New Patient Form

Patient Packet

WELCOME NEW ARGYLL PATIENTS

Welcome to Argyll Medical Group where our motto is "Upgrade to Personal Service Family Medicine".

Your new patient packet has several forms that will assist us in providing you the best possible healthcare service.

  1. Patient Information/ Responsibility Party Information: We ask patients to provide us with their specific personal information to register them as an Argyll patient and for administration purposes.
  2. Consent for Release of Medical Records use: Argyll will take care of obtaining your medical records with this form.
  3. Office Policy on Medication Refills: This informs patients on Argyll’s refill policy on Medications and Mail Away Pharmacies.
  4. Missed Appointment Fee and Cancellation Fee: This informs patients of our missed appointment cancellation appointment
  5. Patient Financial Policy and Statement: Argyll asks patients to work with us to remain the health care provider of choice in the area by fairly paying for services rendered. We find establishing a clear financial agreement with patients from the beginning helps avoid misunderstandings.
  6. Assignment of Insurance Benefits and Collection Policy: We are happy to work with patients to bill their insurance. This form authorizes Argyll to bill the insurance on behalf of the patient. It also provides important information to clarify the patient’s responsibility for any charges not covered by their insurance.
  7. Patient Acknowledgement of Receipt of a Notice and Access of Privacy Practices and Consent / Limited Authorization and Release form & Communication Preferences / Patient Portal Account: This informs patients of Argyll's Privacy Practices, Private Health information release, communications preferences and Patient Portal Access.
  8. Medi-Cal Acknowledgement: We are not contracted with Medi-Cal. As a result, we can not establish a relationship with a patient who is insured with this insurance.

Other resources new patients should be aware of:

Finance Department: We make an effort to be there for you if you have temporary difficulty meeting your financial responsibility for the health services you and your family need. The Finance Department can also answer questions about your bill. New patients should inquire about our Convenience Payment Options.

Group Manager: Argyll is known for our policy of openness with our patients and our "customer service" philosophy for healthcare. Patients are encouraged to bring up concerns or praise regarding the service they receive. Patients may meet with the manager in person, via e-mail, or complete a quality survey.

Personal Service: Argyll is sincere in our commitment to delivering "Personal Service Family Medicine". Our staff is particularly approachable and reachable during business hours. Make sure to take your Argyll physician’s card for the direct number to your office and discuss with the staff the best way to get your concerns addressed in a timely manner. Patients might also consider taking our Business Information and Directory card to their pharmacy etc. to ensure administration between our offices is handled with the convenience and efficiency which Argyll patients have become accustomed.

For any Referrals or Pre-authorization requests, patients may be subject to additional fees based on time spent to complete.

Each practice independently owned. Management services provided by Argyll Medical Group LLC.

There are many questions below that we ask you to answer. They may help me better understand how to treat the concern that brought you here today. They might also remind you of other issues you’d like addressed. Depending on their nature, some of these issues may be covered today and some others may require a separate office visit so we can give them the time and attention they deserve.

Adult History Medical Form

Please approximate your last appoint dates for the following:

Past Medical History

Please check the conditions that apply to you.

For Women

Please check all that apply to you.**

**Always tell your doctor at each exam if you think you may be pregnant or are breastfeeding.

For Everyone

Surgical History

YesNo

Hospital History

YesNo

Family History

YesNo

Social History

Review of symptoms that have may have troubled you over the past month. Please check all that apply to you.

If you have a preference for a provider, please make a selection.

The following providers are currently taking patients

The following providers are NOT taking patients unless approved by the provider

Your Signature