Birmingham Internal Medicine Associates, PC

Transcription

1 Birmingham Internal Medicine Associates, PC Medical History Form Date: Who referred you? Name: Date of Birth: Race (circle one) : *American Indian/Alaskan Native * Asian * Black/African American * Hawaiian/Pacific Islander * White * Other * Unknown Ethnicity: (circle one) * Hispanic/Latino *Not Hispanic/Latino * Unknown *Declined Height: Weight: Marital Status: M S W D Sex: Male Female Pharmacy Name: Phone#: Reason for today s visit: Routine physical Problem, please describe Please check if you had any of these medical problems in the past: ILLNESS YES NO ILLNESS YES NO Acid Reflux Heart Disease Anemia Hepatitis / Jaundice Anxiety High Blood Pressure Arthritis / Joint Pain High Cholesterol Asthma Kidney Infections Back Pain Kidney Stones Blood Transfusion Migraines Bowel Trouble Mood Disorders Breast Cancer Osteoporosis Cancer Pneumonia Chronic Lung Disease Rheumatic Fever Depression Sexually Transmitted Disease Diabetes Stroke Fracture Tuberculosis (TB) Glaucoma Thyroid Disease Headaches Ulcers Heart Murmur OTHER: Please list your last test or immunization: TEST DATE IMMUNIZATIONS DATE Last PAP smear Flu Vaccine Abnormal PAP smear Pneumonia Vaccine Bone Density Test Tetanus Vaccine Colonoscopy / Sigmoidoscopy Hepatitis Vaccine Mammogram Zostervax (Shingles) Vaccine PSA TB skin test

2 Name: Date of Birth: Please list any past injuries or illness: Date Type of Illness or Injury Please list all operations or hospitalizations you have had: Date Surgery or Reason for Hospitalization MEDICATIONS- please list ALL prescriptions, over the counter medications you are now taking; including vitamins and hormones Name Dosage How Often Please list all allergies to medications, foods, latex, etc Allergy Reaction

3 Name: Date of Birth: Family History ILLNESS Yes NO Relative ILLNESS Yes No Relative Anemia Heart Trouble Arthritis Hepatitis/Jaundice Asthma High Blood Pressure Bowel issues/ulcers High Cholesterol Cancer Type: Kidney Infections/ Kidney Stones Chronic Lung Disease Stroke Depression/Anxiety Thyroid Disease Diabetes Tuberculosis Glaucoma HIV/AIDS other FEMALE PATIENTS ONLY Do you use birth control? yes type: no Date of last period What age did you have your first period? How many days are there from the start of a period to the star of the next period? days Flow: Light Medium Heavy How long does your period usually last? days Are you on Hormone Replacement Therapy (hormones)? Yes No Have you gone through Menopause? Yes No At what age? SOCIAL HISTORY Occupation: Do you exercise? None Less than 3 times per week More than 3 times per week Do you smoke? Yes No Packs per day: Number of years smoking: Quit years: Do you drink alcohol? Yes No Drinks per day: Drinks per week: Do you use drugs? Yes No Kind of drug: Frequency: History of Abuse? Yes No Type: Physical Emotional Sexual Are you sexually active? Yes No With your spouse? With men? With women? With both?

4 Name: Date of Birth: CONSTITUTIONAL GASTROINTESTINAL NEUROLOGIC Weight Loss Constipation Memory difficulties Weight Gain Abdominal Pain Speech difficulties Fever Blood in Stool Seizures Fatigue Hemorrhoids Loss of balance Night Sweats Jaundice MUSCULOSKELETAL Hot flashes Heartburn Joint pain or swelling EYES Indigestion Muscle pain Double Vision Nausea Back pain Vision Changes Vomiting Neck pain HEENT Diarrhea ENDOCRINE Congestion GENITOURINARY Loss of hair Drainage Urgency of urination Difficulty tolerating cold Sore Throat Frequency Excessive thirst Hearing Loss Painful urination PSYCHIATRIC Ringing in Ears Losing urine Anxiety Nose Bleeding Nighttime urination Depression Thyroid Mass Blood in urine Impulsive behavior BREAST Decreased sex drive Suicidal thoughts Lumps Painful intercourse Excessive anger Tenderness Possible pregnancy Mood swings Swelling Genital sores Emotional abuse Discharge Discharge from penis Physical abuse Pain in Breast Vaginal discharge Sexual abuse Changes in Breast Vaginal bleeding Sleep disturbance CARDIOVASCULAR SKIN Hematologic/Lymphatic Chest Pain Rashes Bruises, frequently/easy Irregular Heart Beats Itching Cuts do not stop bleeding Rapid Heart Beats Skin dryness Enlarged lymph nodes Fainting Skin lesions ALLERGIC/IMMUNOLOGIC Swelling of Legs Changes to lesions or moles Frequent illness Varicose Veins Acne Seasonal allergies RESPIRATORY Neurologic Other: Wheezing Headaches 1. Cough Dizziness 2. Shortness of breath Muscular weakness 3. Spitting up blood Numbness/tingling 4. Excessive snoring Difficulty concentrating 5.

