New Patient Registration Information

Transcription

1 W E L L S P A N P A T I E N T I N F O R M A T I O N New Patient Registration Information Form 8026-mg R4/ INTELLIPRINT

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3 FINANCIAL POLICY WellSpan Medical Group wants to provide our community with healthcare services and, at the same time, keep costs under control. To do this, we need your help. We ask you to read our payment policy listed below: Your bill is based on the services you received. You are responsible for paying the bill if your insurance company does not cover all the costs. What your health insurance covers is based on an agreement between the company, or person who employs you, and the insurance company. You need to contact your insurance company with any questions about what they will cover. We know that temporary financial problems can sometimes prevent you from making a payment on your account on time. If this happens, you need to contact us at or at once so we can help you with this problem. Wellspan Medical Group will help to arrange a budget plan. If there is a need, we will help you to apply for Medical Assistance or our own Hardship Program. Any bill not paid by the date it is due will be sent to a collection agency. If you do not have health insurance Your Responsibility You must pay your entire bill at the time of service or inform us of your inability to pay. our Responsibility WellSpan Medical Group will provide the services you need, even if you cannot pay. We will not provide services if you are able to pay but choose not to pay. Patient Financial Representatives are available to discuss financial options with you. If you have health insurance We participate with many insurance companies. This means we have signed a contract with them to provide care for the people they cover. The contracts are not all the same, and certain services may not be covered depending on your employee health benefits. If we DO participate with Your insurance plan (including Medicare): Your Responsibility You must pay any co-payment at the time you receive the service. You must pay any deductible amount or any amount that you know is not covered at the time of service. You must pay the amount not paid by your insurance payment is due upon receipt of the statement, except for those from whom WellSpan Medical Group can not collect by law or agreement. If you do not pay we will begin collection efforts. our Responsibility We will send a bill to your insurance company for all services done in our offices.

4 If we do not participate with your insurance plan: Your Responsibility I. You must pay for the service at the time it is given To make it simple, our office accepts cash, checks, VISA, MasterCard, Discover, MAC (debit), and bank drafts. We will charge you a $25.00 fee for any returned checks. our Responsibility II. After you have paid us, we will send your bill to your insurance company. Your insurance will then pay you. StateMent of FInanCIaL ReSPonSIBILItY The patient who receives care and treatment from WellSpan Medical Group must pay any charges that are not paid by insurance or any other party. Other providers, such as x-ray or laboratory, will bill the patient separately. The patient must pay any amount not paid by insurance upon receipt of the statement. 3038_FP PR&M 12/13

5 YH - Form 270

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7 PERMISSION TO RELEASE DIAGNOSTIC/MEDICAL INFORMATION TO ANOTHER INDIVIDUAL Effective Date:* Print Patient s Full Name: Patient s Date of Birth: MR#: I give WellSpan Health entities permission to release diagnostic test results to, and discuss protected health information with, the following person(s): Name Relationship Name Relationship Name Relationship Name Relationship I give Wellspan Health entities permission to release protected health information, in accordance with PA State Education System Guidelines, to the following and sent with the heading of Attention School Nurse: School District & School Name I give WellSpan Health entities permission to leave any protected health information on an answering machine or voic . Yes No By signing this form I give WellSpan Health entities permission to send office correspondence to the address provided. Indicate your relationship to the patient: Patient Patient Representative Print Name (if other than patient) Signature Date This form is good for one year from effective date. 3038_PRDMIAI PR&M 8/14

