New Patient Packet - Crescent Medical Center

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.

📍 Parking Instructions Our address is 63 Eddie Dowling Highway, North Smithfield, Rhode Island 02896. We are located on the 1st floor in Suite 1B. Pull into the parking lot, park in the front or back lot of the building, and enter through the front entrance.

If you have any questions or concerns, please get in touch with us at (401) 227-9036. We look forward to meeting you.

Sincerely,

The Staff at Crescent Medical Center, LLC

Demographics

Name (Last, First, MI)

Today's Date

Street Address

Date of Birth

City

State

Zip Code

Home Phone

Work Phone

Insurance

Marital Status

Emergency Contact Person

Relationship

Emergency Contact #

Race (select one)

Ethnicity (select one)

Preferred Language

What brings you to the office today?

Establish Care (new primary care patient) Other: Problem / Issue (please describe briefly): I was referred by:

Current Medications (include prescriptions, OTC drugs, vitamins & supplements)

Medication Name	Dose / Strength	Frequency

Allergies

Are you allergic to any drug, medication, latex or other substance (including local anesthesia)? If yes, to what?

Type of Reaction

Past Medical / Surgical / Hospitalization History

List any major medical conditions, hospitalizations, surgeries, or procedures. Use additional rows as needed.

Condition / Hospitalization / Surgery / Procedure	Date / Approx. Year

Immunization History

Please list date of most recent dose. Write "Unknown" if unsure, or leave blank if never received.

Vaccine	Date of Last Dose	Notes (e.g. series complete, booster)
Hepatitis B
Tetanus / Tdap
MMR (Measles, Mumps, Rubella)
COVID-19
Influenza (Flu) — most recent
Pneumonia (Pneumococcal)
Shingles (Shingrix)
HPV
Other

OB/GYN History (if applicable)

Number of Pregnancies (Gravida)

Number of Deliveries (Para)

Number of Miscarriages / Abortions

Last Menstrual Period

Last Pap Smear

Last Mammogram

Menopausal Status

Current Contraception Method

Occupation & Previous Providers

Current Occupation / Employer

Previous Primary Care Provider (Name)

Previous PCP Practice / Location

Current Specialists

List any specialists you are currently seeing

Specialty	Provider Name	Phone / Practice

Family History

Have your biological family (parents, brothers, sisters) had any of the following?

Lifestyle / Social History

Question	Answer
Do you currently smoke cigarettes? If yes, how many per week?	Yes No
If you do not currently smoke, did you ever smoke?	Yes No
Do you drink alcohol? If yes, how many drinks per week?	Yes No
Do you use recreational drugs? If yes, name of drug?	Yes No
How many days/week do you exercise?
How would you describe your diet?

Sexual Health & STI Risk

Your provider may discuss this further during your visit.

Review of Systems

Authorizations & Agreements

Authorization to Release Information

I hereby authorize Crescent Medical Center, LLC to furnish all necessary information they may have regarding my condition under their observation or treatment, including the history obtained, x-ray, laboratory, and physical findings, diagnosis and prognosis to my insurance company(ies) and/or physicians.

Assignment of Benefits & Payment Responsibility

I hereby assign all medical benefits, to include major medical benefits to which I am entitled including Medicare, private insurance, and any other health plans to Crescent Medical Center, LLC. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges not covered by said insurance. I hereby authorize said assignee to release all information necessary to secure the payment.

Eligibility Waiver

I understand that my eligibility for coverage may not be able to be confirmed at this time. I wish to receive medical service from Crescent Medical Center, LLC. If it is determined that I am not eligible for coverage, I understand that I will be responsible for payment of all services provided.

Release of Records

Please complete this section with the names of any person, other than yourself, that you would like to have access to your medical information. If there are no names listed we will only be able to speak with you regarding your healthcare. Please consider if you want family members or friends to have access to your health information.

Authorized Person — Name

Relationship

Authorized Person — Name

Relationship

I consent to use electronic signatures for this submission. I understand and agree that by typing my name in the signature fields and saving/submitting this packet, I am signing this document electronically with the same legal effect as a handwritten signature. I consent to receive, complete, sign, save, and submit these forms electronically.

Electronic signature disclosure: By typing my name in a signature field, I intend to sign this document electronically. I agree that my electronic signature has the same force and effect as my handwritten signature. This completed PDF should be saved and submitted from the patient's or authorized representative's email account.