5 Date: Birmingham Internal Medicine Associates, P.C. Patient Registration Form Doctor (circle one): Farley Leong Smith Lockhart Alderson Meadows Referred by: PATIENT INFORMATION Patient Name (first, last): Date of Birth: Address: City: State: Zip: Social Security Number: Home #: Work #: Cell#: Patient s address: Employer: Emergency Contact: relationship: Emergency Contact s number(s): INSURANCE INFORMATION CO-PAY PRIMARY$ CO-PAY SECONDARY $ Primary Insurance Contract #: Group #: Name of Policy Holder: Policy Holder Date of Birth: Secondary Insurance Contract #: Group #: Name of Policy Holder: Policy Holder Date of Birth: AUTHORIZATION OF RELEASE I agree to pay for all services rendered to me as a patient at Birmingham Internal Medicine Associates and hereby authorize release of medical information for processing insurance claims. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION I authorize any holder of medical information about me to release said medical information requested by insurance companies with whom I have coverage or any public agency and it agents to determine benefits for services provided or benefits for related services ASSIGNMENT OF BENEFITS I hereby authorize payment of benefits be made directly to Birmingham Internal Medicine Associates, for services provided to me by the Birmingham Internal Medicine Associates. I understand that I am financially responsible for charges not covered by this agreement. I authorize refund of overpaid insurance benefits where by coverage are subject to coordination of benefits. In the event of default, I agree to pay all costs of collection, including reasonable attorney fees of one third of the balance due. Date x Signature Of Patient Or Signature of Responsible Person

6 Birmingham Internal Medicine Associates, PC Communication Instructions Patient Name: First Last Date of Birth: There will be times during our relationship that this office will need to reach you regarding test results, referrals, medication questions or respond to a question you have. Many times a patient may not be available when we call. Due to the mandates of the Privacy Act, we are unable to leave detailed information on a voic without the written permission of the patient. If you wish to grant permission for Birmingham Internal Medicine Associates, PC (BIMA) to leave personal messages/responses on a private voic , please complete below: Yes, I give permission for BIMA to use the following number to leave detailed voic responses. (We strongly recommend a cell phone number if you have one) Please use the following number to leave a message: This number is my: (circle one) Cell Home Work Patient Signature Date If you DO NOT want a detailed message left for you, please complete below: It is my request that you do not leave a detailed message for me when phoning from Birmingham Internal Medicine Associates. The only message that will be left is one stating the office has called and requests you return the call. Patient Signature Date

7 Birmingham Internal Medicine Associates, PC General Authorization for use and disclosure of PROTECTED HEALTH INFORMATION Date: Patient Name: Date of Birth: I hereby authorize Birmingham Internal Medicine Associates, PC ( BIMA ), its employees and/or agents to use and/or disclose my protected health information ( PHI ) including my account and my medical conditions which may include symptoms, treatments, diagnoses, test results, medications and other health information to the following persons (a) in order to facilitate and coordinate my care, treatment and payment for medical care and treatment or (b) at their request: NAME RELATIONSHIP TELEPHONE # I understand that any PHI which is used and/or disclosed pursuant to this Authorization may be subject to disclosure by the recipient and may no longer be protected by federal or state law. 1. I understand that this Authorization is voluntary, and I have the right to refuse to sign this Authorization. BIMA may not refuse to provide health care treatment to me if I do not sign this Authorization. 2. I understand that upon my request I may see and copy the protected health information described on this Authorization. I understand that my protected health information may include information concerning sexually transmitted diseases, behavioral and mental health services, and treatment for drug and alcohol abuse. I understand that I may be charged a reasonable, cost-based fee for use and disclosures made upon my request. 3. I understand that I may revoke this Authorization in writing at any time by sending my written revocation to the Privacy Officer of Birmingham Internal Medicine Associates, PC. I understand that any revocation will not affect any actions taken by the Practice prior to receipt of my revocation. Unless otherwise revoked, this Authorization will expire 7 days from the date provided above. 4. I agree to release BIMA, its employees, agents, officers, and directors from any and all liabilities and responsibilities for disclosure of the above information to the extent indicated and authorized pursuant to this signed Authorization. Patient or Patient Representative Signature: Patient representative relationship to patient:

8 Birmingham Internal Medicine Associates, PC 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 READ CAREFULLY. The Health Insurance Portability & Accountability Act of 1996 ("HIPAA") is a federal program that requires that all medical records and other individual identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. "HIPAA" provides penalties for covered entities that misuse personal health information. As required by "HIPAA", we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records only for each of the following purposed: treatment, payment and health care operations. Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination. Payment means such activities as obtaining reimbursement for services, confirming coverage billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment. Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost management analysis, and customer service. An example would be an internal quality assessment review. We may also create and distribute de-identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or information about treatment alternatives or other healthrelated benefits and services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer: 1) The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. 2) The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations. 3) The right to inspect and copy your protected health information. 4) The right to amend your protected health information. 5) The right to receive an accounting of disclosures of protected health information. 6) The right to obtain a paper copy of this notice from us upon request. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. This notice is effective as of April 14, 2003, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to

