Patient Information - My Neighborhood Primary Care€¦ · medication administration, infusions,...
Transcript of Patient Information - My Neighborhood Primary Care€¦ · medication administration, infusions,...
Name: _______________________________________ Date of Birth: ________________________________________
Race: Native American, Eskimo Asian/Pacifier Islander Black Multi-Racial White Other Unknown
Ethnicity: Hispanic Non-Hispanic Unknown Other Interpreter Needed Yes No
Mailing Address: _______________________________________________ City: _________________________________
State: _______________________________ Zip Code:______________________________________________________
Social Security Number: _____________________ Email Address: ____________________________________________
Home Phone:___________________________________ Cell Phone:__________________________________________
EMPLOYMENT
Employment Status: Full Time Part-time Not Employed Self-Employed Retired Other _________________
If Applicable, Employer Name: ___________________________________________________________________________
Student Status: Full-time Part-time Not a Student
INSURANCE
Primary Insurance Name of Insurance: ________________________________________________
Subscriber's Name, if different: _______________________Subscriber's SSN: __________________________________
Subscriber's Birth Date: _________________ ID#:_________________________ Group #:_______________________
Patient's Relationship to subscriber: Self Spouse Child Other
Secondary Insurance (If applicable) Name of Insurance: ________________________________________________
Subscriber's Name, if different: _______________________Subscriber's SSN: __________________________________
Subscriber's Birth Date: _________________ ID#:_________________________ Group #:_______________________
Patient's Relationship to subscriber: Self Spouse Child Other
EMERGENCY CONTACT
Name of Emergency contact person: _______________________________ Relationship to Patient: ________________
Home Phone Number:________________ Work Phone Number:___________________________________________
The above information is true to the best of my knowledge. I authorize Arizona Bleeding Disorders Health and Wellness
Center to treat me.
X___________________________________________________________________ _______________________________
Patient/Guardian Date
Patient Information
Page 1
Medical Treatment Consent:
I (the undersigned, and/or the parent or legal guardian) consent to the administration of reasonable and
necessary services in connection with treatment of the above-mentioned patient at Arizona Bleeding
Disorders Health & Wellness Center. This consent includes, but is not limited to, laboratory procedures,
medication administration, infusions, procedures, and/or services rendered to a patient by members of the
medical staff, their representatives, and/or associates, and employees under the instruction of the physician. I
acknowledge that no guarantees have been made to me as to the results of treatments or examination in the
clinic.
Release of Information and Assignment of Insurance Benefits:
Release of Information: I hereby authorize Arizona Bleeding Disorders Health & Wellness Center and any
physician who has rendered services to release any and all information pertaining to my (or the patient’s)
treatment to enable the collection of benefits for the services rendered. The authorization includes release
of information to insurance companies or healthcare providers, in whole or in part, for payment in exchange
for services rendered, whether such payment is in exchange for services rendered by Arizona Bleeding
Disorders Health & Wellness Center or by the physicians. Release of Information is also authorized to any
providers for follow-up medical care.
Assignment of Benefits: I hereby authorize and assign payment directly to Arizona Bleeding Disorders
Health & Wellness Center for benefits, including secondary benefits, due to me for medical services. I
understand that I am financially responsible for charges not covered by any insurance or medical benefit
payor. I further acknowledge that any benefits, when received by and paid to Arizona Bleeding Disorders
Health & Wellness Center will be credited to my account in accordance with this assignment.
I hereby give permission to receive services and treatment by my physician (and/or associates) at Arizona Bleeding Disorders Health &
Wellness Center. I authorize the release of information including protected health information as needed to file for payment for services
incurred. I fully understand my Financial Responsibility for services rendered at Arizona Bleeding Disorders Health & Wellness Center.
_______________________________________ ____________________________________________ Signature of Patient or Personal Representative Printed Name of Patient or Personal Representative
_______________________________________ ____________________________________________ Date * Relationship to Patient (if Personal Representative)
*If Personal Representative, the patient is unable to sign because (check one):
Other (explain):______________________________________________________________________________________________________________________________
Medical Consent
Page 2
Acknowledgment of Privacy Practices
& Release of Personal Health
Information / HIPAA
Patient Name: _________________________________________________Date of Birth: _________________
I acknowledge that I have received a copy of the NOTICE OF PRIVACY PRACTICES: _____________ (initials)
I give permission to Arizona Bleeding Disorders Health & Wellness Center to communicate messages regarding
APPOINTMENTS as follows:
______ You may leave a message on my voice mail /answering machine
______ You may leave a message with ____________________________________________________________
______ You may communicate with me through the Patient Portal
______ Please communicate appointment messages as follows: ________________________________________
I give permission to Arizona Bleeding Disorders Health & Wellness Center to communicate messages regarding
REFERRALS TO ANOTHER PHYSICIAN as follows:
______ You may leave a message on my voice mail /answering machine
______ You may leave a message with ___________________________________________________________
______ You may communicate with me through the Patient Portal
______ Please communicate appointment messages as follows: _______________________________________
I give permission to Arizona Bleeding Disorders Health & Wellness Center to communicate messages regarding
LAB RESULTS, X-RAYS AND OTHER TESTS as follows:
______ You may leave a message on my voice mail /answering machine
______ You may leave a message with ___________________________________________________________
______ You may communicate with me through the Patient Portal
______ Please communicate Test Result messages as follows: ________________________________________
Names of individuals who we have permission to release your health information to:
__________________________________________________________________________________________
__________________________________________________________________________________________
Signature of Patient, Parent or Legal Guardian: _______________________________________
Date: ______________________________
Page 3
PAST MEDICAL HISTORY Please Circle any that apply
Other Medical Conditions (Please List/Explain): __________________________________________________
________________________________________________________________________________________
SURGICAL HISTORY
Type of Surgery Date
Abnormal Pap Smear Emphysema/COPD Hepatitis Seizures
Anemia Enlarged Prostate HIV/AIDS Sickle Cell
Arthritis Glaucoma Irregular Heart Rhythm Skin Problems
Autoimmune Disease Heart Disease Kidney Problems STDs
Blood Clots Heart Attack Liver Disease Stomach Problems
Cancer Heart Failure Lupus Thyroid Problems
Chest Pain Hemophilia Migraines Tuberculosis
Chronic Kidney Disease High Blood Pressure Neck/Back Problems Von Willebrands
Diabetes High Cholesterol Osteoporosis Psychological Disorders
Patient History Form
Page 4
SOCIAL HISTORY
Marital Status: Single Married Divorced Separated Widowed
Have you ever used tobacco? Yes No Current Use Past Use (Quit ______ Years ago)
If so, which type(s)? _________________________ How many times a day? ___________________
Do you consume Alcohol? Yes No If so, how often? How many drinks per week? ________________
Do you use any recreational Drugs? Yes No Do you have a medical marijuana card? Yes No
REPRODUCTIVE HISTORY for female patients only
Age at first period? ________ Number of pregnancies? ____________ Delivery Types:_________________
____________________________________Last Period: _____________________ Menopausal Status:
Have you ever taken oral contraceptive pills? Yes No _______________________________
Is your flow Regular Irregular How often/Long? _________________________________________
Last Pap: _________________ How many pads/tampons do you use in one day? ___________________
Do you have any pain, bleeding or blood clots? Yes No _______________________________
FAMILY MEDICAL HISTORY
Type of Condition Family Member Age Diagnosed
Arthritis
Asthma
Autoimmune Disease (List Type)
Bleeding Disorder (List Type)
Dementia
Depression
Diabetes Type 1 or Type 2
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Obesity
Osteoporosis
Stroke
Substance Abuse
Cancer (List Type)
Patient History Form, Cont.
