Medical New Patient Intake Packet

UN-INSURED SELF-PAY AUTHORIZATION FORM
Name

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I understand that I am responsible for any charges billed to me and will agree to pay such charges on time. If charges are not paid, I acknowledge that I may be subject to future appointments being rescheduled or canceled until past charges are paid in full or an acceptable payment plan is established.
A list of rates are attached.
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If you are unable to pay the entire amount of your visit at your appointment, we will bill the balance. Payment plans are also available. Please speak to our billing department at 314-439-1411 for more information

Novus Self-Pay Rates

Service	NOVUS 100% Self Pay $
New Pt Office Visit (includes basic set of labs)	$140.00
New Pt Preventative office visit - age 65 & over	$140.00
New Pt Preventative office visit -age 18-39	$140.00
New Pt Preventative office visit - age 40-64	$140.00
Established basic office visit w/mirse or provider (level 1 & 2)	$40.00
Established office visit W provider (level 3 & 4)	$110.00
Established office visit W provider (level	$140.00
Established Patient Ann Well Visit age 18-39	$140.00
Established Patient Ann Well Visit age 40-64	$140.00
Established Patient Ann Well Visit age 65 & over	$140.00
EKG	$15.00
HIV Rapid Test	$0.00
In House Rapid Pregnancy Test	$3.00
Rapid /Strep/Covid Test	$15.00
Influenza Vaccine - Regular	$25.00
Influenza Vaccine - High Dose (recommended for 65+)	$40.00
Injection of medication	$14.00
DEXA (Bone Density Scan)	$136.00
BH Counseling Intake	$170.00
BH Counseling 30m	$75.00
BH Counseling 45m	$100.00
BH Counseling 60m	$150.00

** ALL SELF-PAY PATIENTS ARE EXPECTED TO PAY AT THE TIME OF SERVICE.
A minumum of $40.00 is expected to be paid before seeing the provider or you may be subject to rescheduling. Please initial that you have read this.

2026 Patient's Financial Responsibility
Patient Name
Date of Birth:
Your Financial Responsibility
Thank you for choosing NOVUS Health as your healthcare provider. We understand that you have a choice in the healthcare you receive; as such, we look forward to being your partner in your personal healthcare journey. The following information is provided to you as part of our ongoing efforts to keep you informed of the financial services that are a part of health coverage and insurance obligations. By signing this form, you understand the financial obligations that are a part of your healthcare planning.
Please note, this form is required to be signed (and initialed) annually before being seen at the practice.
Financial Responsibility: NOVUS Health accepts most insurance and offers multiple options for those who may have difficulty paying for care at Novus Health and its various services. Please read and initial each section below to signify your understanding of the following:
Please initial
Self-Pay Fee Option: NOVUS Health offers a self-pay fee schedule for individuals who do not have insurance or prefer to pay out-of-pocket. Fees vary based on the following options: New Patient visits, Wellness Visits, Basic Medical Visit, injections, immunizations, Behavioral Health Counseling visits, or Psychiatric Assessments. Check with the front office for current fee options. You may also find the fee schedule on our website at novushealthstl.org.
Please initial
Insurance Co-Payments: NOVUS Health accepts most insurance plans. Most insurance plans require a copay on each visit. By law and in accordance with our contracts with insurance companies, we are required to collect copays. Failure to attempt to collect the copay may result in the cancellation of our insurance contracts and the ability to accept your insurance policy in the future.
Please initial
Co-Insurance & Deductibles: In addition to copay, many insurance plans require additional payments from you. These additional payments may be 1) A deductible, the amount you may have to pay out of pocket before your insurance benefits kick in. 2) Co-Insurance, an amount in addition to your co-pay that you may be required to pay for your care visit. Please know your insurance plan and check with your insurance prior to any appointments to verify if additional costs will be billed to you.
Please initial
Lab Services: NOVUS Health contracts with LabCorp for all laboratory services. Please note that lab services are billed separately from NOVUS Health and will come directly from LabCorp. NOVUS Health does not control the billing systems for lab services. Please check with the front office for LabCorp information regarding any lab fees that have been billed to you.
Please initial
STI Clinic Services: Novus does offer STI testing and treatment services. We seek to make these services as reasonable as possible and, in some cases, at no cost to you. If you are insured, we will bill your insurance company for the office visit and testing/treatment. If you have a copay, you will be expected to pay it at the time of the office visit. However, you will not receive a bill from Novus unless there are services performed outside the usual STI Clinic Service Agreement. If you are uninsured, you may receive a bill for services performed outside the STI Clinic Service Agreement.
Please initial
Payment Billing & Payment Arrangements: NOVUS Health will be moving billing in-house in 2026. If you have a copay or deductible that is not met, you will be expected to pay your copay and possibly your deductible at the time of your visit. All charges not paid at the visit will be billed to you. If you need to make payment arrangements, please get in touch with the billing office or let the front desk know before your appointment, and they will assist you with available options.
Please initial
It is expected that all fees will be paid at the time of service. If the charges due at the time of service (including copays) are not paid, you may be subject to cancellation or rescheduling of your appointment.
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Rev:12/29/2025

2026 Treatment, Payment, and Healthcare Operations Patient's Authorization Form
Patient Name:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance Name:
Subscriber ID #:
I authorize the release of any medical or other information necessary to process Medicare, Medicaid, and/or private insurance claims. I also request payment of government benefits either to myself or to the party who accepts assignment. I authorize payment of medical benefits to the physician or supplier for services provided. The PRIVACY ACT STATEMENT for Form RRB-1500 is available upon request.
I acknowledge that it has been explained that my insurance provider may not cover all of the services I receive at NOVUS Health. I will be responsible for deductible amounts, co-pays, and non-covered services.
I hereby give consent for NOVUS Health to use and disclose protected health information (PHI) about me to carry out Treatment, Payment, and Healthcare Operations (TPHO). With this consent, NOVUS Health may mail to my home or other alternative location, leave a message on voice mail, send a text message (to designated phone) in reference to any items that assist the Center in carrying out (TPHO), including things such as appointment reminders, insurance items, calls relating to clinical care including lab results, etc. unless I have expressed a desire not to be contacted and my desire is documented in my medical record. I also acknowledge that in the case of a medical emergency, such as a "critical" lab result, NOVUS Health will contact me or my designated emergency contact representative.
By signing this Consent, I consent to NOVUS Health's use and disclosure of PHI to carry out TPHO. I may revoke my consent in writing except to the extent that NOVUS Health has already made disclosures upon my prior consent. If I do not sign this Consent or later revoke it, NOVUS Health may decline to provide treatment to me.
AGREED:
Patient Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