Submission timestamp: Generated when printed/saved

I have read and agree to all statements, terms and conditions above.

✎ By typing your name you are providing your electronic signature

Patient / Guardian Signature

Date

Print Name

Date

HIPAA — Notice of Privacy Practices

Patient Name

Date of Birth

Information on Patient Rights Under HIPAA

Notice of Privacy Practices — Health Insurance Portability and Accountability Act

This information is to help you understand your rights under federal privacy regulations, the Health Insurance Portability and Accountability Act, or HIPAA. This page focuses on your right to receive a Notice of Privacy Practices.

What is a Notice of Privacy Practices?

The Notice of Privacy Practices, or Notice, describes Crescent Medical Center's privacy practices. It describes how we use or disclose your medical or health information. It also explains your rights as a patient under privacy regulations, as well as Crescent Medical Center's responsibilities regarding your information.

Why do I need a Notice of Privacy Practices?

We are required by federal regulations to maintain the privacy of your medical or health information. We create a record of the care and services you receive at Crescent Medical Center. We need this record to provide you with quality care and to comply with certain legal requirements. The Notice will help you understand how to exercise your rights regarding your health information.

How do I get a copy of the Notice?

At your first visit to Crescent Medical Center, staff will provide you the opportunity to review and request a copy of the Notice. You may also call our office at (401) 227-9036 and we will send you a copy by mail.

Your Rights Under HIPAA

Right to Access

Inspect and obtain a copy of your health information.

Right to Accounting of Disclosures

Request an accounting of disclosures made on your health information.

Right to Amendment

Request an amendment to your health information.

Right to Confidential Communications

Request that we communicate with you about your health information at alternative locations.

Right to Restrictions

Restrict certain disclosures of your health information.

Right to Complain

File a complaint if you feel your information was used or disclosed inappropriately.

Using and Disclosing Your Health Information

Information on the ways in which Crescent Medical Center uses and discloses your health information for treatment, payment, and health care operations, including information on authorizations to release medical or health information and revoking authorizations.

I have received Crescent Medical Center's Notice of Privacy Practices.

✎ By typing your name you are providing your electronic signature

Patient / Guarantor Signature

Date

Staff Person Signature

Date

Acknowledgement of receipt has been signed and documented in the patient record.

Pharmacy Information Required

Preferred Pharmacy Name

Pharmacy Phone

Pharmacy Address

Pharmacy Zip

Insurance Information Required

Primary Insurance

Primary Member ID

Primary Group #

Secondary Insurance (if any)

Secondary Member ID

Secondary Group #

Medicare / Medicaid ID (if applicable)

Subscriber Name (if not patient)

Subscriber Date of Birth

Self-Pay: If you do not have insurance, all charges are due at the time of service. Please speak with our front desk regarding payment options.

How Did You Hear About Us? New

If referred by a provider or person, please list their name

Preferred Hospital & Advance Directives New

Preferred Hospital for Admission

Healthcare Proxy / Power of Attorney on File?

Yes No In progress

Do you have a Living Will / Advance Directive?

Yes No

Healthcare Proxy Name (if applicable)

AI-Assisted Documentation Consent New

🤖 Artificial Intelligence Scribe During Visits

Crescent Medical Center uses an AI-assisted ambient documentation tool during clinical visits. This technology listens to the conversation between you and your provider to generate accurate clinical notes in real time — solely to improve documentation quality and never replacing your provider's clinical judgment.

The tool generates a draft note for your provider to review, edit, and approve before it enters your chart.
Audio is processed in real time and is not stored or retained after the note is finalized.
Your provider remains fully responsible for all documentation in your medical record.

Cell Phone for Text Reminders

Email Address

I consent to receive appointment reminders via text message I consent to receive appointment reminders and health updates via email I consent to receive health education materials and newsletters

I authorize Crescent Medical Center to use my photograph and/or testimonial for marketing purposes. I do not authorize the use of my photograph or testimonial.

Office Policies Acknowledgement New

Please review the key policies below. By signing, you acknowledge that you have received, read, and agree to Crescent Medical Center's complete Office Policies document, which is available at the front desk or upon request.

