PATIENT REGISTRATION: PATIENTS 18 YEARS AND OLDER

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Brittney Stewart
5 years ago
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1 Date: Patient Health Insurance (Clinic: If unable to scan card, make copy and attach. If card unavailable, write info on this form.) PATIENT REGISTRATION: PATIENTS 18 YEARS AND OLDER Last Name First Name _ Initial Date of Birth Gender: Female Male SSN Address City State Zip (Home) (Cell) Preferred Message/Contact : Home Cell Work (please circle) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other (Multi-racial) Unknown Declined Ethnicity (please circle) Hispanic or Latino Not Hispanic or Latino Other Preferred Language English Spanish Other Employer Who is your current / past primary care provider? Preferred Pharmacy Primary Insurance ID # Group#_ Policy Holder Name Date of Birth Employer Relationship to Patient Secondary Insurance ID# Group#_ Policy Holder Name Date of Birth Employer Relationship to Patient Additional Contact (not living with you) Last Name First Name Number _ Address City State Zip Relationship to Patient Advanced Directives (Living Will) Would you like more information about Advance Directives? Yes No Brochure Provided? Yes No

2 Today's Date: ANNUAL HEALTH HISTORY Name: Date of Birth: Age: Preferred Pharmacy Name: Pharmacy Location: Do you use Tobacco? Yes, Currently No, never No, I am a former tobacco user Type of Tobacco Used: Cigarettes Chewing Other How much per day: Years used: Have you ever tried to quit? Yes No Year Quit: Are you exposed to passive smoke? Yes No Fall Risk: Have you fallen in the last year? Yes No Number of Falls/past year? Do you have problems with walking or balance? Yes No Health Maintenance: Date of last colonoscopy: Date of last Eye Exam: Date of last EKG: Date of last Dental Exam: Women Only: Last menstrual period? Date of last pap: Date of last Mammogram: Are you currently pregnant? Yes No Past Medical History: Please mark all that apply. Allergies Anemia Angina Anxiety Arthritis Asthma Atrial Fibrillation Benign prostatic hypertrophy Blood clots Cancer Type: CVA (stroke) COPD Coronary Art. disease Crohn's Disease Depression Diabetes Gallbladder disease GERD Hepatitis C High Cholesterol High blood pressure Irritable bowel syndrome Liver Disease Migraine headaches Past Surgical History: Year: Year: Angioplasty Angio w/stent Appendectomy Arthroscopy knee Back surgery CABG Carpal Tunnel Cataract extraction Cholecystectomy (gall bladder) Colectomy Colostomy Gastric Bypass Hernia Repair Hip replacement Knee replacement LASIK Liver biopsy ORIF Pacemaker Family History of (mark all that apply and indicate for Mother, Father, Siblings): ADD/ADHD Alcoholism Allergies Alzheimer's disease Asthma Blood disease CAD Cancer: Type Social History: Marital Status: Married Single Divorced Widowed Alcohol Consumption: No Yes Formerly Type: Frequency: Amount: Caffeine: No Yes Type: Caffeine per day: CVA (stroke) Depression Developmental delay Diabetes Eczema Hearing Deficiency High Cholesterol High blood pressure Irritable bowel syndrome Living Arrangements: Alone Family/Sig.Other Other Asst. Living Daily help needed for selfcare Name of Caregiver: Abuse / Neglect: Adults only Are you experiencing neglect and/or conflict in your family and/or relationships? Yes No Explain: Small Bowel Resection Thyroidectomy Tonsillectomy FEMALES ONLY: Breast augmentation Tubal Ligation Breast Biopsy C-Section D and C Hysterectomy Mastectomy Myomectomy Breast reduction TAH/BSO Vaginal Hysterectomy ea t ee i g Learning Disability Mental Illness Migraines Obesity Osteoarthritis Osteoporosis Periphereal Vascular disease Renal disease Seizure disorder Activities of Daily Living: Any difficulty with? Speech/Communication Memory Bathing Household Duties # of Children: Street Drug Use? Yes No Type: Started: Quit: MI (heart attack) Osteoarthritis Osteoporosis Peptic Ulcer disease Renal disease Seizure disorder Thyroid disease Other Other Age/cause of death of: Mother: n/a Father: n/a Siblings: n/a Learning Needs: Are there any needs (learning, ethnic, cultural, or spiritual) we should know about that might impact your care or your ability to understand treatments / procedures/ educational materials? Yes No Please explain: EHR AHH Rev Form 0002E

3 PROTECTED HEALTH INFORMATION RELEASE: PATIENTS 18 YEARS AND OLDER Please check all applicable boxes and fill in any blank spaces where information is requested. Only release information to me personally. You have my permission to speak with my Spouse/Significant Other about my medical care and test results. Spouse/Significant Other s Name You have my permission to talk with my children or other family members involved with my medical care. Name Relationship Name Relationship You have my permission to leave information on my answering machine regarding my medical care and test results. Other, please describe: Emergency Contact: Last Name Address Relationship to Patient First Name City Number State Zip Patient Contact: Patient (Home) (Work) (Cell) Preferred Message/Contact : Home Cell Work Patient Signature Date

4 Financial Policy We will file your insurance claims for you. We do request a copy of your current insurance card to ensure accurate billing. Please keep in mind we do not accept all insurances. If you do not have insurance or if your insurance does not cover the services you need from our clinic, payment is your responsibility. It is also your responsibility to confirm directly with your insurance company to find out whether or not we participate with them, and if they will cover the medical services being provided to you. If your insurance requires a referral, co-pay, deductible, or coinsurance, it is your responsibility to have it with you at the time of service. Failure to do so may result in us having to reschedule your appointment. Medicaid Patients: You must have a valid Medicaid card, presumptive eligibility, or letter/printout from your caseworker at every visit. We also require photo ID, which will be scanned into our computer system. Lack of this information may result in us having to reschedule your appointment. Minors: The parent/guardian accompanying the minor at the time of service is responsible for payment. We will request payment at the time of service. If this is not possible, we will expect you to make acceptable payment arrangements, prior to receiving service. You will receive at least two statements after your visit at our clinic. If your account is not paid in full, or if you have not established an acceptable payment plan, we will refer your account to a professional credit bureau. The credit bureau will send you a notification that a payment is due. The letter will arrive at your last known address. You must respond to this letter, to avoid damage to your credit record. If you do not respond to this letter, your account will be listed for collection and your credit will be adversely affected. I understand and agree that if I fail to pay for services for which I am responsible, after such default and upon referral to a collection agency by Agape Family Health, LLC, I will be responsible for all cost of collecting monies owed, including court costs, and collection agency fees. We are disclosing our policy to you now to avoid misunderstanding in the future. atie t ame p i te ig at e ate elati hip t atie t i mi

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New Child Registration

New Child Registration Date: / / Insurance Information Primary insurance Primary Reason for today s visit: Last Name, First, MI Mailing address City, State, ZIP Which pharmacy do you use? Insurance Co.