2026 HIPAA Privacy Notice& Patient Rights
Your Privacy Matters to Us
Patient Name
DOB:
Safeguarding your health information is important to us. As your healthcare provider, we have developed certain practices to protect your health information. This form summarizes some of the privacy practices that we use here at NOVUS Health
The Health Insurance Portability and Accountability Act of 1996, which is the federal law commonly known as HIPAA, protects any of the health information that can be specifically identified as yours. HIPAA permits, and our privacy practices allow us to use your individually identifiable health information or share it with another healthcare provider or an insurance company in the following circumstances:
1. To treat and care for you, including contacting you for appointment reminders.
2. To obtain payment from you or your insurance company.
3. In connection with our health care operations, which are operational activities typically carried on by health care providers, like quality assessment and improvements, review and/or training of health care professionals, business planning, customer service, grievance resolution, and other general administrative activities.
HIPAA also allows us to use certain health information for the following activities:
1. When required by law.
2. When permitted by HIPAA for such activities, including:
• For public health and safety.
• To health oversight agencies for monitoring in the healthcare system.
• To law enforcement related to its criminal investigations.
• For judicial and administrative proceedings.
• For organ donation.
3. For research.
4. We will also follow other federal and state laws when they provide extra protection regarding your health information. If our use or disclosure is not for one of the activities described above and is not otherwise permitted under HIPAA, we will ask you to complete a written authorization before we use or disclose your health information.
The authorization will:
1. Describe in detail the health information it covers.
2. Identify to whom your health information will be released and how it will be used.
3. Describe when it will be used or released.
4. State the expiration date, or expire in 90 days of signature.
When receiving services from us, you will also be able to decide whether we can discuss your health information with your family and friends. (separate form called HIPAA - Permission to Discuss)
Even if you have provided us with your authorization, you may withdraw that authorization in writing at any time to stop our future disclosures of your health information. Information disclosed before you revoke your authorization will not be returned, and any actions that we have already taken based on prior authorization will not be affected.
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2026 HIPAA Privacy Notice & Patient Rights
Your Rights Regarding Your Health Information
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HIPAA provides you with the following rights regarding your health information.
1. Restricting a Use/Disclosure: You may request a restriction on how we use or disclose your health information.
2. Requesting Confidential Communications: You may request reasonable changes in how or where we may contact you for an appointment, for lab results, or other health information.
3. Inspecting and obtaining copies of your health information: You may ask, in writing, to look at and/or obtain a copy of your health information. There may be a fee associated with your request.
4. Requesting a change in your health information: You may request, in writing, a change or addition to your health information. The law limits the types of changes that may be made, and we may not erase or delete any information in your records.
5. Requesting an accounting of disclosures of your health information: You may ask, in writing, for an accounting of certain types of disclosures made of your health information. Disclosures made with your authorization will not be included in the accounting.
6. Obtaining a Notice of Our Privacy Practices: Our notice explains and informs you of our privacy practices. You may obtain a copy of our notices at our facility.
I have read and understand the above-referenced policy regarding my Health Care Privacy.
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

2026 HIPAA –Permission to Discuss PHI
Permission to Discuss Your Personal Health Information
Patient's Full Name:

First NameLast Name
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
This form is intended for you to give the authority to selected family members, spouses, trusted friends, or partners to have access to your personal medical information, such as:
1. Making or canceling appointments on your behalf.
2. Discuss your medical problems with the physician or staff.
3. Release of lab results, drug samples, or written prescriptions.
This only authorizes information to be given. It does not allow them to make medical decisions on your behalf. A Power of Attorney or an Advance Directive would need to be completed for that purpose.
If you do not want anyone to have access to your medical information, please write "NONE" and sign below.
This may be revoked or amended at any time.
I hereby give my permission to the person(s) listed below to receive information about the care of the above-named patient.
Name:

First NameLast Name
Relationship:
Phone #:
Format: (000) 000-0000.
Name:

First NameLast Name
Relationship:
Phone #:
Format: (000) 000-0000.
Name:

First NameLast Name
Relationship:
Phone #:
Format: (000) 000-0000.
Write "NONE" in the box below if you do not want anyone to have access:
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

2026 Consent to Treat Form
Patient Name:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I give my consent to Novus Health, Inc., to provide me with medical or behavioral health treatment as deemed necessary by the physician or healthcare/behavioral health provider.
I understand that this may include, but not limited to, laboratory tests, X-rays, prescription medications, injections or procedures, and/or counseling.
I have the right to refuse any procedure or treatment, and I have the right to discuss any procedure or medical treatment with my clinician.
I allow Novus Health, Inc. to file for insurance benefits to pay for the care I receive. I understand that Novus Health will send my medical information to my insurance company.
I understand that I must pay my share of the costs if I am uninsured or pay the cost of the services not covered by my insurance company.
I acknowledge that I have read this Consent to Treat form and if requested, I can receive a copy for my records.
Patient's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

