Patient Forms | Packer Medical Center

Signature and Agreement

By entering your full name in the contact form, you acknowledge that your name serves as a digital signature and holds the same legal value as a handwritten signature. This confirms that all the information you have provided is accurate, and you agree to the terms outlined in our Patient Policies. Your name will be used to process your records, consent, and any necessary medical documentation.

Financial Consent Form

The Financial Consent Form is the second required form. After completing your General Consent to Treat Form, please click the button below to complete and electronically submit your Financial Consent Form.

Submit Your Forms

Please complete both required forms online and submit each form electronically by clicking the SUBMIT button at the end of the form.

Both the General Consent to Treat Form and Financial Consent Form must be completed and electronically submitted as part of your patient intake before your appointment is confirmed.

Privacy Notice

All patient information is kept confidential and is securely stored according to HIPAA guidelines. By submitting this form, you consent to the use of your data for medical purposes only.

Please click the button below to review our HIPAA Privacy Policy.

Full Name

Address

Phone

E-mail

Date of Birth

Emergency Contact Name

Enter Emergency Contact Phone

Preferred Pharmacy

Insurance Provider

Insurance Member ID

Patient Signature| By signing below, you confirm that the information provided is accurate and agree to the terms outlined in our Patient Policies.

Date

HIPAA Privacy Acknowledgment I acknowledge that I have received or have been provided access to the Notice of Privacy Practices for the practice. Please review the HIPAA Policy before signing below.

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Consent for Treatment I consent to medical evaluation and treatment by Packer Medical Center. I understand that my medical care may include examination, evaluation, diagnostic testing, treatment, prescriptions, referrals, and other medically appropriate services. I consent to a provider reviewing outside available medical/pharmacy care/information.

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Financial Policy & Billing Agreement I acknowledge and agree to Packer Medical Center's financial policies and accept financial responsibility for applicable charges associated with services provided to me. I understand that applicable copayments, deductibles, coinsurance, self-pay amounts, and other patient-responsibility balances may be due in accordance with my insurance benefits and Packer Medical Center's financial policies.

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Authorization for Release of Medical Records I authorize Packer Medical Center to obtain or release medical information as permitted by applicable law and in accordance with any additional authorization requirements that may apply.

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Authorization and Acknowledgment for Review of Medical and Medication Information

I understand and acknowledge that, as part of my medical evaluation and treatment, my healthcare provider may review available health information reasonably necessary for my care, including outside medical records, health information exchange (HIE) information, pharmacy and medication histories, prior prescription information, and other available healthcare information, as permitted or required by applicable law. I understand that this may include information available through electronic health record and medication-history systems, pharmacies, other healthcare providers, and applicable health information exchanges, including CRISP (Chesapeake Regional Information System for our Patients). I further understand that my healthcare provider may access and review information available through the Maryland Prescription Drug Monitoring Program (PDMP) when permitted or required by law, including controlled-substance prescription information, as part of evaluating medication safety and providing appropriate medical treatment. This acknowledgment does not authorize disclosure or access to information for which a separate authorization or specific consent is required by federal or state law.

I acknowledge that I have read and understand the above information regarding the review of my available medical, pharmacy, medication, HIE, and prescription history as part of my medical care.

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Insurance Assignment of Benefits I authorize payment of applicable medical insurance benefits directly to Packer Medical Center for covered services provided to me.

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Electronic Communication Consent I consent to receive appointment reminders and other practice-related communications by telephone, email, text message, or other electronic communication methods, subject to applicable law and my communication preferences.

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Telemedicine Consent I consent to receive medical services through telemedicine when medically appropriate. I understand that telemedicine has limitations and may not replace an in-person medical evaluation when an in-person examination, diagnostic testing, or treatment is medically necessary.

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No‑Show / Late Cancellation Policy I understand that missed appointments or appointments cancelled with less than 24 hours' notice may be subject to a fee in accordance with Packer Medical Center's no-show and cancellation policy.

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Authorization to Charge Card on File I authorize Packer Medical Center to charge my authorized card on file for applicable patient-responsibility amounts, including copayments, balances, and permitted missed-appointment or late-cancellation fees, in accordance with Packer Medical Center's financial policy and card-on-file agreement.

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Secure Photo Identification & Insurance Card Submission I understand that, as part of the patient registration and intake process, I will receive a secure, protected link through the Tebra patient system for submission of my government-issued photo identification and insurance card. I agree to submit the requested identification and insurance information through the secure Tebra link provided to me during the patient intake process. * I acknowledge and agree to submit my government-issued photo identification and insurance card through the secure Tebra link provided during patient intake.

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Primary Medical Conditions

Current Medications

Allergies

Past Surgeries/Hospitalizations

Family Medical History

Patient Certification I certify that the information I have provided is true, complete, and accurate to the best of my knowledge.

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Required Electronic Signature Acknowledgment I have read and agree to the Electronic Signature Consent & Agreement above and consent to the use of my electronic signature on this form. This checkbox is REQUIRED and the form must not submit unless it has been checked.

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Final Certification By electronically submitting this form, I certify that the information I have provided is accurate to the best of my knowledge. I reaffirm that I have read and agreed to the Electronic Signature Consent & Agreement and that the electronic signatures I entered on this form are intended to serve as my legally binding signatures.

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SMS opt in

I agree to receive SMS/text messages from Packer Medical Center regarding services, scheduling, and account updates. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for assistance. Consent is not a condition of purchase.

Electronic Signature Consent & Agreement

By completing and submitting this electronic form, I consent to the use of electronic records and electronic signatures in connection with my care and my relationship with Packer Medical Center.

I understand and agree that typing my name into a signature field and electronically submitting this form constitutes my electronic signature. I intend my electronic signature to have the same legal force and effect as my handwritten or “wet ink” signature, to the fullest extent permitted by applicable law.

I understand that my electronic signature signifies that I have read, understood, and voluntarily agreed to the information, acknowledgments, authorizations, consents, policies, and agreements associated with the applicable signature field.

I certify that I am the patient identified on this form or the patient's legally authorized representative and that I am authorized to provide the electronic signatures and consents contained in this form.

I agree to the Terms & Conditions and Privacy Policy

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