Patient Registration Form

Transcription

1 Patient Registration Form Date: Name: Maiden Name: (First) (MI) (Last) SSN: Birth Date: Age: Marital Status: Sex: M or F Race: Ethnicity: Language: Mailing Address: City: State: Zip: Physical Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Primary Contact Method (check one): Cell Phone Home Phone Patient Portal Postal Work Phone Secondary Contact Method (check one): Cell Phone Home Phone Patient Portal Postal Work Phone Employed By: Referred By: Spouse s Name: Emergency Contact/Relationship: / Home Phone: Cell Phone: Insurance Information (Please fill out) Name of Insurance Company (Primary): Insurance ID Number(s): Person Responsible for Account: Subscriber s Date of Birth: (Last) (First) (MI) Name of Insurance Company (Secondary): Insurance ID Number(s): Person Responsible for Account: Subscriber s Date of Birth: (Last) (First) (MI) *Please Provide a Copy of your Insurance Card(s) to the Front Desk* *Note: We do NOT bill Tertiary insurance. Assignment and Release The above information is true to the best of my knowledge, I authorize my insurance benefits be paid directly to the physician. I also authorize Dr. John Boston D.O., or insurance company to release any information required to process my claims. I AM AWARE THAT DELINQUENT ACCOUNTS TURNED OVER TO A COLLECTION AGENCY WILL INCUR A 25% CHARGE. Patient Signature: Date:

2 HEALTH HISTORY (CONFIDENTIAL) Patients Name: Reason for Visit: Date of last Physical Exam: SYMPTOMS: Check any symptoms you currently have or have had in the past: General Gastrointestinal Eye/Ear/Nose/Throat Men Only Chills Appetite poor Bleeding gums Breast lump Depression Bloating Blurred vision Erection diff. Dizziness Bowel Changes Crossed eyes Lump in testicles Fainting Constipation Difficulty swallowing Penis discharge Fever Diarrhea Double vision Sore on penis Forgetfulness Excessive hunger Earache Other: Headaches Excessive thirst Ear discharge Loss of Sleep Gas Hay Fever Women Only Loss of weight Hemorrhoids Hoarseness Abnormal Pap Smear Nervousness Indigestion Loss of hearing Bleeding between periods Numbness Nausea Nosebleeds Breast Lump Sweats Rectal bleeding Persistent cough Extreme menstrual pain Stomach pain Ringing in ears Vaginal discharge Muscle/Joint/Bone Vomiting Sinus problems Hot flashes (pain, weakness, numbness) Vomiting blood Vision flashes/halos Nipple discharge Arms Hips Painful intercourse Back Legs Cardiovascular Skin Other: Feet Neck Chest pain Bruise easily Hands Shoulders High blood pressure Hives Date of last period: Irregular heartbeat Itching Genito-Urinary Low blood pressure Change in moles Date of last pap smear: Blood in Urine Poor circulation Rash Frequent Urination Rapid heart beat Scars Date of last mammogram: No bladder control Swelling of ankles Sore(s) that won t heal Painful urination Varicose Veins CONDITIONS: Check any conditions you have or have had in the past: AIDS Chemical dependency High Cholesterol Prostate Problem Alcoholism Chicken Pox HIV Positive Psychiatric Care Anemia Diabetes Kidney Disease Rheumatic Fever Anorexia Emphysema Liver Disease Scarlet Fever Appendicitis Epilepsy Measles Stroke Arthritis Glaucoma Migraine Headaches Suicide Attempts Asthma Goiter Miscarriage Thyroid Problems Bleeding Disorders Gonorrhea Mononucleosis Tonsillitis Breast Lump Gout Multiple Sclerosis Tuberculosis Bronchitis Heart Disease Mumps Typhoid Fever Bulimia Hepatitis Pacemaker Ulcers Cancer Hernia Pneumonia Vaginal Infections Cataracts Herpes Polio Venereal Disease MEDICATIONS (List any you are currently taking- may continue on the back of this sheet) DOSAGE FREQUENCY ALLERGIES to medications/substances Preferred Pharmacy Name: Phone:

3 PATIENTS NAME: (All information is strictly confidential) FAMILY HISTORY Fill in health information about your family Check if any blood relatives had any of the following Relation Age Age at death Cause of death Disease Relationship to you Father Mother Brother Sister Arthritis, Gout Asthma, Hay Fever Cancer Chemical Dependency Diabetes Heart Disease, Strokes High Blood Pressure Kidney Disease Tuberculosis Other HOSPITALIZATIONS Year Hospital Reason for Hospitalization Have you ever had a blood transfusion? Yes No If yes, please list dates: PREGNANCY HISTORY # of pregnancies # of live births Complications (if any) HEALTH HABITS: Check which substances you use and describe how often you use them Caffeine Tobacco Drugs Alcohol Other OCCUPATIONAL CONCERNS: Check if your work exposes you to the following Stress Your Hazardous Substances Heavy Lifting Other Occupation: SERIOUS ILLNESS/INJURIES DATE OUTCOME I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in completion of this form. Signature: Date:

4 HIPAA DISCLOSURE FORM In order to comply with specific rules regarding HIPAA (Health Insurance Portability& Accountability Act of 1996), we ask that our patients complete and sign this privacy and security of health information form. Name: Date: It is not the policy of Dr. John Boston s office to release confidential and/or unauthorized information by home telephone, answering machine, work telephone, voic , or cell phone. Whenever returning telephone calls and the answering machine picks up we cannot leave a message if the name and telephone number are not on the recorded message to identify the residence. Information will also not be left with an unauthorized person who may answer the telephone. I authorize Dr. John Boston s office to leave medical information pertaining to my care by the following methods and will assume responsibility of notifying Dr. Boston s office whenever this information changes. Home Telephone Answering Machine Work Telephone Cell Phone Text Message Address *Due to open Internet Access, the security of content sent through cannot be guaranteed secure. Signature: Go on to page 2!

5 AUTHORIZATION FORM If you would like to allow us to speak, or have information released to someone other than yourself, please complete the following by listing the names of people authorized to receive your health information. Name: Relation: Name: Relation: Name: Relation: I understand that upon request I can receive copies of the Office Policies and Notice of Privacy Practices for the office of Dr. John Boston. Print Name: Date: Signature:

6 No-Shows and Missed Appointments Name: Date: I am aware that there will be a $50 charge for a missed appointment without advanced notice. I am also aware that my co-pay is due at the time of service.! Signature:

7 Office Policies Office Hours Monday- Thursday 7:30 A.M. 6:00 P.M. Closed for lunch 12:00 P.M. 1:00 P.M. Calls will be taken from 7:30 A.M.-12:00 P.M. & 1:00 P.M.-5:30 P.M. Appointments & Phone Calls We will call the day before to confirm your appointment, if there is no answer we will leave a message, please make every effort to return our call before 5:30 that day. We require 24 hour notice to cancel all appointments. No show fee is $50. This will be billed to you, not your insurance. Not showing up to an appointment three times is grounds for termination of the doctor-patient relationship. Patients can call the office no more than 3 times a day. Self Pay New patient visits are $250, due at time of visit. All appointments thereafter are $125, due at time of visit. All testing done, including, but not limited to ABIs, EKGs, injections, labs & PFTs are at additional cost & due at time of visit. Please ask for cost(s) breakdowns before having any tests done. Refills For all prescription refills please contact your pharmacy first. All handwritten prescriptions please call office. Medical Records We require 48-hours notice when providing copies of records. We can provide the first copy of records; either paper or CD free, any additional copies or CD s are $50 each. If you are unable to reach our office please contact 911 or go to your nearest emergency medical facility.