2026 Prescription History Consent Form
Patient Name:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
By signing this consent form, you agree that your provider at NOVUS Health may request and use your prescription medication history from other healthcare providers and/or third-party pharmacy benefit payors for treatment purposes.
This consent provides the health care provider with information about your current and past prescriptions. This allows health care providers to be better informed about potential medication issues and to use that information to improve safety and quality. Medication history data can indicate compliance with prescribed regimens and therapeutic interventions.
You may decide not to consent or sign this form. Your choice will not affect your ability to get medical care, payment for your medical care, or your medical care benefits. Your choice to give or to deny consent may not be the basis for denial of health services.
This consent form will remain in effect until the day you revoke your consent. You may revoke this consent at any time in writing but if you do, it will not influence any actions taken prior to receiving the revocation.
Patient's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Consent for Patient Reminders and Notifications
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
You consent to receive messages from us, your healthcare provider, that utilize an automatic telephone dialing system to deliver a text, voice, or pre-recorded message that may contain health-related information or healthcare management advice at the telephone number(s) you have provided. You understand that you are not required to consent to receive such information or advice from your healthcare provider.
Terms & Conditions
Your request to receive automated voice and text messages from us, your healthcare provider, constitutes your agreement to these terms and conditions. You agree that we may send you automated voice and text messages through your wireless provider to the valid mobile or landline number you provided. You agree to indemnify, defend, and hold us, our technology service vendor - Healow LLC, our electronic medical record vendor - eClinicalWorks LLC, and its affiliated companies harmless from any third-party claims, liability, damages, or costs arising from your request to receive automated voice or text messages or from providing us, your healthcare provider, with a phone number that is not your own. You agree that we and our technology solution vendors will not be liable for failed, delayed, or misdirected delivery of any information sent to or from you, including opt-out requests. You must be 18 years or older to participate or have the express permission of a parent/guardian (but in any case, you must be at least 13 years old). This is a standard-rate messaging program where message and data rates may apply. The frequency of messages may vary depending on the number of messages you are due to be sent by your healthcare provider. Supported carriers include AT&T, Verizon Wireless, T-Mobile®, Metro PCS®, Sprint, Boost, Virgin Mobile, U.S. Cellular®, and others. Additional carriers may be added at any time. Carriers are not liable for delayed or undelivered messages. T-Mobile® is not liable for delayed or undelivered messages.
Frequently asked questions:
What sort of messages can we send you?
As your healthcare provider, we aim to stay in touch with you even when you're not in their office. To keep the lines of communication open and based on need, we can send you messages via voice SMS/text, email, and secure messages on the Patient Portal and using Healow. Examples of communication from our practice can include appointment reminders, prescription refill messages, and health/wellness notifications for tests or other procedures. We respect your need for privacy and will not send you telemarketing-related messages or share your contact details with anyone.

Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What does it mean when you opt in or activate?
By choosing to opt-in for voice and or text messages from us, your healthcare provider's office, you consent to receive phone, text, and/or other electronic messages to the number we have on file for you. We have chosen to use these automated service reminders offered by Healow and eClinicalWorks. Please direct all your communication directly with us, your healthcare provider office, and not our technology vendor companies.
Please note: Phone, emails, and text messages are considered unsecured methods of contact and may result in the disclosure of sensitive information to unauthorized individuals. You assume the risk of activating these services and will not hold the practice responsible.
Can you turn off these services later?
Yes, contact us, your healthcare provider's office, and ask to adjust your communication preferences. You can also text STOP in reply to a text message that you receive from us. On texting STOP, your phone number will be unsubscribed from this service, and you will not receive any further health and wellness messaging notifications via text.
What if you need further help?
Please note that these services are either to remind you of important or necessary steps to take to live a better, healthier lifestyle or to offer you convenient ways to connect with us, your healthcare provider, outside the walls of their clinic. If there is ever an emergency or if you need help, please call 911 or our offices during regular working hours. Should you need additional help, text HELP to reply to a text message and access the same message.
Did you know that simple steps you take can protect your health information online?
You should Password-protect any device from which you view or download your health information on your mobile phone or home computer. Ensure your password meets the criteria for a strong, secure password, which means it consists of at least six characters and combines letters, numbers, and symbols. Also, log out if you use a public computer to access your health information.
Talk or text you soon!
Consent for Patient Reminders and Notifications:
X
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Data Exchange Consent
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Novus Health has selected the OptOut Consent Model to allow patient data exchange with the networks enabled through the Interoperability Hub (e.g. Carequality/CommonWell). This means that we may automatically share medical information with other providers on the same network, computer-to-computer. You must OPT OUT of this practice if you do not want your medical information shared with other providers through electronic exchange.
Our electronic medical record, eClinicalWorks, is CEHRT (Certified Electronic Health Record Technology) certified. This is important because it helps providers capture and share patient data in a structured and safe manner. CEHRT certification ensures that the electronic health IT products and systems are secure and can maintain data confidentiality. Features that protect the security of patient data include audit trails, data encryption, password protection, and access control.
Successful data exchange has become an essential component of collaboration among providers to ensure continuity of care. This gives your providers valuable insight to make informed decisions and improve care coordination to offer the best care for your well-being.
Do you authorize data exchange within the network of providers enabled for your continuity of care?
Opted-In – By signing this consent, I authorize data exchange within the network of providers enabled.
X
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
To OPT-OUT, sign below..
X
date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

