Practice of Chet Gentry, MD; Alison Hicks, FNP-C

Tiffany Ward, FNP-BC; William Wilson, FNP

3300 Williams Enterprise Drive, Cookeville, TN 38506
o: (931) 528-9222 f: (931) 854-0907

We are happy to welcome you as a new patient to our practice!

As a member of our practice, you and your family will be cared for by a team of dedicated health professionals. We function
as a Patient Centered Medical Home. Our goal is to help you be as healthy and fit as possible: mentally, physically, and spiritually. We
want to teach you to manage your own health as cost effectively as possible. We will help you keep your full medical history and
medical care plan here. No matter what your medical conditions, we will help you develop a medical care plan tailored to your needs.
We will assist you in making sure that your medical needs are addressed wherever you are: Home, ER, Hospital, Home Health, Nursing
home, or Hospice. We strive to manage your care no matter where you go in the health system.

Office Hours
Monday – Friday 8:00 a.m. – 5:00 p.m. The schedule of individual providers varies.

Same Day Appointments/Work-Ins (for existing patients)

Though you may choose a preferred provider in our practice, there may be times when you will need to be seen by one of the other
members of our team. All appointments are to be scheduled in advance to properly accommodate each patient’s needs. However, we
understand that health concerns may arise suddenly. Same day appointments or work-ins will be scheduled with an available qualified
provider upon approval. Each physician assistant and nurse provider in our practice consults with Dr. Gentry when the need arises.

Nurse Calls
If you have a question about your care, feel free to call and leave a message for one of the nurses. Someone will return your call within
48 hours during the business week. You may also be able to contact the provider team through the patient portal. Please do not leave
a message if the issue is urgent or life-threatening.

Medication Refills
Unless you have an appointment scheduled to discuss refills, please call the office for prescription refills at least 72 hours prior to your
medication running out. In some instances, you will be required to first make an appointment with a provider.

Lab Studies
All lab studies must be ordered by one of our providers. If you are concerned that you have a condition that requires a lab study (strep
test, urinary screening, etc.), you must first make an appointment with the provider.

Same Day Cancellations/No shows

We are committed to providing all of our patients with exceptional care. When a patient does not show up or cancels without giving
adequate notice, they prevent another patient from being seen. Please call our office by 3:00 pm on the day prior to your scheduled
appointment to notify us of any changes or cancellations. To cancel a Monday appointment, please call us by 3:00 pm on Friday. A
patient is considered a no show if they do not come in or if they arrive more than 20 minutes past their appointment time. Patients
will be billed a $25 same-day cancellation/no-show fee, which is not billable to insurance. Patients who arrive late will be seen only
at the discretion of the provider. In the case of heavy snow/storms, the fee is waived. Excessive (3 or more) no-shows may result in
patient discharge from the practice.

Feedback
Please let us know how we are doing by emailing us at info@innovativefamilycare.com or by speaking to a member of our team. We
are constantly striving to improve!

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 Innovative Family Care, PLLC
Practice of Chet Gentry, MD; Alison Hicks, FNP-C
Chris Klamm, FNP-C; Tiffany Ward, FNP-BC; William Wilson, FNP

Patient Information:
Name: __________________________________ DOB: ___/___/_____ Age: ______ Sex:  Male  Female
Address: _______________________________ City: _______________________ State: ____ Zip: ______
Marital Status:  Single  Married  Divorced  Widowed
Social Security Number: _______ - _____ - _________
Optional:
Race (Check one)
____ American Indian/Alaskan Native
____ Asian ____ Native Hawaiian or other Pacific Islander
____ Black/African American ____ White
Ethnicity (Check one) ____ Of Hispanic Descent ____ Not of Hispanic Descent

Responsible Party or Bill to Information:  Check if the same as above

Relationship: ____________________
Name: __________________________________ DOB: ___/___/_____ Age: ______ Sex:  Male  Female
Address: _______________________________ City: _______________________ State: ____ Zip: ______
Social Security Number: _______ - _____ - _________

Contact Information: Permission to leave voicemail/send message?

Home Phone: (____) ____________________  Yes  No
Cell Phone: (____)_____________________  Yes  No
Work Phone: (____)_____________________  Yes  No
Preferred contact number?  Home  Cell  Work
E-mail: _________________________________ Ok to receive appt reminders via email?  Yes  No

Employer: _________________________________

Emergency contact: Name _____________________ Relationship____________ Phone (____)____________

Authorizations
 I understand that I am financially responsible for services rendered by the physician and his/her staff regardless of
insurance, including reasonable attorney’s fees and costs of collection in the event of default. I authorize my insurance
company to pay benefits directly to the physician.
 I understand that any patient under the age of 18 must be accompanied by an adult with authority to make decisions on
his/her behalf.
 I understand all of the above and hereby state that the information is correct to the best of my knowledge.
 I hereby acknowledge that I have received a copy of the Notice of Privacy Practices for Innovative Family Care, PLLC.
 These authorizations apply to all occasions until revoked. I give my consent for disclosure of my protected health
information for purposes of treatment, payment, daily operations and other disclosures as specifically listed on the Notice
of Privacy Practices given to me by Innovative Family Care, PLLC.

