Arthritis & Rheumatology Center, PC · 2020. 8. 18. · Arthritis and Rheumatology Center PC,...

Arthritis & Rheumatology Center, PC

Phone: (770) 284 3150 | Fax: (770) 284 3170 | Email: [email protected] ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

ARC.V1.00.04.15.20 Page 1 of 13

Patient Intake Form

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Last Name First Name Middle Initial Preferred name

Street Address Appt# City State Zip

Home Phone Cell Phone SSN# Date of Birth Sex Marital status

Employed by Spouse’s Name

Employer’s Address Spouse Employed by

Occupation Business Phone & Ext Spouse’s Occupation Spouse’s Business Phone & Ext

Nearest friend or relative NOT living with you Relationship to Insured Spouse’s Phone#

Policy Holder’s Insurance Information

Pri

mary

Last Name First Name Relationship to Patient

Insurance provider’s name Policy/Subscriber ID: Group#

Insurance Providers complete mailing address (See back of the card) Insurance Providers Phone#

Seco

nd

ary

Insurance provider’s name Policy/Subscriber ID: Group#

Insurance Providers complete mailing address (See back of the card) Insurance Providers Phone#

Referring and Primary Provider’s Information Referring Provider’s Name

Phone#

Address

Primary Care Provider’s Name

Phone#

Address

Referral Source (Doctors office, Insurance network, Family Member, Internet, etc.) Please list below.

about:blankabout:blank



ARC.V1.00.04.15.20 Page 2 of 13

Receipt of Notice of Privacy Practices

This is to acknowledge that I have reviewed and/or have access to a copy of Arthritis and Rheumatology Center, PC's Notice

of Privacy Practices. This information is located at the front office or on Arthritis and Rheumatology Center PC's website,

www.arcenterpc.com

Medicare Insurance Records Authorization

I REQUEST THAT PAYMENT OF AUTHORIZED benefits be made to Arthritis and Rheumatology Center, PC. I

authorize any holder of medical information about me to release to the Center of Medicare and Medicaid Services and its

agents any information needed to determine these benefits or the benefits payable to related services in reference to

Medicare. (NOTE: This office does not accept MEDICAID.)

Out of Network Insurance Notification

This office is out-of-network for these Insurance Plans:

Amerigroup, Wellcare, Peachstate, Humana-X, unless considered state health benefits plan, GA Medicaid or any other type of Medicaid (Other insurances may also apply. Please contact your insurance company to find out.)

I hereby authorize the release of any medical information, including information related to psychiatric care, drug

& alcohol abuse and HIV/AIDS confidential information, necessary to process insurance claims or any medical

information that is required for any healthcare related utilization, review or quality assurance activities or any

healthcare professional requiring this information.

I hereby assign and authorize payment to, of all medical and/or surgical benefits, including major medical

policies, to which i am entitled to under any insurance policy or policies, under any self-insurance program, or under

any benefit plan.

I understand and acknowledge that this assignment of benefits does not releive me of my financial responsibility

for all medical fees and charges incurred by me or anyone on my behalf and I hereby accept such responsibility,

including but not limited to payment of those fees and charges not directly reimbursed to by any insurance policy, self-

insurance program or other benefit plan.

This authorization shall remain in effect until revoked by me in writing. A photocopy of this authorization shall be

considered as effective and valid as the original. I understand that I have the right to receive a copy of this authorization.

Person providing the authorization (Print Name): ________________________________________________________

Relationship to patient if not the Patient: _________________________________________________________________

Patient Portal Information

I Do Do Not want to be signed up for the Patient Portal. If you choose to be signed up for,

then an email shall be automatically sent to you after your appointment is made.

Email ID (required to join Patient Portal): _________________________________________________________________________

I have read and understood all the about policies and agree to abide by its terms.

Date: Signature:




ARC.V1.00.04.15.20 Page 3 of 13

General Office Policies

Please read carefully. A copy can be provided to you upon request.

1. We are committed to meeting your healthcare needs. Our goal is to keep your insurance or other financial

arrangements as simple as possible. Arthritis & Rheumatology Center, PC participates in most major

insurance plans. For a complete list of insurance participants at this practice please call the practice main

line. We will file your insurance for you if we are participating provider of your plan.

2. All Co-Payments and Deductibles are due at the time of service. Please remember to bring your insurance

card (HMO, CMO, PPO, etc.) with you to each appointment

3. On your first visit the physician may order labs and or x-rays. These tests must be performed before your

next visit in order to prevent delays in your potential treatment.

