Your Name:      Email:

Patient Info

     Last Name:      First Name:      MI:

     Date of Birth:      Social Security Number:

     Address:      Address Line 2:

     City:      State:      Zip:

     Primary Phone #:      Back Up Phone # (if applicable):

     Employer:

Spouse or Guardian

     Full Name:      Date of Birth:

     Relationship to Patient:

     Phone #:      Employer:

Primary Insurance Coverage
     Please complete, even if we've taken a copy of your card

Check here for No Insurance/Self Pay

     Insurance Company:      CoPay: $

     Subscriber Name:      Date of Birth:

     Subscriber SSN:      Relation to Patient:

     ID/Policy #:      Group #:

Secondary Insurance Coverage

     Insurance Company:      CoPay: $

     Subscriber Name:      Date of Birth:

     Subscriber SSN:      Relation to Patient:

     ID/Policy #:      Group #:

Emergency Contact Info
     In case of emergency, whom should we contact?

Use the Spouse or Guardian named above

     Name:      Relation:      Phone:

I authorize this office to release to the named insurance company any information necessary to expedite insurance payment. I understand that I am responsible for all charges, regardless of insurance coverage.

     Guarantor Signature:      Date:

Due to reporting requirements by the government and for our electronic medical record, we need these additional questions answered from our patients:

Race
     American Indian or Alaskan Native
     Asian
     Native Hawaiian or Other Pacific Islander
     Black or African American
     White
     Other Race:
     Decline to Specify

Ethnicity
     Hispanic or Latino
     NOT Hispanic or Latino
     Decline to Specify

Language
     English
     Spanish
     Other Language:

Pharmacy of Choice
     Please include the city and street of your preferred pharmacy to ensure prescriptions are sent to the correct location.

     Primary Pharmacy:

     Secondary Pharmacy:

Would you like to be web-enabled in our system? This will allow you to view lab results, see balances accrued, receive appointment reminders, and access your medical records through our clinic's patient portal.

     YesNo

     If yes, please provide your email address:
     This email address will serve as your username for the portal, and be used for related correspondences.

     Name:      Date of Birth:

     Chief Complaint:

Medical History

YouFamily      Cardiovascular Disease        Details:

YouFamily      Hypertension                         Details:

YouFamily      Head/Ear/Neck/Throat         Details:

YouFamily      Respiratory Problems           Details:

YouFamily      Breast Disease                        Details:

YouFamily      Hepatitis/Jaundice                 Details:

YouFamily      Gall Bladder Disease             Details:

YouFamily      Kidney Problems                   Details:

YouFamily      Anemia/Blood Disorders       Details:

YouFamily      Osteoporosis                           Details:

YouFamily      Diabetes                                  Details:

YouFamily      Thyroid Disease                     Details:

YouFamily      Cancer                                    Details:

YouFamily      Dementia/Neuro Disorders   Details:

YouFamily      Alcohol/Drug Problems        Details:

YouFamily      Other                                      Details:

Medications (Name and dosage, please)

Allergies

Hospitalization and/or Surgical History

     Ailment/Operation:      Date:

     Ailment/Operation:      Date:

     Ailment/Operation:      Date:

     Ailment/Operation:      Date:

OB/Gyn History

     First day of last period:      Date of last Pap:

     Current contraception (if applicable):

     Number of pregnancies:      Number of births:

     Number of vaginal deliveries:      Number of C-sections:

Tobacco/Alcohol Use

Are you a:
     Current Smoker
     Former Smoker
     Nonsmoker
     User of tobacco in other forms

Did you have a drink containing alcohol in the past year?
     Yes
     No

If yes, please describe your alcohol usage (how many drinks would you estimate you have per week or per month, whichever is more applicable?)

Is there anything else we should know about your medical or family history? Please list it below:

Dear Patient,

It is our policy to keep all matters regarding our patients in strict confidence. Please take a few moments of your time to provide us with the names of your family and/or friends who may call for information regarding your appointments, results, or any other medical information.

Persons I authorize to obtain information for/about me:

     Name:      Relation:

     Name:      Relation:

     Name:      Relation:

     Name:      Relation:

     Name:      Relation:

I do not authorize anyone to obtain my information at this time.

     Patient or Guardian Signature:      Date:

LIFESTAGES
3908 E Flamingo Ave
Nampa, ID 83687

I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such as quality assessments and physician certifications.

I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that LifeStages has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notices of Privacy Practices.

     Patient Name:

     Relationship to Patient (if not self):

     Signature:      Date:

We would like to take this opportunity to welcome you to LIFESTAGES. Your clear understanding of our policies is important to our relationship. Therefore please read carefully and feel free to ask any questions you may have.

Our office hours are:     Monday-Thursday 8:30am - 5:00pm

If you have an emergency after hours that cannot wait until normal business hours, please call our office and an operator will page the doctor on call. Otherwise please hold non-emergent matters until regular office hours.

Clinic Policies
Please initial after reading each policy, regardless of applicability, unless otherwise noted.

       Refill Requests - Please give at least 24 hours notice on all refills. Contact your pharmacy first, and they will contact us with your needs. Refills will be authorized only during regular office hours. Narcotics (controlled medications) will not be filled after clinic hours, and can only be filled by your primary physician. Please do not wait until you are completely out of a medication before calling for a refill.

