New Patient Registration Form

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Insurance Policy Number
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Your answers on this form will help your clinician understand your medical concerns and conditions better. Best estimates are fine if you cannot remember specific details.
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Operation
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Welcome and Thank You for choosing Dr. Joseph Obeng MD PA for health needs. We are committed to providing you with the highest quality medical care in an efficient, timely and cost effective manner.

  1. Patient is responsible for Deductible, Coinsurance and Co-Pays and Non-Covered Services as well as any cost insurance may not cover. You will be sent an itemize statement regarding the monies that you owe.
  2. Please arrive to appointment a few minutes early to give us any changes that may have changed on your account and any paperwork that you may have to give the Front Desk as Well.
  3. We accept CASH, VISA, MASTERCARD, CHECKS as mean of payment, however WE DO NOT TAKE AMERICAN EXPRESS
  4. If you arrived more that 15 Minutes late to your appointment, you may be asked to rescheduled or wait for the other patients who made it on time to be seen first before you are seen.
  5. We require a 24-hour notice if you must cancel or reschedule your appointment. We reserve the right to charge a $25.00 fee for NO-Show/ Late Cancellations

Patient signature

Notice of Privacy Practice

This notice describes how medical information about you may about you may be used and disclosed an how you can get access to this information. Please Review it carefully. Privacy and protection of personal information is an important principle to Dr. Joseph Obeng MD PA. We are committed to collecting, using and disclosing personal information responsibly and only to the extent necessary for the services we provide. This document describes our privacy policies. We are required by law to maintain the privacy of your health information (protected health information of PHI) and to provide you with this notice of our legal duties and privacy practices with respect to your OHi and have you sign a written acknowledgement that you received the notice. When we use or disclose your PHI, we are required to abide by the terms of this notice.

Permissible Uses and Disclosures with your Written Authorization: In certain situations we must obtain your written authorization in order to use and/ or disclose your PHI. However, we do not need any type of authorization from you for the following uses and disclosures:

  • Treatment: We use and disclose your PHI to provide treatment and other serves to you.
  • Payment: We may use and disclose your PHI to obtain payment for services that we provide to you.

Healthcare Operations: We may use and disclose your health information in connection without healthcare operations. Healthcare Operations include Quality Assessment and Improvement Activities, Reviewing the Competence or Qualifications of healthcare professionals, Evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activates.

Your Authorization: In addition to our use of your health information for treatment payment or healthcare operations you may give us written authorization to use your health information or disclose It to anyone for any purpose. You have the right to revoke automation at any time. You revocation will not affect any use if disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason expect those described in this notice.

Family and Friends: We must disclose your health information to you, as described in the patient rights section if this notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment of healthcare, but only if you agree that we may do so.

Person’s Involved in Care: We may use or disclose health information to notify, or assist in the notification of(including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclose of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of an emergency circumstance, we will disclose health information based on a determination using our professional judgment disclosing only information that will be use in the circumstance. We will also use our professional judgment with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays or other forms of medical health.

Better Health Care For All

Submit an appointments request if you can’t book an appointment online.

Or call — 817 870 1033

817 870 1033

info@obengmd.com

2600 Mall Circle, Fort Worth, TX 76116

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Office Hours

Contact Us

 

Phone #: 817 870 1033
Office Hours

Monday – Friday – 8:00am – 4:00pm

Clinic Hours

Monday – Thursday – 8:00am – 4:00pm

Location

2600 Mall Circle, Fort Worth, TX 76116

Book an Appointment Online