4. There is a $50 No-Show fees for appointments not canceled or rescheduled within 24 hours

5. We have reserved your appointment time exclusively for you, if you are more than 10 minutes late to your

appointment, it may need to reschedule.

6. Lab, X-rays and all diagnostic test results are NOT given over the phone but rather at your next visit. If

there is an abnormal result that warrants immediate attention, the office will contact you asap.

7. All patients must present their insurance card at each visit. If you do not update us regarding new insurance

or additional insurance, this could affect medical claims and delay authorization for medications.

8. Please advise our front office staff if you have a new phone number, address or email

9. Referrals will be processed within 72 business hours from the receipt of request. Referral request received

on Fridays will be processed the following week. If you have change to pharmacies, you will need to update

us at the time of the refill request. If you have not kept up with your follow-up visits, your prescriptions

may not be refilled.

10. This practice Does Not participate in filling out disability claims forms. This includes short-term disability

claim forms. If a case warrants an exception to this policy, it is left to the discretion of the physician.

11. Medical records can be printed at the patient's request with fee of $1 per page, ($25 max) and $10 for CD’s.

There are no charges for sending medical records to other physician. This process can take up to 2 weeks.

12. FMLA forms can be completed under the discretion of the physician with $25 fees. This office does not fill

out long-term or short-term disability forms. Any exception to this policy is at the discretion of the

provider(s).

13. Telephone messages left for our staff after 3.00 p.m. will be returned the next business day.

14. Arthritis and Rheumatology Center PC does not allow patients to switch physicians once seen by original

provider. All our physicians are excellent in their field and have your best interest as their priority.

I have read and understood all the about policies and agree to abide by its terms.

Date: Signature:




ARC.V1.00.04.15.20 Page 4 of 13

Pain / Narcotic Medication Policy Please read carefully. A copy can be provided to you upon request.

1. I agree to take narcotic medication exactly as instructed. I am NOT allowed to change the dosage, amount

or alter the time schedule of taking the medication without first talking to my prescribing physician.

2. Narcotics will NOT be phoned in after business hours or on weekends

3. Only ONE pharmacy will be used for filling narcotic prescription

4. The following are the conditions for immediate termination from the practice.

a. Obtaining narcotics from any other physician while under our care without our knowledge

b. Altering or forging of a prescription is a felony and will be reported.

c. Testing positive for illegal drugs while taking controlled substance prescribed by a physician at

Arthritis and Rheumatology Center PC

5. Patients may be terminated from the practice with 30 days’ notice for non-compliance.

6. We will NOT refill prescription that have been lost or misplaced. Please be responsible in keeping up with

your narcotic prescription

7. Stolen medication can be replaced ONE TIME ONLY, if you have a valid police report

8. In the case of intolerance or ineffective narcotic medication, a different prescription may be given, provided

the unused portion of the previously prescribed medication was returned

9. I have been informed about the use of narcotic adverse side effects such as development of intolerance,

dependence, addiction, withdrawal, constipation, nausea, itching, harmful effects to an unborn child, urinary

retention, impairment of reasoning & judgement and depression of breathing.

10. I will not combine any narcotic medication with the consumption of alcohol and / or illegal drugs.

11. I will not give, trade or sell pain medication

12. I will allow 24 hours for a prescription refill to be authorized. I also understand that request received after

2 p.m. are handled on the next business day.

13. I understand that at any given time I may be tested by urine or blood for drug use and that a positive test

will result in refusal of narcotic medication and possibly subject me to termination from the practice

I have read and understood all the above policies and agree to abide by its terms.

Date: Signature:




ARC.V1.00.04.15.20 Page 5 of 13

Financial Policies Please read carefully. A copy can be provided to you upon request.

❖ We understand how helpful it can be to know in advance how payment arrangements are handled visit to the doctor's

office is necessary. Outlined below are the Arthritis & Rheumatology Center PC's basic Financial policy

❖ Arthritis and Rheumatology Center PC, requires you to provide a copy of your insurance card, co-payment and/or

deductibles at the time of check-in. As our office often performs many procedures in house, it is your responsibility

as a patient, to become familiar with your individual insurance benefits prior to accepting.

❖ If we participate in your insurance plan, we will file your charges with your insurance company on your behalf. if we

do not participate in your insurance plan, payment for services rendered is collected at the time of service.

❖ Failure to provide updated insurance information in a timely manner may cause Insurance denials and non-coverage

for procedures including in-office infusion therapy. Any claims denied due to the lack of updated insurance

information will then become the responsibility of the patient. If new insurance information is provided, we will file

the claim under that plan if the effective date falls within the range of the date of service. If the claim is denied by the

health insurance plan for timely filing, the patient will be responsible for payment of the claim.

❖ After we file the claim with your insurance, we will wait 60 days for payment from your insurance company. If payment

has not been received within 60 days, we will turn the account over to patient responsibility. We ask that you follow

up with your insurance company to make sure your claims are processed in a timely manner. Please communicate

your findings to us so that we may remain on sound financial footing. If for any reason we are not provided notification

of a new insurance plan you are on and the claim is denied for timely filing, the balance will become the responsibility

of the patient.

❖ Although we are reluctant to do so, we utilize a collection agency for accounts not paid within 90 days. Once an account

has been sent to the collection agency, it cannot be retrieved. Prompt payment of any balances remaining after

insurance has paid will keep your account in good standing.

❖ Charges for Lab Services performed outside of our office are billed separately and are not typically included with the

Physicians bill.

❖ Our charges for copying medical records are based on the charge set forth by the Georgia office of Planning and

Budget pursuant to O.C.G.A 31-33-3. In order to comply with the HIPAA regulations, a signed, written request for

medical records must be received along with the payments before records can be released. Varying fees are charged

for forms and letters that may be requested.

❖ Please let us know at least 24 hours prior do your scheduled appointment time if you will not be able to keep your

appointment. Appointments not canceled in a timely manner will be assessed a No-show fee off $50. we accept Visa,

MasterCard, American Express and Discover as well as cash and personal checks drawn on a local bank with pre-

printed name, address and phone number.

❖ Personal checks returned for insufficient funds are assessed a $35 fee. Checks that are returned by the bank as non-

paid are assessed a $35 bad check fee. The amount of the non-paid check plus the $35 bad check fee are due within

10 days. We reserve the right to require payment of the non-paid check and the bad check fee by a method other than

check (cash, credit/debit, money order). Failure to rectify the situation within 10 days, will result in the account being

sent to our collection agency


Date: Signature:




ARC.V1.00.04.15.20 Page 6 of 13

Ways to Help us to help you

We are committed to high-quality healthcare for you and your family. We have compiled a list of information that will

assist us in providing you with the highest level of patient care and customer service. Please familiarize yourself with this

information so you would know what to expect in the event you should need our assistance.

Pharmacy Prescription Refills:

You are encouraged to have prescription refills addressed at the time of your visit with your provider. Should you need a

refill during the interim, please have your pharmacy fax your request to our fax line at 770-284-3170 or send electronically.

This will help expedite the refill process. Please remember that your provider reviews all prescription refill requests and

must approve the refill. The review could take up to 72 hours. Contact your Pharmacy prior to calling our office to confirm

whether your prescription refill has been approved.

Labs, X-Rays and Diagnostic Testing Results:

Labs, X-rays and all Diagnostic test results are NOT given over the phone but rather at your next visit. If there is an

abnormal test result that warrants immediate attention, the office will contact you. It is most important that we have your

current phone number on file so you can receive your results.

Insurance:

Please bring your insurance card with you to every visit. We will need to review it and scan the card. This will assist us in

filing your claim for payment. In the event your coverage has lapsed ore expired on the date the services are rendered,

all charges will be your responsibility and payable that same day. Any Coinsurance, Deductible or Co-payments are

collected upfront at the time of service.

Phones:

To better serve you, if someone does not answer your call at our office, please leave a voicemail message. Messages left

before 3p.m. will be returned to the same day. Please do not leave multiple messages as this delays our response time to

your original message.

We are very pleased that you have chosen our office for your care. If you have any special needs or questions, please let

our staff know or feel free to call the Office Manager at 770-284-3150. Thank you for your confidence in us


Date: Signature:




ARC.V1.00.04.15.20 Page 7 of 13

No Show Policy

❖ When an appointment is missed without a call from someone to cancel or reschedule your appointment, it

is considered a NO-SHOW. When a patient does not appear for their appointment, the time is lost not only

for the physician, but also for the patient we might have been able to schedule at that time.

❖ The NO-SHOW rate has steadily increased over time. Almost every day there is someone that we are not

able to see because we have no remaining available appointments. Even though we try to accommodate as

many of our patients as possible, there is a limit to how many patients we can book as we assume that

everyone will keep that appointment. Therefore, after much consideration, and in fairness to all our patients

who do keep their appointments or call at least 24 hours in advance to reschedule, we feel it is necessary

to implement a NO-SHOW policy as follows

➢ Patient who miss their appointments without calling at least 24 hours in advance

to cancel, will receive a charge of $50 on their account for missed appointment.

At the time of the third missed appointment the patient will be advised that

another no-show may result in discharge/termination from the practice.