       We require 24 hours' notice if you are unable to make your scheduled appointment with your provider. We understand that circumstances arise when you are unable to do so, but we ask that you do your best to provide adequate notice. Our office No-Show fee is $26 for missed appointments or cancellations with less than 24 hours' notice.

       Service/Emotional Support Animals are welcome in the office with certified documentation provided by a clinician. Animals must be leashed AT ALL TIMES and kept by your side.

       Parental consent is required for ALL medical services provided to patients under the age of 18, in accordance with Idaho State Senate Bill No. 1329, effective July 1, 2024. Therefore, a parent or guardian must accompany minors for all appointments, or sign a consent form ahead of time that the patient must provide at check-in.

       If you are not seen in our office by a provider for more than 3 years, you will be classified as a New Patient when rescheduling and subject to appointment availability and charges as such.

       If you are needing our office to complete FMLA/Short Term Disability paperwork on your behalf, please bring in ALL required forms for your employer/insurance at the same time. Multiple sets of paperwork brought in after the initial set may result in a $25 processing fee to be paid before completion of the forms.

Financial Policies

       As a courtesy, we bill your insurance for you. However, it is your responsibility to follow up with your carrier if the claims are not paid. Our billing staff will be happy to assist you with any questions. If payment by insurance is not received, the balance will become your responsibility.

       We require a copy of your current insurance card to ensure accurate billing. Please keep in mind that we do not accept all insurances. It is your responsibility to consult directly with your insurance company to find out whether we participate with them, and whether they will cover the services being provided to you. If your insurance requires a referral, it is your responsibility to ensure this is in place at the time of service. Failure to do so will lead to rescheduling your appointment.

       Balances need to be paid within 90 days of receiving your first statement. Unpaid balances will be reviewed and sent to Bonneville Management Service for payment arrangements, or to Bonneville Collections, whichever applies.

       Some insurance companies bill labs through our clinic, and some do not. If your insurance does not bill through us, you (or your insurance) will receive a separate bill from the lab company, to be paid directly to them. Please ask our staff for a list of insurance companies that handle lab billing in this way.

       All Self Pay (no insurance) will be required to pay in full at the time of service, unless a payment plan has been arranged with our billing manager. We offer a 20% discount on most services for uninsured patients. For your convenience, our staff can give an estimate of charges for your appointment, but these quotes are not exact.

Surgery Policies

       All surgeries will be pre-certified prior to admission and the insurance company will quote benefits. Your Co-insurance percentage is required 5 days prior to admission. The remaining balance will be set up on a monthly payment plan to be paid off no later than 3 months from the surgery date.

       Patients with NO Insurance and needing surgery are required to pay half of the total surgery amount 2 days prior to surgery. The remaining balance will be set up on a payment plan or with Bonneville Management Service.

       If our office does not receive the required down payment by the above deadline, your surgery may be postponed until payment is made.

Medicaid/Medicare Financial Policies      Please check here if not applicable

       Medicaid patients on the Healthy Connections Program are responsible for arranging referrals ahead of the appointment time. If referral from your listed Primary Care Physician is not received by our office at least 24 hours before your scheduled appointment time, your appointment will be rescheduled.

       Your Medicaid ID number and/or card must be provided at time of service. Any charges that are accrued before Medicaid is active are the responsibility of the patient.

       Medicaid only pays for routine physicals every two years. Please be aware that you may be billed for your exam or any other charges accrued from an annual physical visit if coverage is denied by Medicare.

I request that payment of authorized insurance benefits be made, on my behalf, to LifeStages for any services furnished to me by that provider. I authorize any holder of medical information about me to release to the Council on Medical Service and its agents any information needed to determine benefits or the benefits payable for related services. This authorization is in effect until I choose to revoke it.

I understand that I am responsible for all charges regardless of insurance coverage, and I have read and understand the financial policies of LifeStages.

     Patient or Guardian Signature:      Date:

To provide the highest quality care, it is necessary for patients to attend their scheduled appointments on time. As a courtesy, an appointment reminder will be sent prior to your scheduled appointment. However, it is the responsibility of the patient to arrive for their appointment on time, regardless of prior notification. If you are unable to keep your appointment, please notify us as soon as possible. We understand that occasional missed appointments can occur for a variety of reasons.

A 'No Show/Late Cancellation' is defined as missing an appointment without cancelling at least 24 hours before the scheduled time. There will be a charge for a missed or late-cancelled appointment of $26.00. Insurance will not be billed nor will they cover charges for missed or late cancellations.

An appointment is considered missed when any of the following occur:

• The appointment is cancelled within 24 hours of the scheduled meeting time.
• The patient does not present to the office for the scheduled appointment.
• The patient arrives more than 10 minutes late.

After the third missed appointment within a one-year time period, we reserve the right to remove you from our schedule at which point your account will be reviewed by your provider.

I have read and understand LifeStages Missed Appointment Policy and understand that it is my responsibility to plan and attend appointments I have scheduled. Furthermore, I understand that it is my responsibility to give at least 24-hour advanced notice to LifeStages if I cannot attend my scheduled appointment or I will be charged a fee of $25.00 for a No Show or Late Cancellation.

     Patient Name:      Date of Birth:      Date:

    Patient or Guardian Signature:     Relationship to Patient: