Sync template from atomicqms-style deployment

Forms/Intake-Forms/FRM-OPT-001-New-Patient-Registration.md

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+# New Patient Registration Form
+
+| Form ID | FRM-OPT-001 | Revision | 1.0 |
+|---------|-------------|----------|-----|
+
+---
+
+## Patient Information
+
+| Field | Entry |
+|-------|-------|
+| Last Name | |
+| First Name | |
+| Middle Name/Initial | |
+| Preferred Name | |
+| Date of Birth | |
+| Age | |
+| Sex | ☐ Male ☐ Female ☐ Other |
+| Social Security # (last 4) | XXX-XX-_____ |
+
+### Contact Information
+
+| Field | Entry |
+|-------|-------|
+| Street Address | |
+| Apartment/Unit | |
+| City | |
+| State | |
+| Zip Code | |
+| Home Phone | |
+| Cell Phone | |
+| Work Phone | |
+| Preferred Contact Method | ☐ Home ☐ Cell ☐ Work ☐ Email |
+| Email Address | |
+| OK to Leave Message? | ☐ Yes ☐ No |
+
+### Additional Information
+
+| Field | Entry |
+|-------|-------|
+| Marital Status | ☐ Single ☐ Married ☐ Divorced ☐ Widowed ☐ Partnered |
+| Race/Ethnicity (optional) | |
+| Preferred Language | |
+| Interpreter Needed? | ☐ Yes (Language: _______) ☐ No |
+| Employer | |
+| Occupation | |
+
+---
+
+## Emergency Contact
+
+| Field | Entry |
+|-------|-------|
+| Name | |
+| Relationship | |
+| Home Phone | |
+| Cell Phone | |
+| Work Phone | |
+
+---
+
+## Primary Care Information
+
+| Field | Entry |
+|-------|-------|
+| Primary Care Physician | |
+| Practice Name | |
+| Phone Number | |
+| Fax Number | |
+| Address | |
+| Date of Last Visit | |
+
+---
+
+## Referring Provider (if applicable)
+
+| Field | Entry |
+|-------|-------|
+| Referring Physician | |
+| Practice Name | |
+| Phone Number | |
+| Fax Number | |
+| Reason for Referral | |
+
+---
+
+## Insurance Information
+
+### Primary Insurance
+
+| Field | Entry |
+|-------|-------|
+| Insurance Company | |
+| Policy/ID Number | |
+| Group Number | |
+| Policy Holder Name | |
+| Policy Holder DOB | |
+| Relationship to Patient | ☐ Self ☐ Spouse ☐ Child ☐ Other: _______ |
+| Insurance Phone | |
+
+### Secondary Insurance (if applicable)
+
+| Field | Entry |
+|-------|-------|
+| Insurance Company | |
+| Policy/ID Number | |
+| Group Number | |
+| Policy Holder Name | |
+| Policy Holder DOB | |
+| Relationship to Patient | ☐ Self ☐ Spouse ☐ Child ☐ Other: _______ |
+| Insurance Phone | |
+
+---
+
+## Responsible Party (if different from patient)
+
+| Field | Entry |
+|-------|-------|
+| Name | |
+| Relationship to Patient | |
+| Date of Birth | |
+| Address (if different) | |
+| Phone Number | |
+| Email | |
+
+---
+
+## Pharmacy Information
+
+| Field | Entry |
+|-------|-------|
+| Preferred Pharmacy Name | |
+| Address | |
+| Phone Number | |
+| Cross Street/Location | |
+| Preferred Mail Order Pharmacy | |
+
+---
+
+## Medical History Summary
+
+### Current Medications
+*List all current medications including over-the-counter and supplements*
+
+| Medication Name | Dose | Frequency |
+|-----------------|------|-----------|
+| | | |
+| | | |
+| | | |
+| | | |
+| | | |
+| | | |
+
+### Allergies
+
+☐ No Known Allergies (NKA)
+
+| Allergen | Type | Reaction |
+|----------|------|----------|
+| | ☐ Drug ☐ Food ☐ Other | |
+| | ☐ Drug ☐ Food ☐ Other | |
+| | ☐ Drug ☐ Food ☐ Other | |
+
+### Medical Conditions
+*Check all that apply*
+
+| Condition | ☐ | Condition | ☐ |
+|-----------|---|-----------|---|
+| Arthritis | | Liver Disease | |
+| Asthma | | Lung Disease/COPD | |
+| Cancer | | Mental Health Condition | |
+| Diabetes | | Seizures/Epilepsy | |
+| Heart Disease | | Stroke/TIA | |
+| High Blood Pressure | | Thyroid Disease | |
+| High Cholesterol | | Other: _____________ | |
+| Kidney Disease | | Other: _____________ | |
+
+### Surgical History
+
+| Surgery/Procedure | Year |
+|-------------------|------|
+| | |
+| | |
+| | |
+
+---
+
+## Social History
+
+| Field | Entry |
+|-------|-------|
+| Tobacco Use | ☐ Never ☐ Current ☐ Former (Quit year: _____) |
+| If yes, type/amount | |
+| Alcohol Use | ☐ None ☐ Social ☐ Daily |
+| If yes, type/amount | |
+| Exercise | ☐ None ☐ Light ☐ Moderate ☐ Vigorous |
+| Frequency | times per week |
+
+---
+
+## How Did You Hear About Us?
+
+☐ Physician Referral: _________________
+☐ Insurance Directory
+☐ Internet Search
+☐ Social Media
+☐ Friend/Family Member
+☐ Other: _________________
+
+---
+
+## Acknowledgments
+
+### Financial Policy
+☐ I have read and understand the financial policy. I authorize payment directly to this practice of any insurance benefits otherwise payable to me. I understand that I am responsible for any amount not covered by insurance.
+
+### Privacy Practices
+☐ I have received a copy of the Notice of Privacy Practices and understand how my health information may be used and disclosed.
+
+### Release of Information
+☐ I authorize the release of medical information necessary to process insurance claims and for continuity of care with referring and consulting physicians.
+
+### Communication Authorization
+☐ I authorize communication via: ☐ Phone ☐ Email ☐ Text Message for appointment reminders and health information.
+
+### Assignment of Benefits
+☐ I authorize payment of medical benefits to this practice for services rendered.
+
+---
+
+## Patient Portal
+
+☐ I would like to enroll in the patient portal
+
+| Field | Entry |
+|-------|-------|
+| Preferred Email for Portal | |
+
+---
+
+## Signature
+
+| Field | Entry |
+|-------|-------|
+| Patient/Guardian Signature | |
+| Printed Name | |
+| Relationship (if not patient) | |
+| Date | |
+
+---
+
+## For Office Use Only
+
+| Field | Entry |
+|-------|-------|
+| Date Received | |
+| Entered By | |
+| Chart Number | |
+| Insurance Verified | ☐ Yes |
+| Copay Collected | $ |
+| Notes | |
+
+---
+
+*Form FRM-OPT-001 Rev 1.0 - New Patient Registration Form*