❖ We value you as a patient and recognize the difficulties you face in trying to coordinate all the demands

made up on your time. We know that unavoidable emergencies occur sometimes. We hope that you

understand about the need to implement this policy in our attempt to accommodate all of our patient’s time

constraints. Thank you for your understanding and support.

Please sign below indicating that you have reviewed the NO-SHOW policy


Date: Signature:




ARC.V1.00.04.15.20 Page 8 of 13

Authorization for Release of Health Information Please read carefully. A copy can be provided to you upon request.

Note: If the form is not complete, signed and dated, it becomes Invalid and cannot be accepted.

Patients Name: _____________________________________________________________ DOB: ____________________________

Consent to release your medical record information:

In an event, Arthritis and Rheumatology Center PC may need to contact you regarding your Medical Records

or Appointment. For such events, please list the phone numbers and email at which you may be reached:

Home: ____________________________________________ Cell: ___________________________________________________

Work: ____________________________________________ Email: _________________________________________________

In the event you are not available or not reachable:

Do you give permission for Arthritis and Rheumatology Center PC to leave a Voice Message on a voice

messaging device?

Yes, I give permission for HOME / CELL / WORK (please circle all that apply)

No, I do not give permission

Do you give permission for Arthritis and Rheumatology Center PC to release information verbally regarding

your medical records, test results, appointment details or additional information to person(s) listed below?

Yes, I give permission for No, I do not give my permission

List the person(s) to release information to:

1) Name Relationship Contact number

2) Name Relationship Contact number

3)

Name Relationship Contact number

List of Person(s) to restrict from receiving information:

X) Name By signing the form you verify that the information listed above is correct. If you wish to remove or add

additional person(s) to this form you will need to fill out a new form and submit it to the front office.

Patient’s Signature: Date:




ARC.V1.00.04.15.20 Page 9 of 13

Authorization for use or Disclosure of Protected Health Information

What is this? This form gives our practice authorization to pull as well as send your medical records from/to other healthcare institutions and/or practices to be reviewed by our/other physician(s) respectively.

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Last Name First Name Middle Initial

Full Address

Home Phone Cell Phone SSN# Date of Birth Sex

I authorize Arthritis and Rheumatology Center PC to use or disclose my protected health information as indicated

Print above the name of entity to receive this information

Print above the full address of the entity to receive this information I Authorize (Print Entity name) ______________________________________________________________________

to release my protected health information to Arthritis and Rheumatology Center PC as indicated below

Information to be released Purpose of Disclosure

From & to dates: Changing Physicians

History and Physical exam Continue care

Office notes At patients request

X-ray reports Second opinion

Lab reports Legal

Hospital records (OP notes, discharge summary) Insurance/ Workers Compensation

Medication records School

Others: Others:

I understand that this authorization will expire on ___________________________________________________ (Expiration date or Defined event)

I understand that I may revoke this authorization at any time by notifying Arthritis & Rheumatology

Center PC in writing. This authorization will cease to be effective on the date notified except to the extent that

the practice has acted in trust upon this authorization.

Date: Signature:




ARC.V1.00.04.15.20 Page 10 of 13

Initial Patient health Survey

Last name: __________________________________ First name: __________________________________ Date:____________________

DOB: ________________________ Age: ___________, Sex: Male / Female, Height: ____________inch, Weight: ______________lbs.

Race: Hispanic | Asian | African American | White | Refuse to report | Others: ___________________________

Language: English | Spanish | Indian | Korean | Russian | Refuse to report | Others: ___________________

Primary care physician: Name _____________________________________________, Phone: _____________________________________

Address: ________________________________________________________________________________________

Preferred Pharmacy: Name ______________________________________________, Phone: _____________________________________

Address: _________________________________________________________________________________________

New Patient Questionnaire

Reason for your visit (Chief Complaint): ___________________________________________________________________________________

___________________________________________________________________________________________________________________________

Medications: Are you taking any medications (including alternative, herbal and over the counter) now? Yes / No

If yes, please list name and dosage

Name of Medication Dosage Name of medication Dosage

Allergies:

Do you have any allergic or adverse reaction to any medications or substance? Yes / No

Allergic Medication/Substance Reaction to it Allergic Medication/Substance Reaction to it




ARC.V1.00.04.15.20 Page 11 of 13

Full Name: _____________________________________________________DOB: ____________________________________Date:________________________

Review of systems: (Please check if you recently have had any of the following signs and symptoms)

Constitutional: Respiratory: Gastrointestinal: Musculoskeletal: Integumentary/Skin Sleep Problems Shortness of breath Intolerance to

NSAIDS (anti-inflammatory medications)