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9 PATIENT HEALTH ASSESSMENT QUESTIONNAIRE Name: Address: Age: Date: Contact #: Occupation: Sex: M F DOB: Marital Status: Single Married Widowed Divorced Preferred Language: Please list any Hearing, Vision or Reading issues: Do you have an Advanced Directive? Yes No Would you like to make or revise your Advanced Directive? Yes No Please bring all of your prescription medicines and over-the-counter vitamins and supplements to your appointment, OR list all prescription and over the counter medications, supplements and vitamins you take, including the dose or strength. Are you allergic to latex? Yes No Allergies: PAST MEDICAL HISTORY Do you have now or have you ever have any of the following? Heart Disease Yes No Hepatitis Yes No High Blood Pressure Yes No Kidney Stones Yes No Chest Pain Yes No Venereal Disease/STD Yes No Glaucoma Yes No Arthritis Yes No Thyroid Disease Yes No Depression Yes No Lung Disease Yes No Diabetes Yes No Asthma Yes No Stroke Yes No Epilepsy Yes No Blood Disease/Anemia Yes No Cancer (Location) Yes No Gallbladder Disease Yes No Ulcers Yes No Back Disorder Yes No Colitis Yes No Recent tick bites Yes No HIV/AIDS Yes No Other: FAMILY/SOCIAL HISTORY Do you have a family history of: Relationship Your personal Habits: Do you? Heart Disease Yes No Exercise regularly Yes No High Blood Pressure Yes No Smoke or use tobacco? Yes No Diabetes Yes No How Much? Stroke Yes No For how many years? Cancer Yes No Use tobacco in the past? Yes No Thyroid Disease Yes No Drink Alcohol Yes No Depression Yes No How Much? Dementia Yes No Have you ever had a blackout? Other Would you like to cut down? 3038_PHAQ INTELLIPRINT 08/15

10 Patient Name: DOB: PAST SURGICAL HISTORY Please list any operations you have had: PATIENT HEALTH HISTORY-REVIEW OF SYSTEMS FORM GENERAL HEALTH PROBLEMS EYES Fever or chills Yes No Vision problems Yes No Eye pain Yes No EARS, NOSE THROAT HEART Ear problems Yes No Chest pain or tightness Yes No Nose problems Yes No Hard to breathe Yes No Throat problems Yes No STOMACH KIDNEY OR BLADDER Nausea or vomiting Yes No Bladder Problems Yes No Bowel problems Yes No Blood in urine Yes No Blood in stool or vomit Yes No Discharge from vagina or penis Yes No LUNG OR BREATHING PROBLEMS SKIN Coughing Yes No Rash Yes No Wheezing Yes No Growths or lumps Yes No BRAIN OR NERVES MUSCLES AND JOINTS Headaches Yes No Joint pain Yes No Numbness or tingling Yes No Muscle pain Yes No Weakness Yes No Where: GLANDS/HORMONES BLOOD/LYMPH GLANDS Always thirsty Yes No Swollen glands Yes No Always feeling cold or hot Yes No Easy Bruising or bleeding Yes No ALLERGIES EMOTIONAL Seasonal Allergies Yes No Over the last 2 weeks, how often have you? Food Allergies Yes No 1. Little or no interest or pleasure in doing things? Medication Allergies Yes No Not at all Several days Half the days Nearly everyday 2. Felt down, depressed or hopeless Not at all Several days Half the days Nearly everyday Patient Signature Date Provider Signature Date

11 If label not available, please fill in below. NAME: DOB: MRN: Form A ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I hereby acknowledge that I have been provided a copy of WellSpan Health s Notice of Privacy Practices. DATE SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE TIME PRINTED NAME Please see for WellSpan Health Notice of Privacy Pratices. Page 1 of 2 Form #8730 Rev. (09/02/15) *8730*

12 If label not available, please fill in below. NAME: Form B DOB: MRN: DO NOT COMPLETE IF FORM A HAS BEEN SIGNED GOOD FAITH EFFORTS TO OBTAIN ACKNOWLEDGMENT OF RECEIPT OF NOTICE For use only when efforts to obtain acknowledgement of receipt of notice are unsuccessful Personal representative information (if applicable): NAME OF PERSONAL REPRESENTATIVE RELATIONSHIP TO PATIENT I provided the above named patient (or patient s representative) with the WellSpan Notice of Privacy Practices. Describe efforts to provide Notice and obtain signature: Offered copy and individual refused to accept delivery Patient/personal representative was asked to sign form and refused Patient claims they have already received the WellSpan Notice of Privacy Practices Other SIGNATURE PRINTED NAME DATE TIME Page 2 of 2 Form #8730 Rev. (09/02/15) *8730*