NOVUS Health, Inc / 6155 S. Grand Blvd / St. Louis, MO 63111 / Tel:314-652-0100
Medical Information
Patient Name:
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please complete this questionnaire thoroughly. It is very important for us to enter this information into your electronic medical record so that the providers can provide you with the best of care. Thank you.
What are the two most important problems you would like to discuss with the provider?
1)
2)
Do you have pain?
If you have pain, when did it first occur?
Rate it on a scale of 0-10
Describe it:
What makes it better?
What makes it worse?
What treatments have you had?
What other specialists/physicians do you see?
Provider's Name and Location
Specialty
Phone:
Provider's Name and Location
Specialty
Phone:
Provider's Name and Location
Specialty
Phone:

NOVUS Health, Inc / 6155 S. Grand Blvd / St. Louis, MO 63111 / Tel:314-652-0100
Medical Information con't
Patient Name:
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current or prior skin problems:
When you are exposed to sunlight do you:
List any family members with history of skin cancers:
Have you been diagnosed with cancer?
If you have been diagnosed with Cancer, please list.
When was your last colonoscopy or Cologuard test?
Males: When was your last PSA blood test?
Males: When was your last prostate exam?
Female: When was your last Pap Smear?
Female: When was your last mammogram?
Surgeries

Please list all surgeries with dates and serious hospitalizations (as close to the date as you can)
Date
Surgery
Date
Surgery
Date
Surgery
Family Information
Father
What age is your Father now / or when he died?
What medical problems did/does he have?
Mother
What age is your Mother now / or when he died?
What medical problems did/does she have?
# of Sisters
Do your Sisters have any medical problems?
# of Brothers
Do your Brothers have any Medical Problems?

Novus Health Demographics and Insurance Form

Patient Information

S.O.G.I (Sexual Orientation, Gender Identity)

Emergency Contact

Novus Services/Partners

Signature

FINANCIAL INFORMATION

Interested in Learning about NOVUS Cares?

Responsible Party Information - IF DIFFERENT FROM PATIENT

Insurance Information

Signature

UN-INSURED SELF-PAY AUTHORIZATION FORM

2026 Patient's Financial Responsibility

Your Financial Responsibility

2026 Treatment, Payment, and Healthcare Operations Patient's Authorization Form

2026 HIPAA Privacy Notice& Patient Rights

Your Privacy Matters to Us

2026 HIPAA Privacy Notice & Patient Rights

Your Rights Regarding Your Health Information

2026 HIPAA –Permission to Discuss PHI

Permission to Discuss Your Personal Health Information

2026 Consent to Treat Form

2026 Prescription History Consent Form

Consent for Patient Reminders and Notifications

Terms & Conditions

Frequently asked questions:

What does it mean when you opt in or activate?

Can you turn off these services later?

What if you need further help?

Did you know that simple steps you take can protect your health information online?

Talk or text you soon!

Data Exchange Consent

Opted-In – By signing this consent, I authorize data exchange within the network of providers enabled.

Medical Release Form

Release of Medical Records Information

RELEASE RECORDS FROM:

Medical Information

Medical Information con't

Medical Information con't

Surgeries

Family Information

Social History

Alcohol Intake

Illicit Drug Use