Signature of Patient or Authorized Party: ______________________________________ Date: _____________

Relationship to the patient: __________________________________________________
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 Record Release Authorizations

Patient Name: __________________________________ DOB: ___/___/_____

HIPAA (Health Insurance Portability and Accountability Act of 1996) protects your right to privacy. We cannot provide any
information to family (including spouse) and/or friends about you or your health status (for example, test results, x-rays,
prescriptions, surgeries, office notes, etc.) unless you give us written permission. We can only provide information to those
people listed on this form.

You have the right to revoke this form at any time by calling our Medical Records department.

To whom we may release your medical information:

Name: _______________________________________________ Relation: ________________________________

Name: _______________________________________________ Relation: ________________________________

Name: _______________________________________________ Relation: ________________________________

Name: _______________________________________________ Relation: ________________________________

Name: _______________________________________________ Relation: ________________________________

Name: _____________________________________________ _ Relation:________________________________

Patient or Authorized Signature: _________________________________ Date:_______________________

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 Innovative Family Care, PLLC
3300 Williams Enterprise Drive, Suite 1
Cookeville, TN 38506
o: 931-528-9222 f: 931-854-0907

Authorization for Disclosure of Health Information

The purpose of this form is to allow us to communicate effectively with other providers for your care.

Patient Name: _________________________________________________________ DOB: ___/___/_____

Address: __________________________________ City:________________ State: ________ Zip:________
Home Phone: (____)__________________ Cell Phone: (____)__________________

1. I authorize the use or disclosure of the above named individual’s health information as described below.

2. The following individual or organization is authorized to make the disclosure:

Name: ____________________________________________________________
Address: _______________________________ City:________________ State: ________ Zip:________
Phone: ( ____)_________________ Fax: (____)___________________________

3. The type and amount of information to be used or disclosed is as follows:

___ Complete Health Record ___ Lab/Imaging results
___ Physical exam ___ Consultation
___ Immunization record
___ Other (please specify):______________________________________________________________

4. I understand that the information in my health record may include information relating to sexually transmitted disease,
acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also include information
about behavior or mental health services and treatment for alcohol and drug abuse.

5. The information may be disclosed to the following organization:

Innovative Family Care
3300 Williams Enterprise Drive, Suite 1
Cookeville TN 38501
Phone: 931-528-9222 Fax: 931-854-0907

6. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization,
I must do so in writing and present my written revocation to the medical records department.

7. I understand that the HIPAA Privacy rule permits a provider to release information to my Health Insurance Carrier and
to any other health provider for my treatment without my authorization. (45 CFR 164.506)

Patient or Authorized Signature: _________________________________ Date:_______________________

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 Patient Portal
Innovative Family Care allows you to access your health information electronically through secure email by
use of our Patient Portal. Please complete the following if you wish to have access.

Patient Name: _________________________________________________________ DOB: ___/___/_____

Email address: _______________________________________________________

Create a username (All lower case letters, no spaces): __________________________________________

LOGGING ON TO THE PORTAL:

To access your information, go to our website: www.innovativefamilycare.com.

Select PATIENT PORTAL from the sidebar. Click on the link that will pop up. This will take you to the Login Screen. Enter
the username you have created above.

Your initial password will be: Password2#

You will be asked to change the password when you enter for the first time. The password you create must be at least 8
characters and contain a capital letter, lowercase letter, a number and a symbol. No spaces are allowed.

If you need to reset your password, click the link that says, “If you are a patient and have lost your password”. It will ask
you for your username and will ask the question that you create below. The system will then email you another temporary
password.

Password reset question (example: city of mother’s birth): ______________________________________

Password reset answer: ___________________________________________________________________

You will be able to see your lab and x-ray results, visit summaries, and communicate with the providers. When you send
messages, please allow 48 hours (2 business days) for a response. When your response arrives, you will be notified by
email to check your messages in the portal. DO NOT use the Portal to communicate information of an urgent nature.

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 Insurance Information
(please include a copy of your card, front and back)

Name of Primary
Insurance:
If this is a Medicare Advantage plan, check here

Policy #:

Group #:

Name of Insured:
DOB:
Employer:
Gender:  male  female
SS#:
Relation to Patient:

Name of Secondary Insurance:

If this is a Medicare Advantage plan, check here

Policy #:

Group #:

Name of Insured:
DOB:
Employer:
Gender:  male  female
SS#:
Relation to Patient: