One to One Clinic - New Patient Registration Form (no previous TextCare NPP)

New Patient Registration Form
Contact Information
Clinic
Are you an Employee or Dependent?*
Are you an Employee, Dependent, or Retiree?
Patient's Name*

First NameMiddle NameLast Name
Patient or Parent/Guardian's Cell Phone Number (if patient is a minor)*

Area CodePhone Number
Patient's or Parent/Guardian's Work Phone (optional)

Area CodePhone Number
Best number to reach patient or leave a message (if different from cell phone)

Area CodePhone Number
Is it okay to text you about healthcare?*

Yes - You can text me and send detailed health informationYes - You can text me but please do not include health information (texts will be limited to scheduling, notifying me to call the clinic, and appointment reminders)No - Do not text me, I prefer a phone call
Is it ok to leave a detailed voice message including test results?*

YesNo
Patient or Parent/Guardian's Email*
example@example.com
Patient's Date of Birth

MonthDayYear
Date
Patient's Age
Patient's Social Security Number*
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact First and Last Name*
Emergency contact relationship to patient*
Emergency Contact Phone Number:*

Area CodePhone Number
Pharmacy Information
Preferred Pharmacy Name:*
Preferred Pharmacy Phone Number:*

Area CodePhone Number
Preferred Pharmacy Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Demographic Information
Patient's Gender:*

FemaleMaleN/A
Gender Assigned at Birth:

FemaleMaleN/A
Patient's Marital Status:*

SingleMarriedDivorcedWidowedLegally Separated
Patient's Race:*

AsianAmerican Indian or Alaskan NativeBlack or African AmericanNative HawaiianWhitePrefer not to answerOther
Patient's Ethnicity:*

Hispanic or LatinoNot Hispanic or LatinoPrefer not to answerOther
Patient's employment status:*

EmployedSelf-employedRetiredActive DutyUnknownOther
Patient's Health Information
Patient's Current Weight in Pounds:*
Patient's Current Height in Inches:*
Patient's BMI
Allergies: Does the patient have known allergies to medications?*

YesNo
Allergies: Please list any known allergies to medications:*
Medications: Is the patient currently on any medications (including over the counter medications, vitamins, and nutritional supplements)?*

YesNo
Medications: Please list the medications you are currently taking (including over the counter medications, vitamins, and nutritional supplements):*
Does the patient smoke or vape?*

No to bothYes. I smokeYes, I vapeFormer smokerFormer vaper
Does the patient consume alcohol?*

YesNoFormer
Women only (select if applicable)

PregnantBreastfeedingHysterectomy
When is the last time the patient saw a primary care provider for a physical with labs?*

less than 1 year1-5 yearsover 5 years
Who is the patient's primary care provider (or pediatrician if a minor)?

Health History: Personal or Family History ( please list any first or second degree family members - do not include step-family members or those that were adopted)*

	Yes to personal history	No to personal history	Yes to family history	Which relative and what age of diagnosis?
Autism
Birth defects (heart defects, spina bifida)
Blindness from birth or before the age of 40
Blood clots or deep vein thrombosis
Cancer
Cystic Fibrosis
Deafness from birth or before the age of 40
Diabetes
Early Menopause (before age of 40)
Factor V Liden
Heart Disease (including heart attack)
Hemophilia
High Blood Pressure
Intellectual or learning disabilities
Mental illness such as anxiety, depression
Pulmonary Edema
Repeat pregnancy losses (miscarriage, stillbirth)
Sickle Cell Disease
Spinal Muscular Dystrophy
Stroke
Tay-Sashs
Thalessemia
Von Willebrand Disease

Have you had any significant medical events, surgeries, or procedures?*

NoYes
Please list any significant medical events, surgeries, or procedures:*
Authorization to Release Information

Please tell us who we can release health information to
Authorization to Release Medical Information*

SpouseChildrenDo Not Release My InformationOther
Name of spouse to release information to:

First NameLast Name
Spouse's Phone Number

Area CodePhone Number
Names of children to release information to:
Names of other individuals to release information to:
Insurance Information
Primary Insurance Policy Holder's name:*
Primary Insurance Holder's date of birth*

MonthDayYear
Date
Insurance Card FRONT: Please take a photo of the front of your insurance card
Insurance Card BACK: Please take a photo of the back of your insurance card
Driver's License FRONT: Please take a photo of the front of the patient's driver's license or state identification card
Driver's License BACK: Please take a photo of the back of the patient's driver's license or state identification card
Consent to Treat Minor
Parent/Guardian's Name*
Parent/Guardian's Date of Birth*

MonthDayYear
Date
Parent/Guardian's Relationship to Patient*

FatherMotherLegal GuardianOther
Minor's Cell Phone (if the minor is authorized to text message from their phone)

Area CodePhone Number
PARENT/GUARDIAN: By signing below, I attest that I am the parent or legal guardian of the above-listed minor and do hereby consent to and authorize any and all medical care deemed necessary by a qualified One to One medical provider to be rendered independently to the above named minor. This consent form remains in effect until terminated in writing or the minor reaches legal age.
Date Submitted*

MonthDayYear
Date
Signature

Clear
By signing this form, you agree to the below consent agreements and to our use and disclosure of protected health information about you for treatment, payment, and healthcare operations. Please refer to section below for complete Consent to Treatment, Communications Consent, Notice of Privacy Practices, and other policies
If you sign as a personal representative, please describe your legal authority to act for this individual, e.g. power of attorney, healthcare surrogate, etc.

Communications Consent, Notice of Privacy Practices, and Consent to Treatment
General Consent

You consent to treatment by One to One Health providers (Physicans, Physician Associates, and Nurse Practitioners) for your healthcare, including but not limited to exams, testing, medications, and minor procedures. You acknowledge and agree that no garantees have been made to you as the results or outcomes of your care. You understand that state law requres One to One Health to report certain communicalbe diseaes to the Health Department.

If at any time you have questions about your examination, diagnois, or treatments, you will not proceed until your questions have been answered to be fully informed. You understand that giving the providers and nurses all relevant information is important to your proper diagnosis and treatment. You understand complete compliance with your provider's instructions is critical to the success of any treatment prescribed.

Consent to treatment via Telehealth

You acknowledge and agree that One to One will provide virtual primary care services (the “Services”) to you remotely by means of TextCare, a telecommunications technology platform (i.e., via telehealth). You consent to treatment by One to One Health physicians and staff via telehealth, including but not limited to consultation, diagnosis, treatment, and medications. You acknowledge and agree no guarantees have been made to you as to the results or outcome of your care.

Although telehealth may allow you to receive the Services more conveniently, telehealth is not without some disadvantages and risks, including without limitation potential lack of some visual or physical cues otherwise present in a face-to-face meeting or disruptions that could be caused by failures of communication equipment, technologies or service.

You agree to accurately disclose your location prior to receiving treatment. One to One Health providers are only permitted to provide treatment if you are located in a state and jurisdiction in the United States of America in which such providers are licensed to practice medicine.

One to One Health reserves the right, and each medical provider shall have the right, under their sole judgement, to require that a visit for rendering medical care to be conducted using video communications.

You will not engage in any hostile, harassing or other inappropriate behavior when accessing TextCare or otherwise interacting with One to One's professional staff to receive the Services.

Communications Consent

You acknowledge and agree that initiating communications with One to One Health providers using standard SMS and MMS text messaging will be considered as your consent and preference to use SMS and MMS messaging for that visit. You understand that SMS and MMS text messages are not confidential methods of communication and may be insecure. You further understand that, because of this, there is a risk that messaging regarding my medical care might be intercepted and read by a third party.

Any health information received by One to One Health will be considered protected health information and will be subject to our notice of privacy practices.

Protected Health Information

You acknowledge and understand that, although One to One has implemented safeguards to attempt to protect electronic communications, communicating with One to One electronically may not be completely secure, creating a risk of improper disclosure of your protected health information ("PHI") to unauthorized individuals. You hereby expressly authorize One to One to communicate electronically with you for all purposes, including regarding your PHI. One to One will not be liable to you for any damages, losses, injuries, expense or costs that you suffer or incur as a result of or with respect to the use of electronic communications.

Emergency Services

IN CASE OF AN EMERGENCY, YOU SHOULD SEEK IMMEDIATE MEDICAL ATTENTION OR EMERGENCY CARE BY IMMEDIATELY GOING TO AN EMERGENCY ROOM OR BY CALLING 911. Medical concerns that may require emergency treatment should never be raised or addressed through TextCare or related patient portal.

Prescription Policy

One to One's providers are licensed to write prescriptions and will provide prescriptions (to be filled at the pharmacy of your choice) as necessary for treatment or management of medical conditions that are within the scope of the Services provided via TextCare. One to One will never issue prescriptions for controlled substances through the Services provided by TextCare.

HIPAA NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.

One to One Health, including One Doc, PLLC and Two Doc, PLLC, both doing business as One to One Health, and their employees are dedicated to maintaining the privacy of your health information, as required by applicable federal and state laws. These laws require us to provide you with this Notice of Privacy Practices, and to inform you of your rights and our obligations concerning Protected Health Information, or PHI, which is information that identifies you and that relates to your physical or mental health or condition. We are required to follow the privacy practices described below while this Notice is in effect.

Permitted Disclosures of PHI. We may use and disclose your PHI for the following reasons, except as otherwise limited by applicable federal or state law:

A. Treatment. We may use and disclose your PHI to a physician or other health care provider providing treatment to you. For example, we may disclose medical information about you to physicians, nurses, technicians or personnel who are involved with the administration of your care.

B. Payment. We may use and disclose your PHI to bill and collect payment for the services we provide to you. For example, we may send a bill to you or to a third party payor for the rendering of services by us. We may also provide your PHI to our business associates, such as billing companies, claims processing companies and others that process our health care claims.

C. Health Care Operations. We may use and disclose your PHI in connection with our health care operations. Health care operations include quality assessment activities, reviewing the competence or qualifications of health care professionals, evaluating provider performance, and other business operations. For example, we may use your PHI to evaluate the performance of the health care services you received. We may also provide your PHI to accountants, attorneys, consultants and others to make sure we comply with the laws that govern us.

D. Emergency Treatment. We may use and disclose your PHI if you require emergency treatment or are unable to communicate with us.

E. Direct Contact with You. We may use your PHI to contact you to remind you that you have an appointment, to inform you about treatment alternatives or other health-related benefits and services that may be of interest to you.

F. Family and Friends. We may disclose your PHI to a family member, friend or any other person who you identify as being involved with your care or payment for care, unless you object.

G. Required by Law. We may disclose your PHI for law enforcement purposes and as required by state or federal law. For example, the law may require us to report instances of abuse, neglect or domestic violence; to report certain injuries such as gunshot wounds; or to disclose PHI to assist law enforcement in locating a suspect, fugitive, material witness or missing person. We will inform you or your representative if we disclose your PHI because we believe you are a victim of abuse, neglect or domestic violence, unless we determine that informing you or your representative would place you at risk. In addition, we must provide PHI to comply with an order in a legal or administrative proceeding. Finally, we may be required to provide PHI in response to a subpoena discovery request or other lawful process, but only if efforts have been made, by us or the requesting party, to contact you about the request or to obtain an order to protect the requested PHI.

H. Serious Threat to Health or Safety. We may disclose your PHI if we believe it is necessary to avoid a serious threat to the health and safety of you or the public.

I. Public Health. We may disclose your PHI to public health or other authorities charged with preventing or controlling disease, injury or disability, or charged with collecting public health data.

J. Health Oversight Activities. We may disclose your PHI to a health oversight agency for activities authorized by law. These activities include audits; civil, administrative or criminal investigations or proceedings; inspections; licensure or disciplinary actions; or other activities necessary for oversight of the health care system, government programs and compliance with civil rights laws.

K. Research. We may disclose your PHI for certain research purposes, but only if we have protections and protocols in place to ensure the privacy of your PHI.

L. Workers' Compensation. We may disclose your PHI to comply with laws relating to workers' compensation or other similar programs.

M. Specialized Government Activities. If you are active military or a veteran, we may disclose your PHI as required by military command authorities. We may also be required to disclose PHI to authorized federal officials for the conduct of intelligence or other national security activities.

N. Organ Donation. If you are an organ donor, or have not indicated that you do not wish to be a donor, we may disclose your PHI to organ procurement organizations to facilitate organ, eye or tissue donation and transplantation.

O. Coroners, Medical Examiners, Funeral Directors. We may disclose your PHI to coroners or medical examiners for the purposes of identifying a deceased person or determining the cause of death, and to funeral directors as necessary to carry out their duties.

P. Disaster Relief. Unless you object, we may disclose your PHI to a governmental agency or private entity (such as FEMA or Red Cross) assisting with disaster relief efforts.
II. Disclosures Requiring Written Authorization.

A. Not Otherwise Permitted. In any other situation not described in Section A above, we may not disclose your PHI without your written authorization.

B. Marketing and Sale of PHI. We must receive your written authorization for any disclosure of PHI for marketing purposes or for any disclosure which is a sale of PHI.

III. Patient Rights.

A. Right to Receive a Paper Copy of This Notice. You have the right to receive a paper copy of this Notice upon request.

B. Right to Access PHI. You have the right to inspect and copy your PHI for as long as we maintain your medical record. You must make a written request for access to the Privacy Officer at the address listed at the end of this Notice. We may charge you a reasonable fee for the processing of your request and the copying of your medical record pursuant to HIPAA and applicable state law. In certain circumstances we may deny your request to access your PHI, and you may request that we reconsider our denial. Depending on the reason for the denial, another licensed health care professional chosen by us may review your request and the denial.

C. Right to Request Restrictions. You have the right to request a restriction on the use or disclosure of your PHI for the purpose of treatment, payment or health care operations, except for in the case of an emergency. You also have the right to request a restriction on the information we disclose to a family member or friend who is involved with your care or the payment of your care. However, we are not legally required to agree to such a restriction.

D. Right to Restrict Disclosure for Services Paid by You in Full. You have the right to restrict the disclosure of your PHI to a health plan if the PHI pertains to health care services for which you paid in full directly to us.

E. Right to Request Amendment. You have the right to request that we amend your PHI if you believe it is incorrect or incomplete, for as long as we maintain your medical record. We may deny your request to amend if (a) we did not create the PHI, (b) is not information that we maintain, (c) is not information that you are permitted to inspect or copy (such as psychotherapy notes), or (d) we determine that the PHI is accurate and complete.

F. Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures of PHI made by us (other than those made for treatment, payment or health care operations purposes) during the 6 years prior to the date of your request. You must make a written request for an accounting, specifying the
time period for the accounting, to the Privacy Officer at the address listed at the end of this Notice.

G. Right to Confidential Communications. You have the right to request that we communicate with you about your PHI by certain means or at certain locations. For example, you may specify that we call you only at your home phone number, and not at your work number. You must make a written request, specifying how and where we may contact you, to the Privacy Officer at the address listed at the end of this Notice.

H. Right to Notice of Breach. You have the right to be notified if we or one of our business associates become aware of a breach of your unsecured PHI.

IV. Changes to this Notice. We reserve the right to change this Notice at any time in accordance with applicable law. Prior to a substantial change to this Notice related to the uses or disclosures of your PHI, your rights or our duties, we will revise and distribute this Notice.

V. Acknowledgment of Receipt of Notice. We will ask you to sign an acknowledgment that you received this Notice.

VI. Questions and Complaints. If you would like more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made regarding the use, disclosure, or access to you PHI, you may complain to us by contacting the Privacy Officer at the address and phone number at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file such a complaint upon request.

We support your right to the privacy of your PHI. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Please direct any of your questions or complaints to:

One to One Health Privacy Officer
Privacy@121.health
1067 Riverfront Parkway, Suite 201, Chattanooga, Tennessee 37401-2222
423 602 9530
This notice is effective October 1, 2022.
Should be Empty:

New Patient Registration Form

Contact Information

Pharmacy Information

Patient Demographic Information

Patient's Health Information

Authorization to Release Information

Insurance Information

Consent to Treat Minor