Morning stiffness Erythema (redness

Change in appetite Difficulty breathing Limitation of daily activities

Petechial (small purple spots) Fatigue Asthma

Fever Cough Low back pain Ulcers

Weight gain/loss Heavy snoring Bloating/belching Neck pain Psoriasis

Shortness of breath with exertion

Black tarry stools Jaw pain Hair loss

Ophthalmologic: GERD (Gastro Esophageal Reflux Disease)

Achilles tendinitis Cold sensitivity

Visual changes Wheezing Knee pain Sun sensitivity

Eye inflammation Wrist pain Blistering of skin

Red eyes Breasts: Abdominal pain Hand pain Dry skin

Blurred vision Breast lumps Blood in stools Elbow pain Eczema

Dry eyes Breast pain Changes to bowel habits

Ankle pain Itching

Itchy eyes Breast swelling Leg pain Skin nodules

Nipple discharge Constipation Feet pain Rashes

Ear/Nose/ Mouth/Throat:

Decreased appetite Hip pain Raynaud’s phenomenon Hematologic/Lymphatic Diarrhea Carpal tunnel

Difficulty in hearing Bleeding tendencies Difficulty swallowing

Joint stiffness Skin lesions

Runny nose Easy bruising Nausea Leg cramps

Nose ulcers Swollen lymph nodes Vomiting Muscle aches Others: Mouth sore/ulcers Shoulder pain Please specify below

Gum bleeding Cardiovascular: Genitourinary: Joint pain

Hoarseness Heart murmur Blood in urine Sciatica

Sinus problem Heart attack/problems Frequent urination Joint swelling

Difficulty swallowing

Leg pain while walking Pain during urination

Weakness

Ear pain Leg swelling Hesitancy

Ringing in ears Varicosities (big leg vein)

Incontinence (trouble holding urine)

Neurologic:

Sinus pain High blood pressure Sciatica pain

Sore throat Chest pain Awake at night to urinate

Balance difficulty

Swollen glands Chest pressure Coordination

Irregular heartbeat Menstrual problems

Dizziness

Endocrine: Cervicitis Fainting

Thyroid problems Psychiatric: Vaginal ulcers Headache

Frequent thirst Anxiety Abnormal vaginal discharge

Loss of strength

Lack of sexual desire

Feeling depressed Seizures

Excessive sweating Mood swings Problems with erection / impotence

Tingling/ numbness

Heat intolerance Decreased interest in doing normal activities

Tremors

Prostate problems




ARC.V1.00.04.15.20 Page 12 of 13

Full Name: _____________________________________________________DOB: ____________________________________Date:__________________________

Past Medical History:

Please check if you suffer from, or have been treated for any of the following medical conditions: (Please Circle)

Arthritis YES NO Colitis YES NO Diabetes YES NO

Psoriasis YES NO Raynaud’s YES NO Heart disease YES NO

Uveitis YES NO Cancer YES NO Stroke YES NO

Iritis YES NO Osteoporosis YES NO Seizures YES NO

Kidney stones YES NO Hypertension YES NO Glaucoma YES NO

If yes, please explain: _________________________________________________________________________________________________________________

Do you suffer from Anxiety/Depression Yes / No

Drug/Alcohol Addiction Yes / No

Other known conditions: _______________________________________________________________________________________________________________

Past Surgical history: Please list any surgeries you have had in the past:

Type of Surgeries Year Type of Surgeries Year

Have you been admitted to a hospital during the past five years? Yes / No

If yes, please list the name of hospital, reason for admission and year of admission

Hospital Name Reason for admission Year Hospital Name Reason for admission Year

Family History: Please circle if your family suffers from, or have been treated for any of the following medical conditions:

Arthritis YES NO Colitis YES NO Diabetes YES NO

Psoriasis YES NO Raynaud’s YES NO Heart disease YES NO

Uveitis YES NO Cancer YES NO Stroke YES NO

Iritis YES NO Osteoporosis YES NO Seizures YES NO

Kidney stones YES NO Hypertension YES NO Glaucoma YES NO

If yes, please explain: _________________________________________________________________________________________________________________

Do your family suffer from Anxiety/Depression Yes / No and/or Drug/Alcohol Addiction Yes / No

Other known conditions: _______________________________________________________________________________________________________________




ARC.V1.00.04.15.20 Page 13 of 13

Full Name: _____________________________________________________DOB: ____________________________________Date:__________________________

Social History:

Do you smoke? Yes / No if yes, how often? ____________________________________________

Ex-smoker / Quit Date: ______________________________

Do you drink Alcohol? Yes / No if yes, how often? ____________________________________________

Do you use any illicit (street) drugs? Yes / No if yes, how often? _________________________________________

What is your occupation? _________________________________________________________________

Marital Status (Please circle one): Married Single Widowed Divorced

Number of children’s? _______________________

Sexual History:

Are you sexually active? Yes / No

Method of Birth control? None Others: ____________________________________________________

History of Sexually transmitted diseases? Yes / No if yes, please explain _________________________________

(For Women’s only)

Are you pregnant? Yes / No If yes, how many months? ___________

Nursing? Yes / No

Total births: ______________ Total miscarriages: _____________ Last menstrual period: ____________

Prolong or abnormal bleeding? Yes / No

Pelvic pain Yes / No

I understand the above information is necessary to provide me with surgical / Medical Care in a safe and efficient manner. I

have answered all questions to the best of my knowledge. should further information be needed, you have my permission to ask the

respect to healthcare provider or agency, who made release such information to you. I will notify the doctor of any change in my

health or medications.

Patient / Guardian Signature: ___________________________________________________ Date: ________________________________________________

I have reviewed the form and discussed it with the patient:

Physicians Signature: ___________________________________________________________ Date: ________________________________________________

Physician’s Assistant Signature: ________________________________________________ Date: ________________________________________________


Last Name: First Name: Middle Initial: Preferred name: Street Address: Appt: City: State: Zip: Home Phone: Cell Phone: SSN: Date of Birth: Sex: Marital status: Employed by: Spouses Name: Employers Address: Spouse Employed by: Occupation: Business Phone Ext: Spouses Occupation: Spouses Business Phone Ext: Nearest friend or relative NOT living with you: Relationship to Insured: Spouses Phone: Last Name_2: First Name_2: Relationship to Patient: Insurance providers name: PolicySubscriber ID: Group: Insurance Providers complete mailing address See back of the card: Insurance Providers Phone: Insurance providers name_2: PolicySubscriber ID_2: Group_2: Insurance Providers complete mailing address See back of the card_2: Insurance Providers Phone_2: Referring Providers Name: Phone: Address: Primary Care Providers Name: Phone_2: Address_2: Referral Source Doctors office Insurance network Family Member Internet etc Please list belowRow1: ARCV100041520: Page 1 of 13: considered as effective and valid as the original I understand that I have the right to receive a copy of this authorization: Person providing the authorization Print Name: Do: OffDo Not: Offthen an email shall be automatically sent to you after your appointment is made: Date: ARCV100041520_2: ARCV100041520_3: ARCV100041520_4: ARCV100041520_5: Page 6 of 13: ARCV100041520_6: Patients Name: DOB: Home: Cell: Work: Email: messaging device: No I do not give permission: your medical records test results appointment details or additional information to persons listed below: undefined: 1: 2: 3: X: ARCV100041520_7: Page 8 of 13: Last Name_3: First Name_3: Middle Initial_2: Full Address: Home Phone_2: Cell Phone_2: SSN_2: Date of Birth_2: Sex_2: I authorize Arthritis and Rheumatology Center PC to use or disclose my protected health information as indicated: OffPrint above the name of entity to receive this information: Print above the full address of the entity to receive this information: undefined_2: OffI Authorize Print Entity name: Information to be released: undefined_3: OffFrom to dates: undefined_4: OffChanging Physicians: undefined_5: OffHistory and Physical exam: undefined_6: OffContinue care: undefined_7: OffOffice notes: undefined_8: OffAt patients request: undefined_9: OffXray reports: undefined_10: OffSecond opinion: undefined_11: OffLab reports: undefined_12: OffLegal: undefined_13: OffHospital records OP notes discharge summary: undefined_14: OffInsurance Workers Compensation: undefined_15: OffMedication records: undefined_16: OffSchool: undefined_17: OffOthers: undefined_18: OffOthers_2: I understand that this authorization will expire on: ARCV100041520_8: Page 9 of 13: Last name: First name: Date_2: DOB_2: Age: Sex Male Female Height: inch Weight: Others_3: Others_4: Primary care physician Name: Phone_3: Address_3: Name: Phone_4: Address_4: Reason for your visit Chief Complaint 1: Reason for your visit Chief Complaint 2: Name of MedicationRow1: DosageRow1: Name of medicationRow1: DosageRow1_2: Name of MedicationRow2: DosageRow2: Name of medicationRow2: DosageRow2_2: Name of MedicationRow3: DosageRow3: Name of medicationRow3: DosageRow3_2: Name of MedicationRow4: DosageRow4: Name of medicationRow4: DosageRow4_2: Name of MedicationRow5: DosageRow5: Name of medicationRow5: DosageRow5_2: Allergic MedicationSubstanceRow1: Reaction to itRow1: Allergic MedicationSubstanceRow2: Reaction to itRow2: Allergic MedicationSubstanceRow3: Reaction to itRow3: Allergic MedicationSubstanceRow4: Reaction to itRow4: Allergic MedicationSubstanceRow1_2: Reaction to itRow1_2: Allergic MedicationSubstanceRow2_2: Reaction to itRow2_2: Allergic MedicationSubstanceRow3_2: Reaction to itRow3_2: Allergic MedicationSubstanceRow4_2: Reaction to itRow4_2: ARCV100041520_9: Page 10 of 13: Full Name: DOB_3: Date_3: ConstitutionalRow1: RespiratoryRow1: ConstitutionalRow2: Change in appetite: RespiratoryChange in appetite: ConstitutionalRow3: Fatigue: RespiratoryRow3: Asthma: ConstitutionalRow4: Fever: RespiratoryRow4: Cough: GastrointestinalRow1: MusculoskeletalRow1: IntegumentarySkinRow1: MusculoskeletalRow2: Limitation of daily activities: IntegumentarySkinRow2: Petechial small purple spots: MusculoskeletalRow3: IntegumentarySkinRow3: Ulcers: ConstitutionalRow5: RespiratoryRow5: Heavy snoring: GastrointestinalRow2: MusculoskeletalRow4: Neck pain: IntegumentarySkinRow4: Psoriasis: RespiratoryRow6: Shortness of breath with exertion: GastrointestinalRow3: MusculoskeletalRow5: Jaw pain: IntegumentarySkinRow5: Hair loss: GastrointestinalRow4: MusculoskeletalRow6: IntegumentarySkinRow6: OphthalmologicRow1: RespiratoryRow7: Wheezing: GastrointestinalRow5: MusculoskeletalRow7: Knee pain: IntegumentarySkinRow7: Sun sensitivity: OphthalmologicRow2: GastrointestinalRow6: MusculoskeletalRow8: Wrist pain: IntegumentarySkinRow8: OphthalmologicRow3: Red eyes: GastrointestinalRow7: MusculoskeletalRow9: Hand pain: IntegumentarySkinRow9: Dry skin: OphthalmologicRow4: BreastsRow1: Breast lumps: GastrointestinalRow8: MusculoskeletalRow10: Elbow pain: IntegumentarySkinRow10: Eczema: OphthalmologicRow5: Dry eyes: BreastsRow2: Breast pain: GastrointestinalRow9: OphthalmologicRow6: Itchy eyes: BreastsRow3: Breast swelling: GastrointestinalRow10: Changes to bowel habits: MusculoskeletalRow11: Ankle pain: IntegumentarySkinRow11: Itching: MusculoskeletalRow12: Leg pain: IntegumentarySkinRow12: Skin nodules: BreastsRow4: GastrointestinalRow11: Constipation: MusculoskeletalRow13: Feet pain: IntegumentarySkinRow13: Rashes: GastrointestinalRow12: MusculoskeletalRow14: Hip pain: IntegumentarySkinRow14: GastrointestinalRow13: Diarrhea: MusculoskeletalRow15: Carpal tunnel: IntegumentarySkinRow15: Raynauds phenomenon: EarNose MouthThroatRow1: Difficulty in hearing: HematologicLymphaticRow1: Bleeding tendencies: GastrointestinalRow14: Difficulty swallowing: MusculoskeletalRow16: Joint stiffness: IntegumentarySkinRow16: Skin lesions: EarNose MouthThroatRow2: Runny nose: HematologicLymphaticRow2: Easy bruising: GastrointestinalRow15: Nausea: MusculoskeletalRow17: Leg cramps: EarNose MouthThroatRow3: Nose ulcers: HematologicLymphaticRow3: GastrointestinalRow16: Vomiting: MusculoskeletalRow18: EarNose MouthThroatRow4: MusculoskeletalRow19: EarNose MouthThroatRow5: Gum bleeding: MusculoskeletalRow20: Joint pain: EarNose MouthThroatRow6: Hoarseness: CardiovascularRow1: Heart murmur: GenitourinaryRow1: MusculoskeletalRow21: Sciatica: Please specify belowRow1: EarNose MouthThroatRow7: CardiovascularRow2: GenitourinaryRow2: MusculoskeletalRow22: EarNose MouthThroatRow8: Difficulty swallowing_2: CardiovascularRow3: Leg pain while walking: GenitourinaryRow3: Pain during urination: MusculoskeletalRow23: Weakness: Please specify belowRow2: EarNose MouthThroatRow9: Ear pain: CardiovascularRow4: Leg swelling: GenitourinaryRow4: Hesitancy: EarNose MouthThroatRow10: Ringing in ears: CardiovascularRow5: GenitourinaryRow5: Please specify belowRow3: EarNose MouthThroatRow11: Sinus pain: CardiovascularRow6: GenitourinaryRow6: NeurologicRow1: Sciatica pain: EarNose MouthThroatRow12: Sore throat: CardiovascularRow7: Chest pain: GenitourinaryRow7: EarNose MouthThroatRow13: CardiovascularRow8: Chest pressure: GenitourinaryRow8: Awake at night to urinate: NeurologicRow2: Please specify belowRow4: NeurologicRow3: Coordination: CardiovascularRow9: Irregular heartbeat: GenitourinaryRow9: Menstrual problems: NeurologicRow4: Dizziness: Please specify belowRow5: GenitourinaryRow10: Cervicitis: NeurologicRow5: Fainting: EndocrineRow1: GenitourinaryRow11: NeurologicRow6: Headache: Please specify belowRow6: EndocrineRow2: PsychiatricRow1: Anxiety: GenitourinaryRow12: EndocrineRow3: PsychiatricRow2: Feeling depressed: GenitourinaryRow13: Abnormal vaginal discharge: NeurologicRow7: NeurologicRow8: Seizures: Please specify belowRow7: EndocrineRow4: Excessive sweating: PsychiatricRow3: Mood swings: GenitourinaryRow14: NeurologicRow9: Tingling numbness: EndocrineRow5: EndocrineRow6: Heat intoleranceRow1: PsychiatricRow4: Decreased interest in doing normal activities: GenitourinaryRow15: NeurologicRow10: Please specify belowRow8: GenitourinaryRow16: NeurologicRow11: TremorsRow1: Please specify belowRow9: ARCV100041520_10: Page 11 of 13: Full Name_2: DOB_4: Date_4: Arthritis: YES: NO: Psoriasis_2: YES_2: NO_2: Uveitis: YES_3: NO_3: Iritis: YES_4: NO_4: Kidney stones: YES_5: NO_5: Colitis: YES_6: NO_6: Raynauds: YES_7: NO_7: Cancer: YES_8: NO_8: Osteoporosis: YES_9: NO_9: Hypertension: YES_10: NO_10: Diabetes: YES_11: NO_11: Heart disease: YES_12: NO_12: Stroke: YES_13: NO_13: Seizures_2: YES_14: NO_14: Glaucoma: YES_15: NO_15: If yes please explain: Other known conditions: Type of SurgeriesRow1: YearRow1: Type of SurgeriesRow2: YearRow2: Type of SurgeriesRow1_2: YearRow1_2: Type of SurgeriesRow2_2: YearRow2_2: Hospital NameRow1: Reason for admissionRow1: YearRow1_3: Hospital NameRow2: Reason for admissionRow2: YearRow2_3: Hospital NameRow1_2: Reason for admissionRow1_2: YearRow1_4: Hospital NameRow2_2: Reason for admissionRow2_2: YearRow2_4: Arthritis_2: YES_16: NO_16: Psoriasis_3: YES_17: NO_17: Uveitis_2: YES_18: NO_18: Iritis_2: YES_19: NO_19: Kidney stones_2: YES_20: NO_20: Colitis_2: YES_21: NO_21: Raynauds_2: YES_22: NO_22: Cancer_2: YES_23: NO_23: Osteoporosis_2: YES_24: NO_24: Hypertension_2: YES_25: NO_25: Diabetes_2: YES_26: NO_26: Heart disease_2: YES_27: NO_27: Stroke_2: YES_28: NO_28: Seizures_3: YES_29: NO_29: Glaucoma_2: YES_30: NO_30: If yes please explain_2: Other known conditions_2: ARCV100041520_11: Page 12 of 13: Full Name_3: Phone 770 284 3150 Fax 770 284 3170 Email infoarcenterpccom: DOB_5: Date_5: if yes how often: Exsmoker Quit Date: if yes how often_2: if yes how often_3: What is your occupation: Number of childrens: Others_5: if yes please explain: If yes how many months: Total births: Total miscarriages: Last menstrual period: Date_6: undefined_19: Date_7: undefined_20: Date_8: ARCV100041520_12: Page 13 of 13:

Arthritis & Rheumatology Center, PC · 2020. 8. 18. · Arthritis and Rheumatology Center PC,...

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Transcript of Arthritis & Rheumatology Center, PC · 2020. 8. 18. · Arthritis and Rheumatology Center PC,...