Welcome to Crescent Medical Center
Advanced Medicine. Human Touch.
Dear New Patient,
Welcome to Crescent Medical Center, LLC. Before your appointment, please complete the New Patient packet enclosed with this letter and bring it with you or submit it online before your visit, along with your insurance card and photo ID. Failure to bring any of these items will result in your not seeing the doctor. All copays are due at the time of visit.
Arrive approximately 30 minutes before the scheduled appointment, as an intake process will take place before you see the doctor. Please bring your medication list, vaccination records, and any records from other doctors you would like Dr. Naqvi to review.
Lastly, any missed new patient appointment that is not communicated with the staff will no longer be rescheduled in the office.
If you have any questions or concerns, please get in touch with us at (401) 284-7900. We look forward to meeting you.
Sincerely,
The Staff at Crescent Medical Center, LLC
Crescent Medical Center
New Patient Intake Packet
Emergency Contact
Insurance
Medical History
New Patient Intake Packet
Medical Conditions
Past Surgeries / Major Hospitalizations
| Surgery or Hospitalization | Approx. Year | Reason / Notes |
|---|---|---|
Current Medications
| Medication | Dose | How often |
|---|---|---|
Allergies
| Medication / Food / Other | Reaction |
|---|---|
Additional Medical History
Family, Social & Preventive History
New Patient Intake Packet
Family History
| Condition | Mother | Father | Sibling | Other / Notes |
|---|---|---|---|---|
| Diabetes | ||||
| Heart disease | ||||
| Stroke | ||||
| Cancer | ||||
| High blood pressure | ||||
| High cholesterol | ||||
| Mental health disorder | ||||
| Blood clots | ||||
| Other serious illness |
Social History
Preventive Care
Immunizations
Screening & Documentation Notice
New Patient Intake Packet
Safety / Function
Clinical Documentation Assistance
How we may use documentation support tools
Crescent Medical Center may use HIPAA-compliant documentation tools to help your clinician create an accurate visit note. The tool may assist with transcription, summarization, and draft documentation. Your clinician remains responsible for reviewing, editing, and approving the final medical record.
These tools are used to support documentation only. They do not replace your clinician, make independent medical decisions, or determine your treatment plan.
Telehealth Consent
Care by Telehealth
Crescent Medical Center offers select visits by secure video or phone so you can connect with your care team conveniently — great for follow-ups, medication checks, and many other visits where an in-person exam isn't needed. Telehealth visits carry the same privacy protections as an in-person appointment.
As with any technology, connections can occasionally be interrupted, and your clinician will let you know if a visit is better suited to be done in person. Telehealth is not used for emergencies — for urgent or emergency symptoms, call 911 or go to the nearest emergency room.
You're always welcome to request an in-person visit instead, at any time.
Records Release & Communication
New Patient Intake Packet
Authorization to Obtain Medical Records
I authorize Crescent Medical Center to request and receive my medical records from prior clinicians, hospitals, laboratories, imaging centers, pharmacies, and other health care entities as needed for my medical care, including retrieval of my prescription history whenever such a request is triggered.
Communication Consent
People We May Speak With
| Name | Relationship | Phone | What may be discussed? |
|---|---|---|---|
Electronic Signature Disclosure
By typing my name below and submitting this form electronically, I acknowledge that this constitutes my electronic signature and has the same legal effect as a handwritten signature. I authorize the records release and confirm my communication preferences as indicated above.
Paper Signature
HIPAA Notice of Privacy Practices
New Patient Intake Packet
Summary: This Notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Your Rights
- Get an electronic or paper copy of your medical record.
- Ask us to correct your medical record.
- Request confidential communications.
- Ask us to limit what we use or share.
- Get a list of those with whom we have shared information.
- Get a copy of this privacy notice.
- Choose someone to act for you.
- File a complaint if you believe your privacy rights were violated.
Your Choices
For certain health information, you may tell us your choices about what we share. This may include sharing information with family/friends involved in your care, disaster relief situations, fundraising communications, or marketing when applicable.
Our Uses and Disclosures
We may use and share your health information to treat you, run our organization, bill for services, assist with public health and safety issues, comply with the law, respond to organ/tissue donation requests, work with a medical examiner or funeral director, address workers' compensation/law enforcement/other government requests, and respond to lawsuits or legal actions when required.
Examples
- Treatment: We may share information with other professionals treating you.
- Payment: We may use and share information to bill and receive payment from health plans or other entities.
- Operations: We may use information to improve care and manage clinic operations.
Our Responsibilities
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and provide you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. You may change your mind at any time by notifying us in writing.
Complaints
You may complain if you feel your rights were violated by contacting Crescent Medical Center. You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing a complaint.
Changes to This Notice
We may change the terms of this notice. The new notice will be available upon request, in our office, and/or on our website if applicable.
Acknowledgment of Receipt
Good Faith Estimate Notice
New Patient Intake Packet
Summary: Under federal law, health care providers must give uninsured and self-pay patients an estimate of expected costs before providing non-emergency care. This notice explains that right.
Your Right to a Good Faith Estimate
- If you don't have insurance, or you aren't planning to use your insurance, you have the right to receive a Good Faith Estimate of the total expected cost of any non-emergency item or service, including related costs such as tests, medications, equipment, and facility fees.
- You can ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service, or any time you ask.
- If you schedule an item or service at least 3 business days in advance, your provider must give you a written Good Faith Estimate no later than 1 business day after scheduling. If you schedule at least 10 business days in advance, it must be provided no later than 3 business days after scheduling.
- Please keep a copy or photo of your Good Faith Estimate for your records.
If Your Bill Is Higher Than Expected
If you are billed an amount that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill. You may contact our office, or you may start a dispute process through the federal government. Disputing a bill will not affect the quality of care you receive from us.
For More Information
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.
Acknowledgment
Consents, Policies & Signature
New Patient Intake Packet
Electronic Signature Disclosure
By typing my name below and submitting this form electronically, I acknowledge that this constitutes my electronic signature and has the same legal effect as a handwritten signature. I consent to complete and submit these forms electronically.