All Forms Adults

7/27/2019 All Forms Adults

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Welcome to the practice!

Thank you for choosing Novi Internal Medicine & Pediatrics as your FamilysPhysicians.We pride ourselves on providing thoughtful medical care for your whole family.

As your physicians we will be responsible for providing you withthe following services:

Communication of lab results and other testing in a timely manner Recommending & providing Immunizations to prevent diseases Inpatient (hospital) services at Royal Oak Beaumont Hospital & Providence Park Novi Providing you with educational resources that help you manage your chronic diseases &promote good health Work together with other members of your medical team to share in decisions about

your care Save space during our day to accommodate sick visits Have Saturday appointments available for patients that cannot be seen during the week Participate in PATIENT CENTERED MEDICAL HOME to help you accomplish your

personal health care goals Have a physician on call & available by phone 24/7 for emergencies

As a patient of our practice:


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History of the Present Illness

What is the reason for your visit today?:

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Are you having any problems with pain?: No Yes If yes, describe:

_________________________________________________________________________________________________________

Past Medical History

Please list current and past medical problems that you have been treated for:

Alcoholism

Allergy or Asthma

Arthritis

Bleeding Disorder

Cancer

Diabetes

Glaucoma

Heart Trouble

High Blood Pressure

High Cholesterol

HIV or AIDS

Kidney Stones

Obesity

Reaction to Anesthetic

Seizures

Stroke

Thyroid Disorders

Illness or Medical Problem Physician Who Treated You

Past Surgical HistoryPlease list your previous surgeries, and the year that you had the surgery done in.

Surgery (Any reaction to Anesthetic No Yes) Hospital Year

NOVI INTERNAL MEDICINE AND PEDIATRICS, PLLC

ADULT MEDICAL HISTORY FORM

DOS________ Last Name __________________________ First Name _________________________ DOB__________


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Allergies and SensitivitiesList any allergies to medications or foods that you may have and indicate how each affects you.

Allergic To Reaction Allergic To Reaction

Immunizations

Last Tetanus BoosterDate

Recommended every 10 years

Last Inuenza (u vaccine) Recommended for age over 65 or with chronic health problems, otherwise optional

Last Pneumovax (pneumonia) Recommended for age over 65 or with chronic health problems

Last Hepatitis B Vaccine Required for school-aged children; optional for adults

Last Skin Test for TBWas it positive or negative? Recommended if exposed

to persons at high risk for having tuberculosis

Last Measles Mumps Rubella

(booster dose)Recommended for women born after 1956 who plan on becoming pregnant

Family HistoryPlease indicate with a check any of the following medical problems within your family history:

Y=Yourself M=Mother F=Father S/B=Sister or Brother GP=Grandparent A/U=Aunt or Uncle

Y M F S/B GP A/U Y M F S/B GP A/U

High Blood Pressure Stroke

Allergy or Asthma Obesity

Heart Attack Alcoholism

Diabetes HIV or AIDS

High Cholesterol Glaucoma

Cancer Seizures


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Habits and Safety

Are you very active, or get regular exercise? Yes No

Do you always wear your seatbelt when in a motor vehicle? Yes No

Do you have home smoke detectors AND check the batteries regularly? Yes No

If you are elderly or handicapped, do you feel your home is designed to prevent injuries? Yes No

Do you have problems with activites of daily living such as bathing, toileting or xing meals? Yes No

If yes, explain: ________________________________________________________________________________________

Do you currently smoke? Yes No If so, how many packs a day ______ and for how many years? ________

If not, were you a former smoker? Yes No

Do you drink alcoholic beverages? Yes No Amount per week:__________________

If you drink, have people ever criticized your drinking? Yes No

If you drink, have you ever felt bad or guilty about your drinking? Yes No

Have you ever used any recreational drugs (like marijuana, cocaine, heroin, intravenous drugs)? Yes No

Do you have any guns/weapons in the home? Yes No If yes, can your children get to them? Yes No

Education Needs Assessment

Do you have any barriers to learning: None Vision Hearing Cannot Read Cannot Comprehend

Language/needs interpreter Other:_______________________________________________________

How does the patient best learn? Pictures Reading Listening Demonstration Other:______________

Pain Screening

1. Do you have pain now? No Yes 2. Do you have any ongoing pain problems?

No Yes How long? _______________

If you answered yes to question 1 or 2 above, continue with questions 3-13.

3. Location: ____________________________________

____________________________________________

4. Intensity (0-10): Now Usual

5. On a 0-10 scale, what is your level of pain when it is

at its best? ____________

9. What causes or increases your pain?

10. What symptoms are associated with your pain:


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PATIENT REGISTRATION

(Pleaseprintinformation and give your insurance card and drivers license to the receptionist so a copy can be made. Thank you.)

Print Last Name:_____________________________ First Name:______________________ Middle:_______________

Address:_________________________________________ Zip:__________ City:___________________ State:________

Home Phone:______________________ Work Phone:______________________ Cell Phone:______________________

Email:_________________________ Social Security #:_____________________ Date of Birth:_________ Sex: M F

Employment Status: Full-Time Part-Time Retired Self-Employed Unemployed Student

Marital Status: Single Married Divorced Separated Widowed

Do you have any Medication Allergies? Please list___________________________________________________________

Emergency Contact: (other than parent/spouse)____________________________ Relationship To You:_______________

Home Phone Number:_________________________________ Pager/Cell Phone:_______________________________

How did you hear about our practice? Beaumont Advertising Insurance www.novidocs.com Welcome Wagon Other:________________

Heard about us through a Family Member, Friend or other Physician?

We would like to thank them. Please print their name:_________________________________

Person who should receive bill (guarantor or responsible party)

Name:___________________________________ Relationship To Patient:_____________________ Sex: M F

Address:_________________________________________ Zip:_________ City:___________________ State:_________

Home Phone:_______________________ Work Phone:______________________ Email:_________________________

Cell Phone:__________________________ Social Security #:_________________________ Date of Birth:_____________

Appt.

Date:_____________


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Print Last Name:_____________________________ First Name:______________________ Date of Birth:____________

Consent for Clinic Services: I request and authorize health care services that my physician(s) or designee advise. These may includediagnostic, radiology and laboratory procedures, routine therapeutic procedures, routine drugs, and routine medical care. To that end,Instructors working at the Facility oversee students and trainee students and trainees may visit or care for me and may review my health

care information as part of their education. I will tell my nurse or doctor if I do not want students or trainees involved in my care. Iunderstand the Facility may withdraw from me specimens of blood, urine and other bodily uids/tissues for diagnostic purposes, and mayperform other tests not related to my diagnosis with these specimens, and the Facility may dispose of these specimens as it chooses, bylaw.

Payment: We accept cash, debit cards, Visa, MasterCard, and personal checks, with photo ID. After services have been rendered will billyour insurance company, and any outstanding balances are due within 30 days.

Insurance: Remember, your insurance is a contract between you and your insurance company. Novi Internal Medicine and Pediatrics isnot responsible for your deductibles, co-payments, co-insurance payments, percentages, deductibles, non-covered services, or servicesrendered without proper referral authorization, or denied services. If we are providers for your insurance, we will bill your insurance and

collect only the patient responsibility.

Insurance Deadlines: Many insurance companies have timely lling deadlines. It is your responsibility to inform us of any insurancechanges. If we are not provided with accurate information at the time of service, you may be responsible for payment in full for all servicesrendered. Please contact your insurance company to determine if our practice has a contract with your insurance company.

Immunizations: Please inform us if you do not have any immunization coverage, partial, or limited coverage. You may be eligible forVaccine for Children (VFC) program.

Referrals: I understand it is my responsibility to notify us if you may need an authorization and/or a referral within 10 days of yourappointment date. You could incur a fee for failure to notify us for a referral or a pre-certication for services. Some insurance companies

need pre-certication/authorization prior to services rendered. Your primary care physician has the right to refuse to give you a referral, ifthey deem it is not medically necessary, per your insurance contract.

Co-Payments: All co-payments are expected at time of service and may be asked for prior to seeing your physician. When you signedup with your insurance company, you signed an agreement between you and your insurance company stating co-payment is due at time ofservice.

Returned Checks: All returned checks will be assessed a $25 returned check fee, in addition to the amount of the check. You will have 10days to clear up the outstanding check. If you do not pay the check, plus the return fee in the specied time, the check will be sent to acollection agency. In addition, we will only accept cash or credit card for any future visits.

Missed Appointments: We understand there will be times when a scheduled appointment cannot be kept. If you need to cancel orreschedule an appointment, we request that you notify our ofce 24 hours in advance. If your appointment is made for same day and yound yourself unable to keep it, please call to cancel within a minimum of two hours notice in order for another patient to be scheduled. Ifyou do not cancel by the deadline, a $25 missed appointment fee will be added to your account. This fee is not payable by your insurance

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Notice of Privacy Practices (HIPAA)

1. 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.