9 make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of reviewed Notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint. Please contact us for more information: Elisabeth Bottom, Practice Manager Katila Farley, Business Manager For more information about HIPAA or to file a complaint: The U.S. Department of Health & Human Services Office of Civil Rights 200 Independence Avenue, S.W. Washington, D.C (202) Toll-Free: I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. Obtain payment and third-party payers. Conduct normal healthcare operations such as quality assessments and physician certifications. I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that Birmingham Internal Medicine, P.C. has the right to change its Notice of Privacy Practices from time to time and that I may contact Birmingham Internal Medicine, P.C. at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions. Patient or Patient Representative: Date:

10 Birmingham Internal Medicine Associates, P.C. What s NEW? Birmingham Internal Medicine(BIMA) is proud of our new addition, The BIMA Medical Home Newsletter and E-Portal Access. For a monthly subscription receive boutique style service from your physician by accessing your secure online portal. WHY CALL WHEN YOU CAN CLICK? LAB AND TEST NOTIFICATIONS No more waiting on the mail or for phone calls. BIMA now has the ability to relay your lab results, test results, medication changes, and medical record requests directly to your online portal. This will replace the old system of mailing letters (which can be misplaced) and calling results (which end in phone tag ). You can think of it as an electronic mail box. See the E Portal Direction Section for exact directions in setting up your E-Portal account. SEND A MESSAGE TO THE PHYSICIAN/STAFF Two way secure communication with the office. The ability to your Physician/Staff through our new HIPAA secure portal. REQUEST A REFILL Go online to your portal and request medication refills. This ability is great as you can track your requests and correspondence from our office. ONLINE BILL PAY Pay your bill online. No more needing to purchase stamps and mail in payments. IN REVIEW The yearly $75 Subscription to BIMA Medical Home Newsletter allows FULL access to the online portal (two way communication with the office/staff/physician). Along with the additional communication features you will receive s regarding current health issues, medical updates, and local urgent information. Also, you will receive quarterly newsletter written by your BIMA physicians regarding wellness and prevention. Take advantage of this low introductory offer as rates will increase to $75 a year October 1 st 2011 Think of it as an electronic mailbox E PORTAL DIRECTIONS Step One- Log onto Step Two- Click on Patient Web Portal Step Three- Read the waiver, scroll down and click on I agree to the above terms and conditions. Take me to my patient portal now. Step Four- Under New User select create an Account, follow prompts. (You will need your date of birth and social security number as well as a valid address). Step Five- Record your Username and Password, Select Join Birmingham Internal Medicine Portal. Step Six- Click on Consult a Nurse/Physician.submit a note stating you have setup your account and paid your fee. **This step must be completed in order for us to begin communicating with you through your secure portal. You now have access to your Electronic Mailbox with access the two way communication features. A confirmation will be sent to your address. User Name: Password: Please keep in a secure location

11 Birmingham Internal Medicine Associates, PC Financial Policy Thank you for choosing Birmingham Internal Medicine as your healthcare provider. We are committed to providing you the best possible care. Your clear understanding of this financial policy is important to our relationship. Our staff will be happy to discuss our fees and this policy with you should you have any questions. Please read and sign this policy prior to seeing the physician. 1. Payment for services is due at time of services are rendered. For any of your portion that is not covered by insurance, or for our private pay patients, we accept cash, check, Mastercard and VISA. 2. BIMA requires the patient provide proof of identification of the patient prior to treatment. 3. Please present your insurance card at the front desk so that we can accurately file a claim on your behalf. We will follow their guidelines for submission of claims, co-pay amounts and reimbursements. Any contractual differences will be deducted from your balance. 4. All charges are your responsibility whether your insurance company pays or does not pay. Not all services are a covered benefit in all contracts. Insurance companies and employers decide what procedures are covered benefits and which are not. Please check your insurance plan documents for any questions. Fees for uncovered services and unmet deductibles and copayments are due at the time of treatment. 5. Your insurance policy is a contract among you, your employer and the insurance company. BIMA is not party to that contract. Our relationship is with you, the patient. We cannot become involved in disputes between you and your insurer regarding deductibles, copayments, covered charges, secondary insurance and usual and customary charges. 6. Returned checks and balances older than 90 days are subject to placement with a collection agency. 7. If a refund is due to you, we will process the check through our accounting department. 8. Due to varied contractual arrangements between laboratories and health insurance plans, please verify that you are directing our office to a lab that is a participating provider with your insurance plan. Please remember that your lab billing is separate from our physician s billing and you may receive a separate itemized bill from the laboratory. If you are a private pay patient, we can provide an estimated cost of the lab charges. 9. We understand that temporary financial problems may affect timely payments of your balance. We encourage you to communicate any such problems to our staff so that we can assist you in the management of your account. Again, thank you for using Birmingham Internal Medicine Associates. We appreciate the opportunity to serve you. Patient Signature Date of Birth Date