Please be aware that this office does not do pain management and will not prescribe narcotics to new patients, nor on an ongoing basis.

Transcription

1 Patient Information Sheet Last Name: First Name: Middle Initial: Patient Is: Policy Holder Responsible Party RESPONSIBLE PARTY Last Name: First Name: Middle Initial: Address: City, State, Zip: Home Phone: Work Phone: Ext: Cell: Birth Date: / / Social Security Number: - - Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder PATIENT INFORMATION (if not responsible party) Address: City, State, Zip: Home Phone: Work Phone: Ext: Cell: Sex: Male Female Marital Status: Married Single Divorced Separated Widowed Birth Date: / / Age: Soc Sec: I would like to receive correspondence via (like appointment reminders) Employment Status: Full Time Part Time Retired Student Status: Full Time Part Time Employer Referred By: Emergency Contact: Emergency Number: PRIMARY INSURANCE INFORMATION Private Insurance Medicare Medicaid Secondary Cash Pay Please give your card to the receptionist to make a copy for our records. We accept most insurance coverage. All co-pay amounts are due at the time of your appointment. Cash pay patients must pay the full amount of their first appointment at the time of service. After the first appointment, subsequent appointments may be put on a payment schedule, which will entail 100% of any laboratory or vaccine charges plus 50% of the balance at the time of service, and a minimum of $50 per month payments, or 6 equal payments, whichever is greater. Please be aware that this office does not do pain management and will not prescribe narcotics to new patients, nor on an ongoing basis.

2 YOUR HEALTH INFORMATION OUR LEGAL DUTY We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect September , and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. Payment: We may use and disclose your health information to obtain payment for services we provide to you. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those descried in this Notice. To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose

3 health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the personʼs involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. Marketing Heath-Related Services: We will not use your health information for marketing communication without your written authorization. Required by Law: We may use or disclose your health information when we are required to do so by law. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances. Appointment Reminders; We may use or disclose your health information to provide you with appointment reminders (such as voic messages, postcards, or letters). PATIENT RIGHTS Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0.25 for each page, $7.50 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternate format, we will charge a costbased fee for providing your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.) Disclosing Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 5 years, but not before September If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

4 Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances. Entity to Receive Information. Check each person/entity that you approve to receive information. Description of information to be released. Check each that can be given to person Spouse (provide name & phone number) Voice Mail Results of lab tests/x-rays Financial Medical as follows: Parent (provide name & phone number) Financial Results of lab tests/x-rays Medical as follows: Other (provide name & phone number Financial Medical as follows: Refills for prescriptions should be handled by your pharmacy. Please allow 48 business hours for refill authorizations. We are here Monday through Thursday, we do not refill medications over the weekend. Please contact your pharmacy for a refill before you run out of medication. Dr. Wall requires that all patients currently managed by this office have a full physical with blood work yearly. Women who see an ob/gyn will still need to have a physical exam and blood work here for the other body systems. Patients with certain conditions may need to be seen more often. Refills on medications may be held for appointments to be made. Flu shots are given annually in October as supplies last. If you are over the age of 60, please consider the pneumonia. Payment for vaccines are due at the time of service. Please check with your insurance for coverage, we cannot check this for you. We may give you a prescription for the shingles vaccine available at area pharmacies. Thank you for choosing our practice for your health care needs.

5 Health History Please list any current medical conditions that you have (such as diabetes, heart disease, high blood pressure, hypothyroid, asthma, reflux disease, etc) Use back of page if you need more space Please list any surgery that you have had along with the year it was done - Please list your current medications, with dose strength and how often you take it, including any herbal supplements. Medication Strength Taken (Like Omeprazole) (30 mg ) (Once a day) Do you have any allergies to any drugs or foods? Do you currently smoke? Are you a former smoker? If so, how many packs per day do/did you smoke? How many years have you or did you smoke? When did you quit? If you still smoke, are you interested in quitting? Do you drink alcohol? How many drinks per day/week/month/year? Have you ever been a daily drinker? #per day # years? Have you ever used recreational drugs? If so, what drugs? How often and how long? (x times/week or month for x years) How many cups of caffeine-containing beverages do you drink per day? Did you have a flu shot last year? This year? Have you had the pneumonia vaccination? Shingles vaccination? Hepatitis B? Have you had a colonoscopy? Women Last menstrual cycle? Last Mammogram Menstrual periods are (circle) Regular Irregular Menopause Hysterectomy What health conditions are in your family? If deceased, please list age at death. Mother Father Sisters/Brothers

6 Release of Information From Previous Health Care Provider Name Address City, State, Zip Date of Birth SS# Please release my medical records to Dr. Wall for purpose of transfer of medical care to include last year of clinical notes, lab reports, past medical history, problem list, medication list, radiology results, and summary of surgeries, hospitalizations, or any other pertinent information. This authorization is for full disclosure of all records including any information related to psychiatric care, HIV/AIDS status, sexually transmitted diseases, drug or alcohol treatment unless excluded specifically below. For pediatric patients, please include growth charts and immunization records. Excluded information Information to be released from: Name of Health Care Provider Address City, State, Zip Phone Number ( ) Fax ( ) Disclosure: This information will not be re-disclosed to anyone without written permission of the patient or legal guardian, other than what is outlined in our policies. This authority is in effect from the date of the signature for a period of one year. Legal authority if the patient is a minor, the undersigned is a legally authorized person to release the records as a parent or legal guardian. Printed Name if different from patient Notice to Providers please fax the records to secure fax Please do not fax more than 10 pages. If the records are more than 10 pages, please send by postal mail. All we need are a summary of visits and medical history, problem list and current medications along with results of any outside testing less than 5 years old such as x- rays, colonoscopy, MRI or mammograms.