ADVANCED INTEGRATIVE MEDICINE REGISTRATION FORM (Please Print) PATIENT INFORMATION

Size: px

Start display at page:

Download "ADVANCED INTEGRATIVE MEDICINE REGISTRATION FORM (Please Print) PATIENT INFORMATION"

Julianna O’Brien’
5 years ago
Views:

1 Today s date: ADVANCED INTEGRATIVE MEDICINE REGISTRATION FORM (Please Print) PCP: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex: Yes No / / M F Street address: Social Security no.: Home phone no.: ( ) Preferred number for voice City/ State Zip Code: Cell phone: contact: ( ) Home Cell Work Occupation: Employer: Employer phone no.: ( ) PHARMACY INFORMATION: LOCAL PHARMACY NAME:. CITY: PHONE: Other family members seen here: MAIL ORDER PHARMACY: PHONE: Chose/referred to our clinic because: INSURANCE INFORMATION (Please give your insurance card to the receptionist.) Person responsible for bill: Birth date: Address (if different): Home phone no.: Is this person a patient here? Yes No / / ( ) Occupation: Employer: Employer address: Employer phone no.: Is this patient covered by insurance? Please indicate primary insurance Yes No ( ) Subscriber s name: Subscriber s S.S. no.: Birth date: Group no.: Policy no.: Patient s relationship to subscriber: Self Spouse Child Other / / $ Name of secondary insurance (if applicable): Subscriber s name: Group no.: Policy no.: Copayment: Patient s relationship to subscriber: Self Spouse Child Other IN CASE OF EMERGENCY Name of local friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.: ( ) ( ) The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I understand that payment is my responsibility regardless of insurance coverage. I understand that failure to pay outstanding balances within 90 days of notification of the amount due will result in submission to an outside collection agency and may be dismissed from AIM. I understand that any missed appointments without 24 hour notice will result in a $25 or $75 fee, depending on visit type. A $15 returned check fee will be charged for checks returned due to insufficient funds. I also authorize ADVANCED INTEGRATIVE MEDICINE or insurance company to release any information required to process my claims. Patient/Guardian signature

2 PATIENT INFORMATION SHEET ADVANCED INTEGRATIVE MEDICINE NAME: DOB: DATE: ALLERGIES: SOCIAL HISTORY: Recreational Drug Use: Current / Past / Never Smoking: Currently Past Never Packs/day: Exercise: times per week Alcohol: Currently Past Never Drinks/day: Occupation Caffeine: Currently Past Never Drinks/day: List ALL MEDICATIONS you take, including over the counter (OTC) medications and vitamins. Include specific doses and when taken. If you don t know please call your pharmacist to confirm Medications/dose/frequency OTC and Vitamins/dose/frequency PREVENTATIVE HISTORY: (PLEASE FILL OUT WITH APPROXIMATE DATE) Flu Vaccine : Measles Vaccine : Pneumovax(pneumonia) : Shingles Vaccine : Tdap : Tuberculin PPD skin : Vaccine(tetnus,pertussis) test Colonoscopy : Normal/ Abnormal Dxa (Bone Density) Female Patients: Last Menstrual Period : Normal/ Abnormal Total number of pregnancies: Total number of miscarriages or abortions: SURGERY AND PROCEDURE HISTORY: (circle) Mammogram Pap smears: Uses birth control: : Normal/Abnormal : Normal/Abnormal : Normal/Abnormal NO prior surgical Colon surgery Hernia Tonsillectomy history Appendectomy Gall Bladder surgery Hysterectomy Tubal ligation Breast Lumpectomy Heart surgery Mastectomy Vasectomy Cataract surgery Hemorrhoids Back/ spine surgery OTHER HOSPITALIZATIONS/SURGERIES:

3 .PERSONAL MEDICAL HISTORY: (please circle/fill in all that apply) ADHD Dementia Hernia Parkinson s Disease Alcoholism Depression/Anxiety Hepatitis Peripheral Vascular Allergies, Seasonal Diabetes: 1 or 2 High Cholesterol Peptic Ulcer Anemia Diverticulitis High Blood Pressure Psoriasis Arthritis DVT (blood clot) HIV/Aids Pulmonary Embolism Asthma Eczema Irritable Bowel Synd. Rheumatoid Arthritis Bipolar Emphysema/COPD Kidney Disease Sciatica Bladder problems/ Gallstones Kidney Stones Seizure Disorder Incontinence Bleeding problems GERD (acid reflux) Lupus Sleep Apnea Carpal Tunnel Glaucoma Liver Disease Stroke Cancer: Headaches/Migraine Macular Degener. Thyroid Disorder Crohn s / Colitis Heart Attack (MI) Neuropathy Osteopenia/osteoporosis Heart Disease Nose Bleeds Other medical problems not listed above: FAMILY HISTORY: FATHER: Living: Age Deceased: Age Alcoholism Blood Clot/DVT Depression Kidney Disease Anemia Bipolar Diabetes 1 or 2 Osteoporosis Asthma COPD/emphysema High Cholesterol Stroke Arthritis Dementia High Blood Pressure Thyroid Disorder Cancer: Other: MOTHER: Living: Age Deceased: Age Alcoholism Blood Clot/DVT Depression Kidney Disease Anemia Bipolar Diabetes 1 or 2 Osteoporosis Asthma COPD/emphysema High Cholesterol Stroke Arthritis Dementia High Blood Pressure Thyroid Disorder Cancer: Other: SIBLINGS: List other medical providers that you see on a regular basis ( i.e. Cardiologist, Mental Health Provider, Kidney Doctor, etc.) PATIENT SIGNATURE: PROVIDER REVIEWED: DATE: DATE:

4 10455 Park Meadows Drive Unit 102 Lone Tree, Colorado HIPAA Privacy Rights Form PATIENT INFORMATION Name (Last, first, middle initial) Social Security # or Patient ID Street address, City, ST, ZIP Code Primary phone number Other phone number Please list below how you would like to be contacted with results or medical issues: Home Phone Cell phone Work Phone address Text Message Please list below the person or persons that may receive your test results or whom we may discuss your medical issues with: Please list the phone numbers you authorize Advanced Integrative Medicine to call and leave test results, confirmation calls, or detailed medical issues on: Phone number Phone number I authorize Advanced Integrative Medicine to leave medical results on my personal voic YES NO I have read the Notice of Privacy Practices YES NO SIGNATURE: DATE: Privacy Official signature Attach additional documentation, if applicable.

5 A.I.M. NOTICE OF PRIVACY PRACTICES 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. We are required by law to maintain the privacy of your protected health information, to notify you of our legal duties and privacy practices with respect to your health information. This Notice summarizes our duties and your rights concerning your information. Our duties and your rights are set forth more fully in 45CFR Part 164. I. Uses and disclosures we may make without written authorization. We may use or disclose your health information for certain purposes without your written authorization, including the following: Treatment. We may use or disclose your information for purposes of treating you. For example, we may disclose your information to another health care provider so that they may treat you; to provide appointment reminders; or to provide information about treatment alternatives or services we offer. Payment. We may use or disclose your information to obtain payment for services provided to you. For example, we may disclose information to your health insurance company or other payer to obtain payment for treatment. Healthcare Operations. We may use or disclose your information for certain activities that are necessary to operate our practice and ensure that our patients receive quality care. Other Uses or Disclosures. We may also use or disclose your information for certain other purposes allowed by 45 CFR or other applicable laws and regulations, including the following: To avoid a serious threat to your health or safety or the health and safety to others. As required by state or federal law such as reporting abuse, and/or neglect. For certain public health activities such as reporting certain diseases. For certain public oversight activities such as audits and licensure actions. In response to a court order, warrant or subpoena. For research purposes if certain conditions are satisfied. In response to requests by law enforcement to locate a victim or witness, to certain crimes. To coroners, funeral directors, or organ procurement organizations as necessary to allow them to carry out their duties. II. Disclosures we may make unless you object. Unless you instruct us otherwise, we may disclose your information as described below. PARTNERSHIP AGREEMENT 1

6 To a member of your family, relative, friend, or other person who is involved in your healthcare or payment for your healthcare. We will limit the disclosure to the information relevant to that person s involvement in your healthcare or payment. III. Your rights concerning your protected health information. You have the following rights concerning your health information. To exercise any of these rights, you must submit a written request to the Privacy Officer Identified below. You may request additional restrictions on the use or disclosure of information for treatment, payment or healthcare operations. We are not required to agree to the requested restriction except in the limited situation in which you or someone on your behalf pays for an item or service, and you request that information concerning such item or service not be disclosed to a health insurer. We normally contact you by phone, mail at your home address and possibly by if you have given your address. You may request that we contact you by alternative means or at alternative locations. We will accommodate reasonable requests. Please understand that there are risks associated with the online/cell phone communications between physician and patient. The risks are very real and very important to understand. You may inspect and obtain a copy of records that are used to make decisions about your care of payment for your care, including an electronic copy. We may charge you a reasonable costbased fee for providing the records. We may deny your request under limited circumstances, e.g., if we determine that disclosure may result in harm to you or others. You may request that your protected health information be amended. We may deny your request for certain reasons, e.g., if we did not create the record of if we determine that the record is accurate and complete. You may receive an accounting of certain disclosures we have made of your protected health information. You may receive the first accounting within a 12 month period free of charge. We may charge a reasonable cost based fee for all subsequent requests during that 12 month period. You may obtain a paper copy of this Notice upon request. You have this right even if you have agreed to receive the Notice electronically or by reading the laminated copy at the front. IV. Changes to this notice. We reserve the right to change the terms of this Notice at anytime, and make the new Notice effective for all protected health information that we maintain. You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint with us by notifying our Privacy Officer. All complaints must be in writing. If you have any questions or concerns please contact: Julie Snook, , Park Meadows Drive Unit 102, Lone Tree, Colorado PARTNERSHIP AGREEMENT 2

7 PARTNERSHIP AGREEMENT 3

PATIENT INFORMATION. PRIMARY INSURANCE Ins Co. Name: PRIMARY POLICYHOLDER PARENT/GUARDIAN INFORMATION (REQUIRED IF PATIENT UNDER 18 YEARS OF AGE)

PATIENT INFORMATION. PRIMARY INSURANCE Ins Co. Name: PRIMARY POLICYHOLDER PARENT/GUARDIAN INFORMATION (REQUIRED IF PATIENT UNDER 18 YEARS OF AGE) PATIENT INFORMATION Name: Sex: of Birth: Social Security #: Address: Apt # City: State: Zip: Primary Phone: Primary Phone Type: Cell Home Work Secondary Phone: Secondary Phone Type: Cell Home Work Email: