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  • Comprehensive Evaluation and Wellness Questionnaire

  • Dear Patient,

       You are scheduled for a full preventive care examination, otherwise knowns as an “Annual Wellness” or Physical Exam”.  This type of visit includes a check of your height, weight, bloodwork, and vital signs and recommendations for preventative care and on-going health maintenance.

       However, if you have new or acute symptoms that you want to address during this visit or have chronic conditions that need follow up, then it will also be billed as a problem-focused visit in addition to your preventative visit. 

        Your medical insurance plan likely covers preventative care visits differently than problem-focused visits, which may in turn affect your financial responsibilities, including co-payments or deductibles.  We want you to be aware of these facts.

        If you have any questions about this policy, please speak to one of the Patient Service Representatives at our Front Desk.

     

    Sincerely,

    Eileen Testa

    Eileen Testa

    Administrator

  • To ensure that our practice receives your form, please click the green "Submit" button below.

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  • Medications

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  • Other Issues Affecting Your Health

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  • Depression Screening (PHQ-9)

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  • Alcohol Screening

  • Insurance Summary

    It is a requirement of your insurance company that our practice have an updated copy of your insurance card annually.
  • Please upload images of your insurance card

    Uploading images of your insurance card now can help quicken the check-in process.
  • DISCLAIMER: The section below is to upload images of your insurance cards. If you are not using a mobile device, please skip the below section and bring your insurance cards to your appointment. Thank you

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  • HIPAA PRIVACY AUTHORIZATION FORM

    NINTH STREET INTERNAL MEDICINE ASSOCIATES, INC.


    Authorization for use or disclosure of protected health information. (Required by the Health Insurance Portability and Accountability Act – 45 CFR Parts 160 and 164)

    Please list names and relationships of all persons that you authorize Ninth Street Internal Medicine Associates to release your medical information to during the course of your care:

               
             
             
         
    I hereby authorize all medical sources to release and disclose the following protected health information to:

    NINTH STREET INTERNAL MEDICINE ASSOCIATES

    805 Locust Street

    Philadelphia, PA 19107

    Phone: 215-440-8681


    Specific Information to be disclosed:   

       
          
          
            
    The information for which I’m authorizing disclosure will be used for the following purpose: 

       
       
         
       

    Important Information About Your Rights:


    I understand that my records are protected under the Health Insurance Portability and Accountability Act, Federal Privacy Act, P.L. 93-575, the Federal Alcohol and Drug Abuse Act, P.L. 92-282, the Pennsylvania Mental Health Procedures Act, 1976 and the Pennsylvania Confidentiality of HIV Related Information Act, and therefore cannot be disclosed without my written consent unless otherwise provided for in the regulations. Under the Mental Health Act, this authorization expires one (1) month from the date of my signature. Under the Federal Alcohol and Drug Abuse Act, this authorization shall become void ninety (90) days from the date of my signature. In addition, I understand that I may revoke this authorization (except to the extent that action has been taken in reliance thereon) at any time by written, dated communication to the Ninth Street Internal Medicine and/or that my consent expires under the circumstance above. I understand that once copies of my information are provided, NSIM cannot prevent re-disclosure by the recipient. I understand that any information disclosed in response to this request will NOT include information related to my treatment for AIDS/HIV, psychiatric care/treatment, treatment for drug/alcohol, unless I specifically consent to release of this information by checking any or all the boxes below:

       
       
      

  • 2025 HIPAA Privacy Authorization Form

  • NINTH STREET INTERNAL MEDICINE ASSOCIATES, INC.

  • Authorization for use or disclosure of protected health information. (Required by the Health Insurance Portability and Accountability
    Act – 45 CFR Parts 160 and 164)
    Please list names and relationships of all persons that you authorize Ninth Street Internal Medicine Associates to release your
    medical information to during the course of your care:

  • I hereby authorize all medical sources to release and disclose the following protected health information to:
    Ninth Street Internal Medicine Associates
    805 Locust Street, Philadelphia, PA 19107
    Phone: 215-440-8681 - Fax: 215-440-9953

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  • Important Information About Your Rights
    I understand that my records are protected under the Health Insurance Portability and Accountability Act, Federal Privacy Act, P.L. 93-575, the Federal Alcohol and
    Drug Abuse Act, P.L. 92-282, the Pennsylvania Mental Health Procedures Act, 1976 and the Pennsylvania Confidentiality of HIV Related Information Act, and therefore
    cannot be disclosed without my written consent unless otherwise provided for in the regulations. Under the Mental Health Act, this authorization expires one (1)
    month from the date of my signature. Under the Federal Alcohol and Drug Abuse Act, this authorization shall become void ninety (90) days from the date of my
    signature. In addition, I understand that I may revoke this authorization (except to the extent that action has been taken in reliance thereon) at any time by written,
    dated communication to the Ninth Street Internal Medicine and/or that my consent expires under the circumstance above. I understand that once copies of my
    information are provided, NSIM cannot prevent re-disclosure by the recipient. I understand that any information disclosed in response to this request will NOT include
    information related to my treatment for AIDS/HIV, psychiatric care/treatment, treatment for drug/alcohol, unless I specifically consent to release of this information
    by checking any or all the boxes below:

  • (Initial) I acknowledge that I have been provided a copy of Ninth Street’s Internal Medicine’s Notice of Privacy Practices
    explaining my rights and permitted uses and disclosures with regard to my protected health information.
    (Initial) I acknowledge that this authorization is only good for one calendar year.

  • Click on the green "Submit" button below to send your answers to us. Thank you for taking the time to complete this form.

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