2. WE HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI)

We are legally required to protect the privacy of your health information. We call this information protected health information or PHIfor short, and it includes information that can be used to identify you that we have created or received about your past, present, or futurehealth or condition, the provision of healthcare to you, or the payment for this health care. We must provide you with this notice aboutour privacy practices that explains how, when and why we use and disclose your PHI. With some exceptions, we may not use or discloseany more of your PHI than is necessary to accomplish the purpose of the use or disclosure. We are legally required to follow the privacypractices that are described in this notice. However, we reserve the right to change the terms of this notice and our privacy policies atany time. Any changes will apply to the PHI we already have. Before we make an important change to our policies, we will promptlychange this notice and post a new notice near the main entrance. You can also request a copy of this notice from thecontact person listed in Section 7 below at any time.

3. HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION.

We use and disclose health information for many different reasons. For some of these uses or disclosures, we need your prior specificauthorization. Below, we describe the different categories of our uses and disclosures and give you some examples of each.3.1. Uses and Disclosures Relating to Treatment, Payment or Health Care Operations.

We may use and disclose your PHI for the following reasons:3.1.1. For treatment. We may disclose your PHI to physicians, nurses, medical students and other health care personnel whoprovide you with health care services or are involved in your care. For example, if youre being treated for a knee injury, we maydisclose your PHI to the physical therapy department in order to coordinate your care.3.1.2. To obtain payment for treatment. We may use and disclose your PHI in order to bill and collect payment for the treatmentand services provided to you. For example, we may provide portions of your PHI to our billing department and your health plan toget paid for the health care services we provided to you. We may also provide your PHI to our business associates, such as billing

companies, claims processing companies and others that process our health care claims.3.1.3. For health care operations. We may disclose your PHI in order to operate our hospitals, clinics, urgent care and otherhealth care service locations. For example, we may use your PHI in order to evaluate the quality of health care services that youreceived or evaluate the performance of the health care professionals who provided health care services to you. We may alsoprovide your PHI to our accountants, attorneys, consultants and others in order to make sure we are complying with the laws thataffect us.

3.2. Certain Other Uses and Disclosures That Do Not Require Your Consent

3.2.1. When disclosure is required by federal, state or local law, judicial or administrative proceedings, or law enforcement.

For example, we make disclosures when a law requires that we report information to government agencies and law enforcementpersonnel about victims of abuse, neglect or domestic violence; when dealing with gunshot and other wounds, or when ordered in

a judicial or administrative proceeding.3.2.2. For public health activities. For example, we report information about births, deaths and various diseases to governmentofficials in charge of collecting that information, and we provide coroners, medical examiners and funeral directors necessaryinformation relating to an individuals death.


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4. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI

You have the following rights with respect to your PHI4.1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask that we limit how we use and

disclose your PHI. We will consider your request but are not legally required to accept it. If we accept your request, we will putany limits in writing and abide by them except in emergency situations. You may not limit the uses and disclosures that we arelegally required or allowed to make.

4.2. The Right to Choose How We Send PHI to You. You have the right to ask that we send information to you at an alternate address(for example, to your work address rather than your home address) or by alternate means (for example, e-mail instead of regularmail). We must agree to your request so long as we can easily provide it in the format you requested.

4.3. The Right to See and Get Copies of Your PHI. In most cases you have the right to look at or get copies of your PHI that we have,but you must make the request in writing. If we dont have your PHI but we know who does, we will tell you how to get it. We willrespond to your within 30 days after receiving your written request. In certain situations, we may deny your request. If we do, wewill tell you, in writing, our reasons for the denial and explain your right to have the denial reviewed.If you request copies of your PHI, we will charge you a reasonable copying fee.

4.4. The Right to Get a List of the Disclosures We Have Made. You have the right to get a list of instances in which we have disclosedyour PHI. The list will not include any of the 4 uses or disclosures listed in section 3.1, 3.2 and 3.3. The list also will not include

any uses or disclosures made before April 14, 2003.We will respond within 60 days of receiving your request. The list we will give you will include disclosures made in the last six yearsunless you request a shorter time. The list will include the date of the disclosure, to whom PHI was disclosed (including theiraddress, if known), a description of the information disclosed, and the reason for the disclosure. We will provide the list to you atno charge, but if you make more than one request in the same year, we will charge you $25 for each additional request.

4.5. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI or that a piece of important informationis missing, you have the right to request that we correct the existing information or add the missing information. You must providethe request and your reason for the request in writing. We will respond within 60 days of receiving your request. We may denyyour request in writing if the PHI is (i) correct and complete, (ii) not created by us, (iii) not allowed to be disclosed, or (iv) not partof our records. Our written denial will state the reasons for the denial and explain your right to file a written statement of

disagreement with the denial. If you dont file one, you have the right to request that your request and our denial be attached to allfuture disclosures of your PHI. If we approve your request, we will make the change to your PHI, tell you that we have done it, andtell others that need to know about the change to your PHI.

4.6. The Right to Get This Notice by E-Mail. You have the right to get a copy of this notice by e-mail. Even if you have agreed toreceive notice via e-mail, you also have the right to request a paper copy of this notice.

5. HOW TO COMPLAIN ABOUT OUR PRIVACY PRACTICES

If your think that we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI, you mayfile a complaint with: Novi Internal Medicine and Pediatrics, PLLC, HIPAA Privacy Officer - (See section 7 of this notice.).You also may send a written complaint to :

Secretary of the Department of Health and Human Services

200 Independence Avenue SWWashington, DC 20201We will take no retaliatory action against you if you file a complaint about our privacy practices.

6. WHO WILL FOLLOW THIS NOTICE OF PRIVACY PRACTICES

This notice describes the practices of the employees medical staff externs and volunteers of Novi Internal Medicine and Pediatrics


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ACKNOWLEDGMENT OF RECEIPT OF

NOTICE OF PRIVACY PRACTICES

By signing below I acknowledge that I have received a copy of this office's Notice of Privacy Practices.

Patient name:______________________________________________________

Patient Signature____________________________________________________

Date:______________________________________________________________

Documentation of Failure to Obtain Signed Acknowledgement

On ______________, 20__ , _________________________________ presented this

Acknowledgment of Receipt of Notice of Privacy Practices Form to:

_______________________________________, the Patient.


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NOVI INTERNAL MEDICINE AND PEDIATRICS, PLLC39475 Lewis Drive, Suite 130

Novi, Michigan 48377Office: (248) 374-0502 Fax: (248) 374-0567

When Your Doctor Needs To Contact You, But You are Not Available

As required by HIPAA (Health Information Portability and Accountability Act) you have a right to nominate one ormore persons to act on your behalf of receiving information with respect to your health information that pertainsto you. By completing this form you are informing us of your wish to designate the name or names of individualsand telephone numbers where we can leave detailed information about your health care concerns. These

individuals can be your spouse, family member or friend. By completing this form you are informing us of yourwith to designate the named person as your personal representative. You may revoke this designation at anytime by signing and dating the revocation of your copy of this form.

Authorization Section

I designate the following person(s) to receive information about my health care and act as my personalrepresentative with the use and/or disclosure of health information pertaining to me.

1)________________________________________________________________________________________Print Last Name First Name Telephone Number Other Telephone

2)________________________________________________________________________________________Print Last Name First Name Telephone Number Other Telephone

The authority of this/these person(s) when acting as my personal representative is restricted to the followingfunctions:__________________________________________________________________________________

I understand that I may revoke this designation at any time by signing the revocation section of my copy.


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NOVI INTERNAL MEDICINE AND PEDIATRICS, PLLC39475 Lewis Drive, Suite 130

Novi, Michigan 48377Office: (248) 374-0502 Fax: (248) 374-0567

When Your Child Needs To See The Doctor, But You Cannot Be There

Anytime you cannot come to the doctors office with your child, be sure you send the child to the doctors officewith an adult (19 years and older), and give that adult written permission to get treatment for your child.

By law, a doctor cannot treat a child, except in life or death situations, unless the parent or guardian givesconsent. Your childs care, or immunizations, could be needlessly delayed because you cannot get to the office.Therefore, if you cannot come to the office with your child, make sure that the adult that brings your child to theoffice can make medical decisions for your child.

Your child might have a croupy cough and fever. The doctor might want to run a blood test and your child mightneed a shot. If you are not there, and the adult who brings your child does not have your permission to allowthe doctor to run the test or get the shot, your child's treatment will be delayed. You can avoid this by makingsure that the adult caregiver has the proper written consent to make medical decisions for your child. You mayrevoke this designation at any time by signing and dating the revocation of your copy of this form.

Outpatient Treatment Permit/Authorization

1)________________________________________________________________________________________Print Last Name First Name Middle Initial Date of Birth

The undersigned does hereby grant to the individuals listed below (name of two adult individuals who will beresponsible for the care of your child or children in your absence) the limited Power of Attorney to act for me andto give the required consents and authorizations for delivery of medical care, diagnoses and treatment, ifnecessary from________________(todays date) and to do all other necessary things as I might or could do ifpersonally present, to include but not limited to:

Health maintenance visits (routine and immunizations) Acute illness (outpatient care and treatment)

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