Become a patient

We look forward to welcoming you to Pine Park Health!

Patient Enrollment Form

Practice

• GSC
• PPH

Record Source

• Salesforce Web Enrollment Form

Enrolling as the Patient

Who are you enrolling as the patient?*

• Myself
• Someone else

Care Location

Where will the patient receive care?

• Senior living community or group home
• GSC Clinic on S. McCarran

State of Residence

Which state does the patient live in?*

• Arizona
• California
• Nevada
• Reno

Patient Information

Legal Name

• Legal First Name*
• Legal Last Name*
• Legal Middle Name
• Preferred First Name

Date of Birth*

Community Name*

Gender*

• Female
• Male
• Other

Race

• White
• Black
• American Indian or Alaskan Native
• Asian
• Native Hawaiian or Other Pacific Islander
• Other

Ethnicity

• Hispanic or Latino/a
• Not Hispanic or Latino/a
• Prefer Not to Answer

Preferred Language

• English
• Spanish
• Chinese (Mandarin)
• Chinese (Cantonese)
• Vietnamese
• Tagalog
• Korean
• Hindi
• Farsi
• Russian
• Arabic
• Other

Patient Contact Information

Primary Phone

• Primary Phone Type
  • Mobile
  • Landline

Secondary Phone

• Secondary Phone Type
  • Mobile
  • Landline

Email

Address

• Apartment
• City
• State
• Zip

Medical Decision-Maker Authorization*

Is someone else authorized to make medical decisions for the patient?*

• Yes
• No

Authorized Person Information

• First Name
• Last Name
• Relationship to Patient
• Email
• Primary Phone
• Primary Phone Type
• Secondary Phone
• Secondary Phone Type
• Patient Portal Access*
  • Yes
  • No

Emergency Contact

• First Name
• Last Name
• Relationship to Patient
• Email
• Primary Phone
• Primary Phone Type
• Secondary Phone
• Secondary Phone Type
• Patient Portal Access*
  • Yes
  • No

Billing Contact

Who should we contact regarding billing questions?*

• Patient
• Healthcare Representative or POA
• Emergency Contact
• Someone Else

Billing Contact Method

• Billing Contact Information
  • First Name
  • Last Name
  • Relationship to Patient
  • Email
  • Primary Phone
  • Primary Phone Type
  • Secondary Phone
  • Secondary Phone Type
  • Patient Portal Access*
    • Yes
    • No

Mailing Address for Statements

• Address
• Apartment
• City
• State
• Zip

Appointment Scheduling Contact*

• Patient
• Healthcare Representative or POA
• Emergency Contact
• Someone Else

Appointment Reminders

• Would you like to receive appointment reminders via SMS?
  • Yes
  • No

Patient Insurance Information

Medicare Number*

Medicare Advantage Details*

• Medicare Advantage Plan Information
• Medicare Advantage Plan Name
• Medicare Advantage Membership ID

Supplemental Insurance Information

Supplemental / Medigap Plan Details

• Supplemental / Medigap Plan Name
• Supplemental / Medigap Plan ID

Health Intake Information

Medication Management*

• Patient
• Community
• Someone Else

Preferred Pharmacy

• Preferred Pharmacy Name
• Preferred Pharmacy Address

Medical History and Current Medications

• Brief summary of medical history and diagnoses
• Brief summary of current medications and supplements

Medical Records Release

List of Providers

• List any providers we should contact for your medical records.

Acknowledgments and Authorization

• Consent to Treatment
• Consent to Bill Insurance & Financial Responsibility
• Enrollment in Chronic Care Management (CCM) & Advanced Primary Care Management (APCM)
• Rights of the Patient
• Use of AI Documentation Tools
• HIPAA Notice of Privacy Practices

Signature

• I confirm that I have reviewed and agree to the terms above.*

Signature Options

• Type your name to sign*
• Today's Date*

All of your submitted information is secure and confidential.