5295 NE Elam Young Parkway, Suite 180
Hillsboro, Oregon 97124
Ph: 503-615-0960 / Fax: 503-615-8572
DATE
FIRST
M.I
LAST
D.O.B
AGE
SEX
SS#
HOME PHONE
CELL PHONE
EMPLOYER
OCCUPATION
EMAIL ADDRESS
(This provides you with access to our web portal)
HOME MAILING ADDRESS:
STREET
CITY/STATE
ZIP
PHYSICAL ADDRESS :
STREET
CITY/STATE
ZIP
WOULD YOU LIKE PHONE
REMINDERS? YES [ ] NO [ ]
PREFERRED CONTACT METHOD:
HOME PHONE [ ]
CELL PHONE [ ]
DO YOU HAVE AN ADVANCED
DIRECTIVE?
IF YES, WHERE IS IT KEPT?
IF NO, WOULD
YOU LIKE ONE?
FIRST
M.I
HOME PHONE
WORK PHONE
CELL PHONE
HOME MAILING ADDRESS:
STREET
CITY/STATE
ZIP
D.O.B
SS#
AGE
SEX
NAME
PHONE
RELATIONSHIP TO PATIENT
SINGLE [ ]
MARRIED [ ]
WORK PHONE
(IF DIFFERENT)
YES [ ]
YES [ ]
EMAIL [ ]
NO [ ]
NO [ ]
PARENT/RESPONSIBLE PARTY:
LAST
(FOR THOSE UNDER 18)
RELATIONSHIP TO PATIENT
EMERGENCY CONTACT:
HOW DID YOU HEAR ABOUT
OUR OFFICE?
FINANCIAL POLICY
A health insurance policy is a contract between a patient, the patient’s employer, and the insurance carrier. It is the patient’s
responsibility to verify service, providers and facilities eligible for coverage. We bill insurance as a courtesy to you.
We have contractual relationship as a “preferred provider” with many carriers and are bound by our contracts to collect
copayments at the time of service, in addition to any charges not covered by insurance. If you do not have your copayment at
check in, your appointment may be rescheduled.
Without a current insurance card, you will be charged for the price of your appointment, and billed for any additional services if
applicable.
Payment of an account balance not covered by insurance is due within 30 days. If your account becomes delinquent, there will be
no medical services of any kind until your account balance has been paid.
If you cancel or reschedule your appointment with less than 24 hours notice, or fail to show for your appointment, you may be
subject to a $25 fee.
If you use a check for payment of co-pay or account balance, you are authorizing us to electronically (or by paper draft) present the
check to your bank account for collection of the amount on the check, plus a $25 NSF fee if the funds are not available.
We will make every attempt to assist you in successfully fulfilling your financial obligation to us. However, delinquent accounts may
be transferred to a credit reporting collection service. While actively in collections, you will be discharged from our practice.
CONSENT – AUTHORIZATION TO RELEASE INFORMATION – ASSIGNMENT OF BENEFITS AGREEMENT/CONTRACT
I consent to and authorize all treatment that may be considered necessary or advised by the physicians.
I hereby authorize Michel Hicken, MD PC and/or the providers to release to my insurance company any information acquired in the
course of my treatment in accordance with applicable law. I also authorize release of information to business associates in order to
carry out treatment.
I will provide the office with a current copy of my insurance card(s), and inform the office of any changes in my insurance and
contact information as they occur in order to meet timely filing limits. Without insurance I will pay for necessary charges up front
and understand that I may be billed for any remaining charges.
I hereby agree to full responsibility for all expenses incurred and hereby assign to Michael Hicken, MD PC and/or the providers,
any and all insurance benefits due this patient to the full extent of my financial obligation to said doctor.
I understand insurance coverage is a relationship between the insured and their insurance company, and I agree to accept
financial responsibility for charges incurred. In the event of nonpayment, I will bear the cost of collection and/or court costs and
reasonable legal fees should this be required.
PATIENT CENTERED PRIMARY CARE MEDICAL HOME
Our office is considered to be part of the Patient Centered Primary Care Home (PCPCH) network. We will be your medical home and
provide you with the high quality care you deserve. Please ask our staff if you have any questions in regard to this.
PATIENT SIGNATURE:
(OR GUARDIAN IF UNDER 18)
PLEASE PRINT NAME:
DATE:
HISTORY & PHYSICAL EXAMINATION
DATE:
NAME:
D.O.B:
CURRENT MEDICATIONS
NAME
DOSE
HOW OFTEN
MEDICATION ALLERGIES:
PAST OR CURRENT MEDICAL CONDITIONS (Please check all that apply)
HEART ATTACK
HEART MURMUR
STROKE
ASTHMA
DIABETES
HEPATITIS
THYROID DISEASE
CONGESTIVE HEART FAILURE
HIGH CHOLESTEROL
ANXIETY/PANIC ATTACKS
HEARTBURN/ACID REFLUX
HIGH BLOOD PRESSURE
CHRONIC BACK/NECK PAIN
CHRONIC DIARRHEA
STOMACH ULCERS
DEPRESSION
KIDNEY DISEASE
SEIZURES
ALCOHOLISM
COPD/EMPHYSEMA
ARTHRITIS
PRIOR SURGERY/DATES:
CONDITIONS IN FAMILY MEMBERS (Please check all that apply)
HEART ATTACK
DIABETES
HIGH CHOLESTEROL
ARTHRITIS
SEIZURES
COPD/EMPHYSEMA
DEPRESSION
CONGESTIVE HEART FAILURE
STROKE
HIGH BLOOD PRESSURE
ASTHMA/ALLERGIES
DEPRESSION
KIDNEY DISEASE
ALCOHOLISM
OTHER
HAVE YOU EVER SMOKED REGULARLY? YES [ ] NO [ ]
DO YOU CURRENTLY SMOKE? YES [ ]
YEAR YOU STARTED?
YEAR YOU QUIT?
ALCOHOL USE:
NEVER [ ]
SOCIALLY [ ]
REGULARLY [ ]
DAILY [ ]
LIVING SITUATION:
ALONE [ ]
SPOUSE [ ]
PARTNER [ ]
FRIENDS [ ]
HOW MANY CHILDREN DO YOU HAVE?
OCCUPATION:
NO [ ]
HOW MUCH?
RARELY [ ]
NUMBER OF CHILDREN AT HOME?
ASSISTED HOME [ ]
FAMILY [ ]
PATIENT PRIVACY NOTICE
We are required by law to protect the privacy of your medical information and to provide you with written notice describing how
medical information about you may be used and disclosed and how you can access this information.
 We may use or disclose to others your medical information for the purpose of providing or arranging for your health care,
the payment or reimbursement of the care that we provide to you, and the related administrative activities supporting your
treatment.
 We may be required or permitted by certain laws, regulations, or circumstances to use and disclose your medical
information for certain purposes without your authorization. Under other circumstances we may need your written
authorization (that you may later revoke) in order to use or disclose your medical information.
 As our patient, you have important rights relating to inspecting and copying your medical information that we maintain,
amending or correcting that information, obtaining an accounting of our disclosures of your medical information,
requesting that we communicate with you confidentially, requesting that we restrict certain uses and disclosures of your
health information, and expressing concerns if you believe your rights have been violated.
 We have a detailed notice of privacy practices available that fully explains your rights and our obligations under the law.
We may revise our notice from time to time.
 You have the right to receive a copy of our most current notice in effect.
PATIENT SIGNATURE:
(OR GUARDIAN IF UNDER 18)
PLEASE PRINT NAME:
DATE: