Last Name: First Name: Middle Initial: Date of Birth: / / Social Security # Gender: F M (circle one)

Transcription

1 Please write legibly How did you hear about us? Please check ALL that apply: Drive by/signage Friend/Family: Employer (Name): Sign Guy Google/Yelp/SAUC Website Neighboring Business (Name): Flyer/Mailer School (Name): Physician/Insurance Referral (Name): Reason for today s visit: *Would you be interested in participating in Medical Research? Yes/ NO If yes, please check ALL that apply: Pain Headache PATIENT INFORMATION: Last Name: First Name: Middle Initial: Date of Birth: / / Social Security # Gender: F M (circle one) Address: (leave blank if address is current on your photo ID) City: State: Zip: Home phone: ( ) - Cell phone: ( ) - * *Please note is not a secure form of communication. Please circle your preferred form of contact? Home Phone, Cell Phone, INSURED AND/OR PARENT/GUARDIAN INFORMATION Relationship to the Insured Self Spouse Child Name of your Primary Insurance Insured Name: Insured DOB Insured SS# Address (if different from above): Secondary Insurance: Relationship to the Insured Name of your Secondary Insurance Insured Name: Insured DOB Insured SS# Primary Care Physician: Phone # ( ) - PATIENT EMPLOYER INFORMATION: Employer: Occupation: Location/Address: Phone # ( ) - PATIENT EMERGENCY CONTACT INFORMATION: Emergency Contact: Home Phone # ( ) - Cell Phone # ( ) - Relationship to patient: Rev Please fill out and sign both sides of this sheet and turn it n as soon as it is completed, so we can assist you more efficiently. Then complete the front and back of the medical history form (the next page) and read and sign the HIPPA Notice..

2 Patient History ---Patient Name: List all known allergies: Medications: Please list any prescription, over-the-counter, or herbal medications you are taking. If you have a long list, please allow us to make a copy if available. Past Medical History: Have you ever had any of the following? (Check all that apply) Abdominal Pain AIDS/HIV Alcohol Dependence Allergies/Seasonal Allergies Alzheimer s Disease Anemia Anxiety Appendicitis Arthritis Asthma Attention Deficit Disorder Back Problems/Disorder Bell s Palsy Bipolar Bronchitis Cancer, unspecified Cardiac (Heart) Arrhythmias Cardiac Problem/Condition Carpal Tunnel Cellulitis Congestive Heart Failure Crohn s Disease Deep Vein Thrombosis Dermatitis, Rashes, Eczema Depression Diabetes- Type 1 Diabetes- Type 2 Diverticulitis; Colon Problems Dizziness/Vertigo Earache Emphysema Epilepsy Fibromyalgia Gastric Reflux/GERD GI Bleeding PLEASE TURN PAGE OVER AND COMPLETE THE OTHER SIDE Gout Headache Heart problems Hematuria Hepatitis Hernia: Herpes Zoster Hyperlipidemia Hypertension (High blood pressure) Hypoglycemia Insomnia Kidney Problems Kidney Stones Lupus Menopausal Migraine Murmur Narcolepsy Ovarian Cyst Pain Joint Specifiy Pneumonia Pregnancy Reflux Sinusitis Sprain(s) Stroke Thyroid Problems Urinary Tract Infections Other: Other: Other:

3 Females--- Last Menstrual Period Date / / or years ago Past Surgical History: please list any previous surgery with date or time frame Procedure Date/Time Frame Procedure Date/Time Frame Family History: please write which family member(s) have/had the following conditions- F- Father M-Mother S- Sister B-Brother A Adopted (Unknown) GFP-Grandfather (Father s) GMP-Grandmother (Father s) GFM-Grandfather (Mother s) GMM-Grandmother (Mother s) Condition Relation to patient Condition Relation to patient Allergies High Cholesterol Aneurysm Kidney Stone(s) Arthritis Kidney Failure Asthma Lupus Cancer Lymphoma-Non-Hodgkins Crohn s Disease Migraine Depression Sinusitis Diabetes Stroke Gout Thyroid problems Headaches Ulcerative Colitis Heart Attacks High Blood Pressure Social History: Tobacco use: o Never a smoker o Current some days smoker o Every day smoker o Former smoker pack(s)/can(s)/cigar(s) in a day for years o Smokeless tobacco use Date quit / / Drug use: on/a o Marijuana o Cocaine o Heroin o Steroids o PCP o Acid o Inhalants Alcohol use: drinks in one DAY WEEK YEAR (please circle) Exercise: Caffeine: times per week drinks per day Please write any other medical condition you feel the medical staff should be aware of:

4 PLACE STICKER HERE Administrative Purposes Only CONSENT FOR MEDICAL TREATMENT 1. CONSENT TO TREAT: I, for myself (or the patient named below), present to Southern Arizona Urgent Care (SAUC) for certain medical services and treatment. I consent to and authorize the administration of such treatment to me and any preliminary, further, or additional diagnostic procedures, medical treatment, and laboratory testing, including HIV testing, that may be, in the judgment of my physician or other health care practitioner, necessary or advisable at the time treatment is performed. I understand that any invasive procedure or other treatment requiring separate, specific consent will be explained to me and I will be provided the opportunity to consent to or decline that treatment. I understand that I have the right and the opportunity to discuss proposed course of treatment with my health care provider and that I have the right to consent or refuse any proposed course of treatment. I acknowledge that the practice of medicine is not an exact science and that no guarantees or assurances have been made to me by my physician or other health care practitioner of SAUC regarding the results, outcome or effect of any treatment or procedure which may be given or performed. Any tissues, parts or fluids removed from me may be disposed of by SAUC in accordance with its customary practices and any applicable laws and regulations. 2. ASSIGNMENT AND FINANCIAL RESPONSIBILITY: I assign to SAUC and authorize payment directly to SAUC and any treating physicians, of any health care benefits which may be due and payable under any insurance coverage that I may have. I agree to pay at the time of services any required co-payments, co-insurance and deductibles. I understand that I am liable and responsible for any charges due SAUC for services provided to me which are not covered by insurance. If I am eligible to receive Medicare benefits, I assign to SAUC and authorize payment directly to SAUC and any treating physicians, of any Medicare benefits for services furnished to me at SAUC. I certify that the information given by me in applying for such benefits is correct. I authorize any hold of medical or other information about me to release to the Centers for Medicare and Medicaid Services ("CMS") and its agents any information needed for payments of such benefits. I authorize the Social Security Administration to release information about my entitlement to benefits to SAUC and to physicians providing services to me. I agree to pay SAUC for the services rendered to me. I understand and agree that the payment for these services, to the extent it is not paid by my insurance company, is due and payable in full upon notification of balance due. Any information provided by me (including communications, addresses, and family information) may be used by SAUC as well as SAUC's agents and representatives in their attempts to collect any amounts due for services rendered. If this account is referred to any attorney for collection, I agree to pay court costs and reasonable attorneys' fees. I understand that, unless I request otherwise, SAUC will maintain my credit card information securely encrypted in my electronic patient information file. My credit card will not be charged without by previous authorization. 3. HIV/HEPATITIS TESTING: In the event of an exposure of a health care provider to my blood or body fluids in a manner which may transmit HIV (human immunodeficiency virus), Hepatitis B or Hepatitis C virus, I hereby consent to testing of my blood and/or body fluids for these infections and the release of the test results to the health care provider who has been exposed. 4. PATIENT RIGHTS: I have been informed of and received a written statement of my Patient Rights. I may obtain a copy of my Patient Rights upon request by phone, mail, or in person. 5. DISCLOSURE OF INFORMATION: I consent to the use and disclosure of my protected health information ("PHI") for treatment, payment and healthcare operations as authorized by law. I understand that the Notice of Privacy Practices ("NPP") provides information about how SAUC may use and disclose my PHI and my access to rights to my PHI. I acknowledge that I have been provided with a copy of SAUC's NPP and have been given an opportunity to ask questions about SAUC s privacy policies. SAUC may amend the privacy practices. I may obtain a revised NPP upon request by phone, mail, or in person. 6. By signing below, I certify that this form has been fully explained to me and that I understand its contents. I have had the opportunity to ask questions about the services provided, treatment, my rights, my care, and other information provided in this form, and have had them answered to my satisfaction. If this form is signed by patient s representative, he/she certifies that he/she is duly authorized as the patient s general agent or representative to execute the foregoing and accept its terms. I HAVE READ, UNDERSTAND, AND AGREE TO THIS CONSENT FOR MEDICAL TREATMENT Signature of Patient or Personal Representative Relationship to Patient Date Signed PRINT Name of Patient Birth Date of Patient (Rev )

5 HIPAA 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. This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you to pay your health care bills, to support the operation of the physician s practice, and any other use required by law. TREATMENT We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. PAYMENT Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. HEALTHCARE OPERATIONS We may use or disclose, as needed, your protected health information in order to support the business activities of your physician s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. We may use or disclose your protected health information in the following situation without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglects: Food and Drug Administration requirement: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: research: Criminal Activity: Military Activity and National Security: Workers Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirement of Sections We will send/fax your protected health information (lab/x-ray results, encounter notes, etc.) to your healthcare organizations by written request from you or them only. We will share your protected health information with third party business associates that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associated involves the use or disclosure of your protected health information we will have a written contract that contains terms that will protect the privacy of your protected health information. Page 1 of 2 (Rev )

6 HIPAA Notice of Privacy Practices We may use your protected health information as necessary to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you information about products or services that we believe may be beneficial to you. You may contact us to request that these materials not be sent to you. Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law. You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A designated record set contains medical and billing records and any other records that your physician and the practice use for making decisions about you. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information complied in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your protected health information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us out-of-pocket in full. If we do agree we will comply with your request unless the disclosure is required by law, or is needed to provide you with emergency treatment. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation for you as to the basis for the request. Please make this request in writing. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. You have the right to be notified upon a breach of any of your protected health information. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at this time. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment. COMPLAINTS You may complain to us or the U.S. Department of Health & Human Services at if you believe your privacy rights have been violated by us. We will not retaliate against you for filing a complaint. Southern Arizona Urgent Care (520) This notice was published and becomes effective on 07/02/14. We are required by law to maintain the privacy of, and provide individuals with this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with an employee about your concerns. SUMMARY We respect your privacy and we will not disclose your PHI to anyone not involved in your care unless you give us permission to do so. We will release your information to others involved in your health care, as required by law, or for payment of your medical bills. Signature below is only acknowledgement that you have received this Notice of our Privacy Practices Print Name Signature Date Page 2 of 2