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Register with DocTalker Family Medicine

Welcome to the DocTalker Family Medicine registration page. To register as a new patient, please enter your information in the fields below. Please do not use this form if you are already a patient (you have seen any of our practitioners in the past). To set up patient portal access or amend your information, please contact us.

If you are already a registered patient with online access, you can log in here

Basic Contact Information

First Name * Middle Name (or initial) Last Name *

Date of Birth *

Social Security Number Nickname/Preferred Name Gender * Pronouns Race Ethnicity

Your Address

Address 1 * Address 2 City * State * Zip Code * Timezone

Contact Information

Mobile Phone Number Home Phone Number Work Phone Number Preferred Contact Number Email Address (Primary) * Secondary Email Address Home Fax Number

Contact Preferences

Non-medical automated notifications (such as informational or educational emails, news about the practice, promotions, or marketing emails) Email: SMS/Text:

Emergency Contact

First Name * Middle Name Last Name * Relationship to Patient Email Address Phone Number *

Insurance Information

DocTalker does not participate directly with insurance, Medicare or Medicaid. Upon request DocTalker will provide the necessary forms to submit to insurance but it is the patient’s full responsibility to submit for reimbursement. Secondary Services ordered on the patient’s behalf may be covered by insurance. For this purpose we ask you to provide insurance and or Medicare information.

Plan Name Group Number Member ID Insurance Type

Medical Information

Please enter your basic medical information below. You may also add or edit this information after you've signed up.

Height (in INCHES) Weight (in POUNDS) Personal Medical History (please also include surgeries and hospitalizations) Relevant Family Medical History (indicate which family member if applicable)

Set Username and Password for Patient Portal

Please create a username and password that you will use to log into the Patient portal in the future.

Your username must be at least 4 characters long

Username *

Your password must be at least 8 characters long and include at least one number or special character.

Password * Confirm Password *

The patient portal gives you access to your medical records and lets you securely communicate with your doctors. When you sign up, you will receive an email with instructions for logging in.

"I consent to having medical information sent to my email address (we cannot guarantee the security of messages delivered by email)." "I have read and accept the terms of the privacy policy below:" *

Notice of Privacy Practices

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.

The Practice provides this Notice to comply with the Privacy Regulations issued by the Department of Health and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Our Thoughts About Your Protected Health Information:

We understand that your medical information is personal to you, and we are committed to protecting the information about you. With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Example of uses of your health information for treatment purposes:

We obtain treatment information about you and record it in a health record. During the course of your treatment, the doctor determines a need to consult with the doctor who referred you to us or another specialist in the area. The doctor will share the information and obtain input.

Example of use of your health information for payment purposes:

The health insurance company requests information from us regarding medical care given. We will provide information to them about you and the care given if requested.

Example of use of your information for health care operations:

We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services. We may also use or disclose information about you for internal or external utilization review and/or quality assurance, to business associates for purposes of helping us to comply with our legal requirements, to auditors to verify our records, to billing companies to aid us in this process and the like. We shall endeavor, at all times when business associates are used, to advise them of their continued obligation to maintain the privacy of your medical records.

Your Health Information Rights

The health record we maintain and billing records are the physical property of the practice. The information in it, however, belongs to you. You have a right to:

Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office. We are not required to grant the request but we will comply with any request granted;
Obtain a paper copy of this Notice of Privacy Practices for Protected Health Information ("Notice") by making a request at our office;
Request that you be allowed to inspect and copy your health record and billing record—you may exercise this right by delivering the request in writing to our office;
Appeal a denial of access to your protected health information except in certain circumstances;
Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office;
File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information;
Obtain an accounting of disclosures of your health information as required to be maintained bylaw by delivering a written request to our office. An accounting will not include internal information for treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care;
Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office; and,
Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.

If you want to exercise any of the above rights, please contact our Nurse Manager, Gail Hale, at (703) 938 4600 ext. 2 during normal hours. She will provide you with assistance on the steps to take to exercise your rights.

