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New Patient Packet

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Andrew Gottesman, MD Patient Forms

7515 Greenville Avenue, Ste 706, Dallas, TX 75231 | Phone: 214-360-9877 | Fax: 214-360-9256

PATIENT INFORMATION:

Patient’s Name:

DOB:

Last Name:

First:

Middle Initial:

Address:

City:

State:

Zip:

Marital Status:

Sex:

Social Security#:

Home#:

Cell#:

Work#:

Email Address:

Internal Medicine or Family Practice Physician Name:

Phone Number:

Cardiologist Name:

Phone Number:

Other Physicians whom we should send follow up information to:

Phone Number:

PHARMACY INFORMATION: *ALL prescriptions are done electronically* MUST HAVE*

Local Pharmacy Name:

Address:

Ph#:

Mail in Pharmacy Name:

Phone#:

BILLING INFORMATION: (Responsible Party if different from the patient)

Last Name:

First:

Date of Birth:

Street Address:

Social Security#:

Employer:

Relationship to the patient:

Primary Insurance:

Secondary Insurance:

CANCELLATION POLICY: Office visits and Procedures:

All office visits must be confirmed or cancelled by you 1 full business day in advance. If we are unable to confirm your appointment, it will be automatically cancelled. You will not be seen if you show up at the office. If you fail to show up for your confirmed appointment you will be charged a $50.00 fee.

All colonoscopies and endoscopies must be confirmed or cancelled 5 business days in advance. If we are unable to confirm your procedure appointment it will be cancelled and it will NOT be done if you show up at the surgery center or hospital. If you fail to show up for your confirmed procedure, we will charge your card $100.00.

Patient Agreement and Consent: I hereby authorize Andrew Gottesman, MD, or his designee, to furnish appropriate and necessary details of my medical records to my insurance carrier, should this be requested to facilitate payment of claims, or coordinate ongoing medical care. I hereby authorize payment of medical benefits by my medical insurance carrier to my physician, Andrew Gottesman, MD, for medical services rendered.

Signature:

Date:

PERSONAL HISTORY

Height:

Weight:

ALL MEDICATIONS: (Including over the counter supplements, pain medications, herbs, vitamins)

ALLERGIES:

Please list all medications you are allergic to:

HOSPITALIZATIONS and SURGERIES

Type of surgery or reason for admission:

Date of surgery or reason for admission:

Date of colonoscopy:

HABITS:

Do you currently smoke? Y N If so, how much:

Have you ever smoked? Y N If so, how much: How many years:

Do you drink alcohol? Y N If so, how much: Have you ever been a heavy drinker? Y N

Do you have tattoos? Y N

Do you have body piercings (other than ears)? Y N

Have you ever injected or snorted street drugs? Y N

Have you ever had a blood transfusion? Y N If so, when:

FAMILY HISTORY

Please list any Aunts, Uncles or Grandparents with colon polyps, colon cancer and liver disease not listed in history above:

PERSONAL HEALTH QUESTIONNAIRE

Poor appetite

Does food get stuck when you swallow

Pain with swallowing

Awakened at night with heartburn

Heartburn before meals

Heartburn after meals

Nausea

Vomiting

Cough while lying flat

Cough while eating

Feel poorly after eating wheat

Constipation

Unexplained weight loss

Diarrhea

Change in bowel habits

Rectal bleeding in the last year

Anemia in the last 6 months

Frequent bloating

Feel full after bowel movement

Ulcerative colitis

Crohn’s disease

History of colon polyps

History of colon cancer

Frequently exhausted

Family History liver disease

Liver disease

History of pancreatitis

Yellowing of the skin

Hepatitis C

Please explain any concerns to be addressed by a gastroenterologist; Dr. Gottesman:

MEDICATION HISTORY FOR INSURANCE APPROVAL

We MUST HAVE this information to get medications approved through your insurance:

Aciphex
Cimetidine
Dexilant
Famotidine
Lansoprazole
Maalox
Mylanta
Nexium
Omeprazole
Pantoprazole
Pepcid
Prevacid
Protonix
Prilosec
Ranitidine
Tagamet
Tums
Zegerid
Zantac

FINANCIAL POLICY

In the interest of maintaining a good doctor-patient relationship, we assume that you will responsibly handle your financial obligations to this practice. We understand that sometimes it may be difficult to meet your financial obligations. If this should occur, we encourage you to discuss your account, and any payment arrangements that you desire, with the office manager.

1. Insurance - As a courtesy to you, this office will file claims for all visits and procedures, whether they are delivered in the office, outpatient center, or the hospital. You are responsible for payment of all co-pays, deductibles, co-insurance and non-covered services.

2. Referrals - You are required to know whether or not your insurance requires a referral and obtain that referral before you are scheduled to be seen in the office, or have a procedure performed.

3. No Insurance - Patients who do not have insurance are expected to pay for all services rendered, at the time of service.

4. Returned Checks - Your account will be charged a $40 fee for each returned check.

5. Past Due Accounts - Patients who fail to make payment arrangements will be turned over to a collection agency.

6. Non-Covered Services - Medicare and certain other insurance companies may deny payment for services they do not deem reasonable and necessary.

7. Scheduling Appointments - We will call you several days prior to your appointment to confirm your office visit.

8. Missed Appointments - Service charges will need to be paid prior to rescheduling your appointment.

9. Ownership Interest - Dr. Gottesman has invested in North Central Surgical Center LLP.

10. Procedures - When a procedure is scheduled, we will require a credit card number or check to cover estimated expenses.

Patient Statement Signature:

Date:

NOTICE OF PRIVACY PRACTICES

I have downloaded, or received a copy of this office's Notice of Privacy Practices, for my review. I understand that the Notice of Privacy Practices explains how my medical information will be used and disclosed, and that I am entitled to receive a copy of this document upon my request.

Signature of Patient or Authorized Representative:

Date:

Printed Name of Patient or Personal Representative:

The following persons are allowed to receive any medical information contained in my records:

Medicare Patients Only

Effective January 1, 2012

To our Medicare Patients: Dr. Andrew Gottesman has changed his payment policy for our patients with Medicare Part B. We will be collecting all fees due to us at the time of service.

Please acknowledge the receipt of these policy changes by your signature:

Signature:

Date:

Name:

Signature:

Date:

Additional Information:

Patient’s Name: DOB:

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What the New Patient Packet Includes

The New Patient Packet is a standardized collection of forms and authorizations that clinics use to gather a patient's demographic details, medical history, insurance information, consent for treatment, and privacy notices at intake. It centralizes required signatures, disclosures, and optional questionnaires so administrative and clinical staff have a single, consistent record to begin care. For clinics using electronic workflows, the packet can be presented as a single PDF or a multi-step digital form with embedded signature and date fields, enabling secure electronic capture and auditable completion traces for each signer.

Why a Standardized Packet Matters for Patient Intake

Using a New Patient Packet standardizes intake, reduces missing data, documents consent, and speeds administrative processing. It also creates a clear chain of custody for patient records and signatures, which supports compliance with ESIGN, UETA, and HIPAA when electronic capture and retention practices are followed.

Why a Standardized Packet Matters for Patient Intake

Who Completes and Relies on the New Patient Packet

Primary users include reception, medical assistants, billing teams, and clinicians who need accurate intake data.

  • Primary care and specialty clinics managing first visits and follow-up care.
  • Dental and behavioral health practices collecting medical history, consent, and billing details.
  • Hospital outpatient departments and community health centers enrolling patients and verifying coverage.

Patients complete the packet before or during the first visit; proxy signers include parents, legal guardians, and authorized representatives.

Core Sections Typically Included in a New Patient Packet

A professional New Patient Packet groups intake, consent, insurance, privacy, medical history, and billing into a clear, consistent package for efficient processing.

Identification

Collect full legal name, date of birth, address, contact numbers, email, emergency contact, and government ID information to verify identity and match clinical records across systems.

Medical History

Structured fields for allergies, medications, chronic conditions, past surgeries, immunizations, and family medical history to help clinicians assess risk and prepare appropriate care plans.

Insurance

Insurance carrier, policy and subscriber numbers, group IDs, and authorization requirements; include secondary coverage and consent to bill insurers to prevent claim denials.

Consents

Treatment consent, minor assent, telehealth consent, and specific procedure consents; each must include signature, printed name, and date to be valid under clinical protocols.

Privacy Notice

HIPAA Notice of Privacy Practices and any state privacy addenda; patient acknowledgment of receipt or consent to electronic delivery should be captured and timestamped.

Billing & Payments

Payment responsibility, copay expectations, assignment of benefits, and authorization for balance billing or automatic payment methods when applicable.

Required Data Fields at a Glance

Full Legal Name: Exact name from government ID
Date of Birth: Use MM/DD/YYYY format
Home Address: Street, city, state, ZIP
Insurance Details: Carrier, policy, subscriber ID
Emergency Contact: Name, relationship, phone number
Signature and Date: Handwritten or electronic signature with date

Step-by-Step: Completing the New Patient Packet

Follow these steps to complete and submit the New Patient Packet accurately, whether on paper or electronically.

  • 01
    Review the packet: Read all sections before entering any data.
  • 02
    Enter patient details: Complete name, DOB, address, and contact fields.
  • 03
    Provide insurance: Enter carrier, policy numbers, and subscriber information.
  • 04
    Sign and date: Sign required consents and include today's date.

How to Configure an Online New Patient Packet

Configure the online packet to match your clinic's intake workflow, reducing manual entry and routing errors.

Field Configuration
Document Upload Accept PDF, DOCX; preserve original formatting.
Magic Fields Auto-detect name, DOB, and email to pre-fill fields.
Conditional Logic Show consent fields only when applicable.
Signer Authentication Use email or SMS code; require BAA for PHI.

Where Completed Packets Are Sent or Filed

Routes for completed packets vary; use the clinic's EHR, billing system, or secure storage depending on the form type.

  • To EHR: Attach signed PDF to patient chart with timestamp.
  • To Billing: Send insurance data and signatures to billing team.
  • To Records: Store original packet in secure document repository.
  • To Patient: Provide signed copy via secure email or patient portal.

Technical Requirements for Digital Submission

Digital submission needs platform features that protect PHI and capture a clear audit trail and meet state notarization requirements when applicable.

  • Supported file types: PDF, DOCX, HTML; preserve original layout.
  • Integrations: Connects with EHR, Google Workspace, NetSuite.
  • Security standards: TLS 1.2/1.3 and AES-256 encryption.

Timing Expectations for Packet Completion and Processing

Typical timing expectations for collecting and processing the New Patient Packet reduce scheduling delays and ensure insurance verification.

Before first appointment:

Complete packet at scheduling or 24–48 hours prior.

Same-day arrivals:

Complete in reception; allow 15–30 minutes.

Insurance verification window:

Verify coverage and authorizations within 48–72 hours.

Special procedures:

Obtain procedure-specific consents at least 72 hours prior.

Records release processing:

Process requests within 7–14 business days per clinic policy.

Common Mistakes When Preparing the Packet

  • Leaving signature or date fields blank is common; unsigned consents invalidate treatment authorizations and can delay or prevent scheduled procedures.
  • Entering nicknames, abbreviated addresses, or incorrect policy numbers causes billing errors and may require re-submission of documents to insurers.
  • Failing to capture HIPAA acknowledgment or a signed BAA when using third-party portals creates compliance exposure for protected health information.
  • Using inconsistent formats for dates or phone numbers leads to duplicate records and complicates follow-up communications with patients and payers.

Risks of an Incorrect or Incomplete Packet

Care Delays: Treatment postponed or refused
Claim Denial: Insurance claim rejected
HIPAA Violation: Potential breach notification
Billing Errors: Incorrect patient charges
Legal Exposure: Liability from improper consent
Regulatory Fines: Penalties under HIPAA/state law

eSignature Pricing and Feature Comparison for New Patient Packets

Basic pricing and feature differences across common eSignature vendors used for New Patient Packets, with signNow presented first for comparison.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Frequently Asked Questions About the New Patient Packet

Common questions and practical answers to issues that arise when preparing, signing, and storing New Patient Packets.


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