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  • New Patient Evaluation and Medicare Annual 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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  • Patient Portal Access

     Our practice offers a HIPAA secure patient portal for our patients that will allow you to send and receive non-urgent secure messages to our office regarding your health records, laboratory tests, and appointments, as well as give you access to view portions of your medical record online.

    *We will respond to these email communications within 2 business days. Please note that urgent medical issues requiring same day attention continue to require that contact our office by phone. In addition, if you rarely check your email, please do not sign up for the patient portal.

  • 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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  • CONSENT TO OBTAIN COMPLETE PRESCRIPTION MEDICATION HISTORY

    Our practice utilizes an integrated tool within our electronic medical records system that provides us with up-to-date information about all prescriptions given to you by all of your providers. It will allow us to view all medications dispensed to you, and help us to prevent adverse medication interactions. Please be assured that this is for the NSIM providers only and you may opt out of this feature at any time.

    By clicking below you certify that you have read and understand the scope of your consent and that you authorize access to your prescription medication history

       

    *If you do not wish to take advantage of this service, please check below:
    *      

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  • Physical Activity and Pain

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  • Activities of Daily Living

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  • Other Health Issues

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  • Bladder Control

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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

  • 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

  • Specific information to be disclosed:

  •     Entire Medical Record Only information related to (specify):  

  •     Only the period of events from to (please describe):

  •     Other (please describe):

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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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