13 AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION * * * PLEASE READ AND COMPLETE ALL ITEMS * * * Patient Name: Alias/Maiden Name: Date of Birth: Last 4 of Social Security Number: Phone Number: Address: I authorize the use/disclosure of health information about me as described below: Obtain from: To obtain from: Disclose to: (What Hospital/Practice/Service) (Release to What Organization/Practice/To Whom) Address: Fax No.: Address: Fax No.: Share the following information from my medical record: From: To: (Please Specify the Dates of Service) Abstract of Hospital Medical Records: History & Physical, Emergency Department Physician Notes, Discharge Summary, Consultation Reports, Operative & Procedure Reports, Laboratory Reports, Imaging Reports, All Other Diagnostic Studies, etc. Abstract of Medical Group Records: Physician Office Notes, Consultation Reports, Procedure Reports, Pathology Reports, Laboratory Reports, Imaging Reports, All Other Diagnostic Studies, Psychiatric and Psychological Evaluations, Mental Health Progress Notes, etc. Diagnostic Test Results (please specify): Imaging (please select one format): CD and Reports Film and Reports Reports Only Billing Statements Grant the following authorized user,, access to my entire Electronic Medical Record. This DOES NOT authorize the user to disclose, modify, or provide any official medical advice on my behalf. Other (please specify): For the purpose of: Further Medical Care Personal Insurance Benefits Legal Investigation Billing Inquiries Establish Payment Plan Other (please specify): I would like to receive this information via (please select one): Paper CD Secure Notification Address: I must provide a valid address, either my own or that of my designated recipient. An notification will be provided with instructions to retrieve the requested records from a secure portal. These records will only be available as PDF documents on the secure portal for 30 days following the date of the Notification of Availability. This Authorization includes the release of any records identified below unless I check NOT to disclose such records. Checking or not checking the box is no indicator that such information exists. Records NOT to disclose: AIDS/HIV Related Information and/or Testing; Behavioral/Mental Health Services; Drug and/or Alcohol Treatment. Page 1 of 2 Form #2606 Rev. (04/16) *2606*

14 AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION I understand the following: There may be charges for the copies of my health record due to procedural and regulated steps involved with the release of information process. All fees are regulated by state and federal law, and are updated annually by the Pennsylvania State Legislature. I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment, or my eligibility for benefits. I may inspect or copy any information used/disclosed under this authorization. The information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and will no longer be protected under the terms of this authorization. However, certain protected records may not be redisclosed per Pennsylvania state laws and regulations, and/or Federal confidentiality rules. I may revoke this authorization at any time. If I decide to revoke this authorization, I must present my written revocation to the Health Information Management Release of Information Office. I understand that the revocation will not apply to information that has already been released in response to this authorization. This document authorizes release of information entered into my medical records prior to or within 12 months after the date of my signature. This authorization will expire in 12 months from the date of signature. This authorization will not be accepted unless it is completed in its entirety. A copy of this form will be accepted in lieu of an original. My signature acknowledges that my representative or I received a copy of this document, that I have read and understand the content of this authorization, and voluntarily consent to the release of the information. Signature of Patient/Representative * Date Print Name of Representative and Relationship to Patient * Signature of Witness Date * A personal representative is the person, under applicable law, with authority to act on behalf of the patient or decedent. Legal documentation may be required. THIS PORTION TO BE COMPLETED WHEN A PATIENT IS PHYSICALLY UNABLE TO PROVIDE A SIGNATURE: We, the undersigned, do verify that the above Authorization has been read to the patient and that he/she understands the nature of the release and freely gives his/her verbal consent for the release of the above information. Verbal consent requires the signatures of two witnesses: Signature of Witness Signature of Witness Date Date PLEASE MAIL OR FAX THIS FORM TO: WellSpan Health Phone Number: (717) Health Information Management Release of Information Fax Number: (717) South George Street York, PA * * * IMPORTANT: Please send copies of medical records directly to the requesting practice or physician. * * * Requests for health information and invoices are processed by: Page 2 of 2 Form #2606 Rev. (04/16) *2606*