Download Welcome to Alpine Family Medicine!

Welcome to Alpine Family Medicine!
ALPINE FAMILY MEDICINE
Peter V. Sundwall Jr., M.D.
Daniel W. Egan, M.D.
Thank you for choosing us to care for your family. Our goal is to treat you like we would want to be treated.
Circle your doctor’s name: Egan/Sundwall
Patient Name: __________________________________________
Street Address: ________________________________________________________________________
City: ____________________________________Zip: _________________________________________
Home Phone: ______________________________________Cell Phone: __________________________
Patient SSN: ____________________________________________Birth Date: _____________________
E-mail ___________________________Pharmacy & Location: __________________________________
Emergency Contact Name and Relationship: _________________________________________________
Emergency Contact Phone: __________________________________
Responsible Party (Guarantor Primary Insurance):
Guarantor Name: _________________________ Date of Birth: _________________________________
Guarantor SSN: ___________________________ Insurance Name: ______________________________
Policy number: ____________________________Relationship to Patient:_________________________
Guarantor Address: ________________________ City: _____________________Zip: ________________
Guarantor Phone: _________________________
Employment Information: _____________________________ Work Phone#______________________
Responsible Party (Guarantor Secondary Insurance):
Guarantor Name: _________________________ Date of Birth: _________________________________
Guarantor SSN: ___________________________ Insurance Name: ______________________________
Policy number: ____________________________Relationship to Patient:_________________________
Guarantor Address: ________________________ City: _____________________Zip: ________________
Guarantor Phone: _________________________
Employment Information: _____________________________ Work Phone#_______________________
I hereby give my consent for Alpine Family Medicine to use and disclose my protected health information (PHI) to carry out
treatment, payment and health care operations (TPO).
I have the right to review the Notice of Privacy Practices prior to signing this consent. Alpine Family Medicine reserves the right to
revise its notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to
Alpine Family Medicine, 155 W Canyon Crest Rd. Ste., 200 Alpine Utah, 84004.
With this consent, Alpine Family Medicine may call my home, leave messages, send me regular mail, or e-mail in reference to any
items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls or communications pertaining
to my clinical care, including laboratory test results, among others.
By signing this form, I am consenting to allow Alpine Family Medicine to use and disclose my PHI to carry out TPO.
I also agree to be responsible for any fees not covered by insurance and any collection charges (which will include a 40%
collection fee added to the account balance), interest charges of 1.5% (18% APR), Late payment fees or legal fees on accounts past due.
I authorize Alpine Family Medicine, LLC to charge my major credit/debit card, which I provide to be kept on file, with the patient
portion of balance remaining including late payment fees, if said portion has not been paid within 90 days from original billed date. I
understand that I will be immediately forwarded to a collection company without notice, in the event that the amount charged to my major
credit/debit card to bring my account current, does not clear or is declined.
No Show/Late Policy: I understand that in order for Alpine Family Medicine to stay on schedule, I agree to keep all scheduled
appointments or notify of cancellation within 24 hours. This will include same day appointments that are scheduled and not kept. I
understand that I may be billed $25.00 for appointments if I am more than 30 minutes late or do not show.
I authorize Alpine Family Medicine to use and disclose my health information to the following
persons:______________________________________________________________________________
Print Patient’s Name
________________________________________
Print Name of Legal Guardian (if applicable)
Date
___________________________________________
Signature of Patient or Legal Guardian