Page 5
Caffeine Use: Yes No How Much?_____________ Exercise: Yes No How Often?__________
ALLERGIES Please list all known allergies and reactions below
MEDICATIONS Please list all medications
Medication Name Dose Frequency Taken for
Drug Reaction
Name, Address and Number (Phone and Fax)
Local Pharmacy
Mail-in Mail Order Pharmacy
Are you allergic to iodine? Yes No
Are you allergic to latex? Yes No
If you have no known allergies, please circle: No Allergies
Medication & Allergy List
Page 3
Page 6
Arizona Bleeding Disorders Health & Wellness Center My Neighborhood Primary Care
Please carefully read each statement and sign below. This policy has been put in place to ensure that financial payments due are recovered so that we may continue to provide quality medical care for our patients. It is important that we work together to assure that payment for services is as simple and straightforward as possible. Our staff will be glad to discuss these policies with you.
I understand that if I do not have my insurance card, referral, and/or coh payment that my appointment may be rescheduled until such time that I can provide the required documents or payments.
I understand that reminder appointment calls from the office are a courtesy only, and that I am responsible for keeping track of my appointment and being on time.
I understand I am financially responsible for any co-payments, deductibles, coinsurance and all charges which are not covered by my insurance. I understand that verification of coverage is not a guarantee of payment of benefits. My insurance company determines benefit payments. I understand I will be responsible for the portion not covered by my insurance. If I have an outstanding balance on my account, I agree to pay the balance in full or agree to a payment plan before I am allowed to schedule another appointment. Exceptions are at the sole discretion of the clinic Management.
I understand that if I am unable to make a scheduled appointment I need to contact the office at least 24 hours prior to my scheduled appointment. A $50 FEE MAY BE ASSESSED FOR ALL MISSED APPOINTMENTS NOT CANCELLED WITH AT LEAST 1 BUSINESS DAY WITH A 24 HOUR NOTICE.
I understand there is a $25 charge for a Nonh Sufficient Funds (NSF) check.
I understand there may be a $10h $40 charge for all forms deemed appropriate, filled out by the Physician (e.g. Disability, FMLA, etc.). When dropping forms off, I must allow 5h 7 days for completion.
I understand if my account is not paid in full within 120 days, I may be turned over to a collection agency for further processing and incur an additional 35% fee. Legal action fee will be 50%. In addition, I will be discharged from the practice.
I have read and I understand the above Financial Policy and I agree to abide by its terms
Signature of the Patient or the Patient’s Legal Representative Date
Print Name If not the patient, state your relationship to the patient or describe your authority to act on behalf of the patient
Financial Policy
Page 3Page 3
Page 7
Arizona Bleeding Disorders Health & Wellness CenterMy Neighborhood Primary Care
821 N 5th Ave Phoenix, AZ 85003 (P) 602-680-7722 (F) 602-682-5415
Medical Records Request and Release Form
Patient Name: DOB: _______________________________
Patient Address: City State Zip Code
I, the undersigned, hereby authorize __________________________________________________
at (F) _________________________________to provide my medical records to the Arizona
Bleeding Disorders Health & Wellness Center/My Neighborhood Primary Care. I understand
that the entire medical record, including information pertaining to drug or alcohol abuse and
psychological or psychiatric treatment, will be provided unless I specify that the following information
should not be released: ___________________________________________________________
Release or transfer of the specified information to any person or entity not specified herein is
prohibited. An additional written consent must be obtained for a proposed new use of the information
or for its transfer to another person or entity.
I understand that I have a right to receive a copy of this authorization upon my request.
Copy requested: Yes No
Patient’s Signature: Date:
or Personal Representative:
Request Received By: Date:
Please Fax the above requested medical records to Arizona Bleeding Disorders Health & Wellness
Center Attn: Jessica Jackson at 602-682-5415.
____ Send all records (complete chart) ____ Send last 5 years____ Send last 1 year
Page 8