient Acknowledgement

MEMORIAL HERMANN INFORMATION EXCHANGE "MHIE"
PATIENT CONSENT FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION.

Northeast Primary Care Associates, P.A.

Medication Management Agreement

Receipt and Acknowledgement of
Northeast Primary Care Associates, PA
General Practice Information Notice

Insurance Authorization and Assignment

Office Hours

New Patients

New Patient Form

Please fill out all the sections below so we can expedite your first visit:

Northeast Primary Care Associates, PA

8901 FM 1960 Bypass Road West, Suite 201 Humble, Tx 77338 281-548-3627

Northeast Primary Care Associates, PA

Health History Questionnaire

Northeast Primary Care Associates, PA

Family Medical History Form

Northeast Primary Care Associates, PA

8901 FM 1960 Bypass Road West, Suite 201 Humble, Tx 77338 281-548-3627

Physician's Disclosure of Financial Interest

Patient Acknowledgement

MEMORIAL HERMANN INFORMATION EXCHANGE "MHIE" PATIENT CONSENT FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION.

Northeast Primary Care Associates, P.A.

Medication Management Agreement

Receipt and Acknowledgement of Northeast Primary Care Associates, PA General Practice Information Notice

Insurance Authorization and Assignment

Make An Appointment

Office Hours

8901 FM 1960 Bypass Road West, Suite 201
Humble, Tx 77338
281-548-3627

8901 FM 1960 Bypass Road West, Suite 201
Humble, Tx 77338
281-548-3627

MEMORIAL HERMANN INFORMATION EXCHANGE "MHIE"
PATIENT CONSENT FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION.

Receipt and Acknowledgement of
Northeast Primary Care Associates, PA
General Practice Information Notice