Appointments

Please arrive 15 minutes early for your first visit and 10 minutes early for follow-ups. Late arrivals may need to be rescheduled at the provider's discretion.

Cancellations

Please cancel at least 24 hours in advance. Repeated no-shows or late cancellations may result in a fee and may affect your ability to schedule future appointments.

No-Show Policy

Missed appointments without prior notice (no-show) may incur a $25–$50 administrative fee. Three no-shows may result in discharge from the practice.

Copays & Payments

All copays, coinsurance, and known deductibles are due at the time of service. We accept cash, check, and major credit/debit cards.

Prescription Refills

Refill requests require 48–72 hours. Controlled substance prescriptions require an in-person visit. Please plan ahead — urgent refill requests cannot always be accommodated.

After-Hours

For urgent concerns outside office hours, call our main line at (401) 227-9036 and follow the prompts. For life-threatening emergencies, call 911 or go to the nearest emergency room.

Photo ID & Insurance

We will photocopy your photo ID and insurance card(s) at each visit to keep your records current. Your signature below authorizes us to retain these copies in your chart.

Telehealth

Crescent Medical Center offers phone and video visits where clinically appropriate. By participating in a telehealth visit, you consent to receive care via these platforms, subject to state regulations.

I have read, understood, and agree to the office policies summarized above and the complete Crescent Medical Center Office Policies document.

✎ By typing your name you are providing your electronic signature

Patient / Guardian Signature

Print Name

Date

Relationship to Patient (if Guardian)

As your primary care provider, we want to hear from you BEFORE you go to the hospital. Maybe we can save you a trip — and a lot of time and money. We have same-day appointments and we want to see you.

When you see your doctor and avoid a trip to the emergency department, you benefit in many ways:

📍Convenient Locations

⏱Shorter Waiting Time

📋Less Paperwork

💰Lower Cost

🩺Personalized Care for You

Urgent Conditions & Services We Treat

Allergic Reactions (mild)
Asthma (mild)
Colds and Coughs
Cuts and Lacerations (minor)
Earaches and Infections
Fever and Flu
Insect and Animal Bites
Migraines
Nose Bleeds
Rashes and Skin Reactions
Sexually Transmitted Diseases
Strep or Sore Throat
Sprains and Strains
...and more

⚠ After-Hours Assistance

If you need medical assistance outside our regular office hours, please call our main line and follow the instructions for after-hours care.

Always call your doctor BEFORE visiting the emergency department.
(401) 227-9036

Welcome to Crescent Medical Center

Patient History Form

Patient History Form

Patient History Form

General

Eyes

Ears

Nose

Mouth

Lungs

Cardiovascular

Gastrointestinal

Urinary

Musculoskeletal

Neurologic

Skin

Emotional

Male

Female

Breast Problems

Endocrine

Cardio-Respiratory

Patient History Form

Authorization to Release Information

Assignment of Benefits & Payment Responsibility

Eligibility Waiver

Release of Records

Information on Patient Rights Under HIPAA

Notice of Privacy Practices — Health Insurance Portability and Accountability Act

What is a Notice of Privacy Practices?

Why do I need a Notice of Privacy Practices?

How do I get a copy of the Notice?

Your Rights Under HIPAA

Authorization to Release Healthcare Information

Patient Consents & Office Policies

🤖 Artificial Intelligence Scribe During Visits

We Want You to Call First

Welcome to Crescent Medical Center

Patient History Form

Patient History Form

Patient History Form

General

Eyes

Ears

Nose

Mouth

Lungs

Cardiovascular

Gastrointestinal

Urinary

Musculoskeletal

Neurologic

Skin

Emotional

Male

Female

Breast Problems

Endocrine

Cardio-Respiratory

Patient History Form

Authorization to Release Information

Assignment of Benefits & Payment Responsibility

Eligibility Waiver

Release of Records

Information on Patient Rights Under HIPAA

Notice of Privacy Practices — Health Insurance Portability and Accountability Act

What is a Notice of Privacy Practices?

Why do I need a Notice of Privacy Practices?

How do I get a copy of the Notice?

Your Rights Under HIPAA

Authorization to Release Healthcare Information

Patient Consents & Office Policies

🤖 Artificial Intelligence Scribe During Visits

Text / Email Appointment Reminders & Health Notifications

Photography & Testimonial Authorization (Optional)

We Want You to Call First