Our Responsibilities

The practice is required to:

Maintain the privacy of your health information as required by law;
Provide you with a notice of our duties and privacy practices as to the information we collect and maintain about you;
Abide by the terms of this Notice;
Notify you if we cannot accommodate a requested restriction or request; and
Accommodate your reasonable requests regarding methods to communicate health information with you.

Other Disclosures and Uses

Notification Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

Communication with Family

Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or in payment for such care if you do not object or in an emergency.

Food and Drug Administration (FDA)

We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

Workers Compensation

If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Public Health

As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Abuse & Neglect

We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.

Correctional Institutions

If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your protected health information necessary for your health and the health and safety of other individuals.

Law Enforcement

We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.

Health Oversight

Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings

We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order.

Disaster Relief

We may use and disclose your protected health information to assist in disaster relief efforts.

Other Uses

Other uses and disclosures besides those identified in this notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.

Website

We maintain a website that provides information about our entity, this notice will be on the website.

Changes to This Notice

We reserve the right to change this notice at any time. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we may receive from you in the future. We will post a copy of the current notice in the Practice. The notice will contain on the first page, in the top right-hand corner, the date of last revision and effective date. In addition, each time you visit the Practice for treatment or health care services you may request a copy of the current notice in effect.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact our nurse manager, who will direct you on how to file an office complaint.

All complaints must be submitted in writing, and all complaints shall be investigated, without repercussion to you. The Nurse Manager, Gail Hale can be reached at (703) 938 4600 ext. 2. You will not be penalized for filing a complaint.

Alan Dappen, M.D.
Elizabeth Gallagher, P.A.-C
Anissa M. Ben Aida, MSN, FNP-BC

I understand that DocTalker Family Medicine as opted out of Medicare and agree to the terms below:

Medicare Opt-Out Acknowledgement

By registering online, the registering patient (Beneficiary) or his/her legal representative agrees, understands and expressly acknowledges that has opted out of the Medicare program and agrees, understands and expressly acknowledges the following:

Beneficiary or his/her legal representative accepts full responsibility for payment of the physician’s charge for all services furnished by the physician.
Beneficiary or his/her legal representative understands that Medicare limits do not apply to what the physician may charge for items or services furnished by the physician.
Beneficiary or his/her legal representative agrees not to submit a claim to Medicare or to ask the physician to submit a claim to Medicare.
Beneficiary or his/her legal representative understands that Medicare payment will not be made for any items or services furnished by the physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
Beneficiary or his/her legal representative enters into this contract with the knowledge that he/she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and the beneficiary is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted out.
Beneficiary or his/her legal representative understands that Medi-Gap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
Beneficiary or his/her legal representative acknowledges that the beneficiary is not currently in an emergency or urgent health care situation.
Beneficiary or his/her legal representative acknowledges that a copy of this contract has been made available to him.

I acknowledge that I have received and read a copy of Doctalker Financial Policies. I understand these policies and agree to the policies as stated.

Doctalker Family Medicine Financial Policies

We would like to thank you for choosing Doctalker Family Medicine as your medical provider. Doctalker is a fee for service/ direct pay practice. Our services include house calls, office visits, phone calls, prescription refills and email or portal messages and are billed on a time basis by 5 minute increments at an hourly rate of $480. Office visits have an additional charge of $15 per visit. House calls have an arrival fee of $100 plus distance fee if applicable.

Day of Service

Payment is due at the time of service. We have opted out of Medicare which means NO claims can be submitted for our services. For other insurances we can provide paid invoices for you to submit for reimbursement. We do not file insurance.

You will receive a statement from our office for any balance due. We accept credit cards and checks. Payments can be made by phone.

Returned Checks

Returned checks are subject to a $25 administrative fee.

Medical Records

There is an administrative fee of $25 for medical records request. There is no charge to forward records if you choose to change practitioner.

Billing

If you believe you have received a bill from us in error please contact our Nurse manager. If you cannot pay the entire balance please call to make payment arrangements.

Collections

Accounts that are not paid within 90 days begin our in house collections process.

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