ARIZONA MEDICAL INSTITUTE PATIENT INFORMATION SHEET

Transcription

1 ARIZONA MEDICAL INSTITUTE PATIENT INFORMATION SHEET Date: / / Drivers License/ Identification #: ** **Patient Name: ** Date of Birth: / / Age: **Preferred Language: **Race: ** Ethnicity: Female Male **Address: **City/State/Zip: **Home Phone: **Cell Phone: **SS #: Employer: Work #: Ext: **Emergency Contact: **Relationship: **Telephone: Do you currently have a living will? Yes No Do you currently have a Medical Power of Attorney? Yes No If patient is a minor (under 18 years of age), please complete the following: Mother s Name: First Middle Last Home #: Cell #: Work#: Ext: Father s Name: First Middle Last Home #: Cell #: Work #: Ext: Who has legal custody of the patient? Both Parents Mother Father Guardian (If guardian, complete following) Guardian s Name: Address: First Middle Last If different from above Do you have insurance? Yes No If yes, complete the following insurance/billing information: PRIMARY INSURANCE: Insurance Company Name: ID #: Subscriber: Relationship to Subscriber: Subscriber s Date of Birth: Subscriber s SS #: SECONDARY INSURANCE: Insurance Company Name: ID #: Subscriber: Relationship to Subscriber: Subscriber s Date of Birth: Subscriber s SS #: GUARANTOR (person responsible for co-payments and for charges which are NOT covered by insurance): Guarantor s Name: Guarantor s SS #: Address (required for accurate billing): Referred By: If different from above Former/previous doctor: Have you had information from another Dr/facility forwarded to this office? Yes No If yes, who from? Reason for transferring your care: Relocation Insurance Accessibility Other: AUTHORIZATION: I HEREBY AUTHORIZE AMI, ANY INSURANCE COMPANY, ANY ORGANIZATION, EMPLOYER, HOSPITAL, PHYSICIAN, DENTIST OR PHARMACIST USE/DISCOLOSE/RELEASE MY PROTECTED HEALTH INFORMATION AND/OR OTHER INFORMATION TO TREAT ME. TO PROVIDE CONTINUED OR FUTURE TREATMENT TO DETERMINE BENEFITS. TO AUTHORIZE PAYMENT AND/OR PROCESS CLAIMS FOR PAYMENT. I HEREBY AUTHORIZE PAYMENT OF BENEFITS ON MY BEHALF UNDER MY INSURANCE PLAN (S) OR ANY GOVERNMENT SPONSORED PLAN DIRECTLY TO AMI. I UNDERSTAND THAT I AM RESPONSIBLE TO PAY AMI IN FULL OR SET UP A PAYMENT PLAN WITHIN 60 DAYS FOR ANY NON-COVERED SERVICES OR ANY SERVICES DENIED OR NOT PAID BY MY INSURANCE. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO UPDATE AMI OF ANY CHANGES THAT OCCUR AND I MUST COMPLETE A NEW PATIENT INFORMATION SHEET. IN THE EVENT OF NO CHANGES A NEW PATIENT INFORMATION SHEET WILL BE UPDATED ANNUALLY. I UNDERSTAND THAT SHOULD MY ACCOUNT BE REFERRED TO A COLLECTION AGENCY I AGREE TO PAY FOR ANY FEES ASSOCIATED WITH THE COLLECTION OF THE OUTSTANDING BALANCE. I UNDERSTAND I MUST PAY MY CO-PAYMENT AND/OR DEDUCTABLES AT EACH VISIT BY CASH, VISA, MASTERCARD, DISCOVER OR AMERICAN EXPRESS. I CERTIFY THAT THE INFORMATION I HAVE GIVEN IS COMPLETE, TRUE AND ACCURATE. MY SIGNATURE BELOW SIGNIFIES I UNDERSTAND AND AGREE TO THE POLICIES OF AMI. SIGNATURE: DATE:

2 ARIZONA MEDICAL INSTITUTE ADOLESCENT MEDICAL HISTORY (11 THRU 20) **First Name: ** Last Name **DOB: / / **PHARMACY NAME: **PHARMACY PHONE: **PHARMACY ADDRESS/CROSS-STREET: Do you have any specific concerns about your health? Please specify. CURRENT MEDICATIONS (INCLUDING OTC): 1. Dose: Times/day: 2. Dose: Times/day: 3. Dose: Times/day: MEDICATION ALLERGY OR VACCINE REACTIONS: Name of medication or vaccine? PAST MEDICAL HISTORY: What reaction occurred? Acne Chronic Kidney Disease Herpes ADD/ADHD Chronic Sinusitis Hypothyroidism Allergies Chronic Colltis Irritable Bowel Syndrome Anemia Diabetes, Type: Migraines Asthma Depression Insomnia Back Pain Eczema Kidney Stones Bipolar Disorder Endometriosis Cardiac Murmur Heart Disease SOCIAL HISTORY: How many years have you lived in AZ? States before AZ: What grade are you in? What grades do you get? Are there school problems? If so, please specify: Who lives at home with you? Are there problems at home? If so, please specify: Exercise? What do you do for exercise? Health Diet? Smoker? Amount smoked/week: Alcohol? Alcohol per week: Have you ever been sexually active? Same sex or opposite sex? SLEEP: Hours per night: Any sleeping problems? If so, please specify: EXPOSURE/HABITS: TV-hours per day: Video games-hours per day: Computer-hours per day: Exercise: Do any household members smoke? PREVENTATIVE CARE: Has you been seen by a dentist? Date of last visit: When was your last physical? SELECT WHICH OF THE FOLLOWING VACCINES YOU HAVE HAD: Chicken Pox (Vaccine or Disease) Meningitis Vaccine (MCV) Tetanus Vaccine (Tdap) HPV Vaccine FAMILY MEDICAL HISTORY Mother: Alive Deceased, Age: Father: Alive Deceased, Age: Brothers: Sister: Alzheimers Arthritis Asthma Cancer, Type: Heart Disease High Cholesterol Depression Stroke Alcoholism Diabetes, Type: High Blood Pressure Migraine Obesity Osteoporosis Thyroid Disorder Kidney Disease Alzheimers Arthritis Asthma Cancer, Type: Heart Disease High Cholesterol Depression Stroke Alcoholism Diabetes, Type: High Blood Pressure Migraine Obesity Osteoporosis Thyroid Disorder Kidney Disease Alzheimers Arthritis Asthma Cancer, Type: Heart Disease High Cholesterol Depression Stroke Alcoholism Diabetes, Type: High Blood Pressure Migraine Obesity Osteoporosis Thyroid Disorder Kidney Disease SOCIAL HISTORY: What grade is your child in: What grades does your child get? Are there problems at school? Who lives at home with your child? Are there problems at home? If so, please specify: How did you hear about Arizona Medical Institute?

3 ARIZONA MEDICAL INSTITUTE Vicente Diaz Gonzalez, MD Cynthia Aponte, FNP BC Katherine Major, PA C AUTHRIZATION FOR RELEASE OF HEALTH INFORMATION AUTORIZACION PARA DIVULGAR SU INFORMACION DE SALUD Patient Name: Date of birth: (Nombre del paciente) (Fecha de nacimiento) Previous Name: Social Security #: (Nombre anterior) (# de seguro social) Address: City, state, zip: (Direccion) (Ciudad,estado, codigo postal) Telephone: Medical records #: (# telefonico) (# de historia clinica) I request and authorize: (Solicito y autorizo) Doctor name (Nombre de doctor) Address (Direccion) City, state, zip (Ciudad, estado, codigo postal) Phone (# telefonico) Fax (# de fax) To release my healthcare information to: Arizona Medical Institute (Para liberar mi informacion de salud para) 3050 North Litchfield Road, Suite 130 Goodyear, AZ Phone: (623) Fax: (623) I specifically authorize the following healthcare information: (Autorizo especificamente la siguiente informacion sobre la salud) o Entire medical record (including mental health care, communicable diseases, HIC or AIDS, alcohol/drug abuse treatment) (Historia clinica complete (incluyendo el cuidado de la salud menta, las enfermedades transmisibles, el VIH o el SIDA, el alcohol/abuso de drogas tratamiento)) o All records between the dates of and (Todos los registros entre las fechas de) o Records pertaining to (Los registros relativos a) o Other: (Otro) Reason for this request: (La razon para esta peticion) 1. New PCP/doctor 2. Further medical care (specialist, etc) 3. Continuity of Care (Nuervo Medico) (Ademas cuidado medico (especialista, etc)) (La continuidad de la atencion) 4. Insurance Company 5. Disability Determination 6. Attorney/legal investigation (Compania aseguradora) (Determinacion de incapacidad) (Abogado/investigacion legal) This authorization shall become effective immediately and shall remain in effect for one year after date of signature. I understand I have the right to revoke this authorization at any time. I understand to revoke this authorization I must do so in writing and the revocation will not apply to information that has already bee released. I understand that any disclosure that any disclosure of information carries with it the potential for unauthorized redisclosed and the information may not be protected by federal confidentiality rules. I release the providers, its employees and business associates from any legal responsibility or liability for the disclosure. By signing this form, I have given my consent freely, voluntarily and without coercion. I acknowledge that I have read it in full, I understand it and agree to its terms. Printed name of patient or legally authorized individual (Nombre impreso del paciente o persona legalmente autorizada) Date Signature of patient or legally authorized individual (Firma del paciente o persona legalmente autorizada) Relationship (Relacion)

4 Arizona Medical Institute Consent for Use and Disclosure of Protected Health Information Consentimiento para el uso y divulgación de información de su salud protegida Purpose of Consent: By signing this form you authorize the disclosure of your protected health information. You also give us consent to leave messages / mail at the phone number /address provided office regarding your healthcare matters and authorizing additional persons or entities to receive and use your Protected Health Information on your behalf. Propósito del Consentimiento: Al firmar este formulario usted autoriza la divulgación de su información de salud protegida. Asimismo, usted nos das u consentimiento para dejar mensajes a su casa y / o por correo con respecto a los asuntos de salud y la autorización de otras personas o entidades para recibir y utilizar su información de su salud protegida en su nombre. Patient Name / Nombre del Paciente DOB / Fecha de nacimiento I wish to be contacted in the following manner (check all that apply): Deseo ser contactado de la siguiente manera (marque todas las que apliquen): Telephone / Teléfonico Mail / Correo Telephone # # teléfonico OK to leave message with detailed information / Está bien dejar mensaje con información detallada Leave message with call-back number only / Está bien dejar mensaje con el numero de devolución de llamada sólo OK to mail to home address / Está bien enviar por correro a mi dirección de casa OK to fax to this number / Está bien enviar por fax a este numero OTHER / OTRO OK to speak to another authorized person: Yes/Si No/ No Está bien para hablar con otra persona autorizada: Name of authorized person Date of birth Relationship Nombre de la persona autorizada Fecha de nacimiento Relación Name of authorized person Date of birth Relationship Nombre de la persona autorizada Fecha de nacimiento Relación Patient Signature Witness Signature Date Date

5 ARIZONA MEDICAL INSTITUTE MEDICAL CONSENT FORM 1. MEDICAL CONSENT: The patient is under the control internal of his/her Medicine/Pediatric Physician and the undersigned consents to any X Ray, examination, laboratory and/or surgical procedures under general and specific instructions of any provider of Arizona Medical Institute. 2. CONSENT TREATMENT: I hereby agree to the performance of treatment services as in the opinion of the providers at Arizona Medical Institute are deemed necessary. 3. RELEASE OF INFORMATION: Arizona Medical Institute may disclose all or any part of the patient s record to any person or corporation which is or may be liable under a contract to Arizona Medical Institute or to any patient or to the family member or employer of the patient for all or part of the medical charges, including, but not limited to medical service companies, workers compensation carriers, welfare funds or the patient s employer. 4. ASSIGNMENT OF BENEFITS: In the event the undersigned in entitled to medical benefits of any type whatsoever arising out of any policy of insurance insuring patient or any other party liable to patient said benefits are hereby assigned to Arizona Medical Institute for application on patient s bill, and it is agreed that Arizona Medical Institute may receipt for any such payment and such payment shall discharge the said insurance company of any and all obligations under the policy to the extent of such payment, the undersigned and or patient being responsible for charges not covered by this assignment. 5. FINANCIAL AGREEMENT: The undersigned agrees weather he signs as agent or as patient that in consideration of the services to be rendered to the patient, the hereby individual obligates himself to pay the account in accordance with the regular rates and terms of the facility. Should the account be rendered to any attorney for collection, the unsigned shall pay reasonable attorney s fees and collection expenses. A 1% service charge will be assessed on all account balances past 30 dates. Any disputes will be resolved in our jurisdiction. The undersigned certifies that he has read the foregoing, is in the patient or is duly authorized by the patient as the patient s general agent to execute the above and accept the terms. Patient s Signature Date Guardian s Signature Date IF THE PATIENT IS A MINOR, PARENT OR GAURDIAN MUST AUTHORIZE TREATMENT TO BE ADMINISTERED TO PATIENT.

6 ARIZONA MEDICAL INSTITUTE MINOR CONSENT FORM Minor Patient s Name: DOB: I hereby acknowledge and give permission to Arizona Medical Institute to provide medical care for said minor in my absence. A minor cannot authorize treatment for themselves. This medical care may include service and supplies related to the minor s health and may include, but not limited to, taking blood, preventative, diagnostic, therapeutic, maintenance, counseling, assessments or review of physical or mental status/function of the body and ordering medication. With this consent form, I give authorization to the person(s) listed below, to bring minor to Arizona Medical Institute for said medical treatment. Name of Individual Relationship to Minor Signature of Parent/Guardian, Caregiver Date Minor lives with: Both Parents Mother Father Guardian Mother Name: Address: DOB: Phone: Father Name: Address: DOB: Phone: Guardian Name: Address: DOB: Phone: PERMISSION GIVEN OVER THE PHONE REQUIRES TWO WITNESS SIGNATURE: Name of Parent, Guardian, Caregiver: Phone: Witness #1 Signature Title Witness #2 Signature Title

7 ARIZONA MEDICAL INSTITUTE Patient Name/Nombre del Paciente: Date of Birth/Fecha de Naciemento: Pharmacy/Nombre de Farmacia: Pharmacy Phone/Numero de Farmacia: Pharmacy Location (Crossroads)/Direccion de su Farmacia:

8 ARIZONA MEDICAL INSTITUTE OFFICE POLICIES Thank you for choosing Arizona Medical Institute as your primary care provider. We are committed to providing you with quality and affordable health care. In order to help us serve you it is important that you understand our Policies and Procedures. Please read this carefully, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request. WALK IN POLICY/WAIT TIMES We see patient by appointment and do our best within the limits of circumstances that we can control, to see our patient on time. We feel that patient deserve our attention during the appointment time we have reserved for them, therefore, we request that all patient call for an appointment before coming into our office. We do have same day sick appointments available with our Nurse Practitioner Cynthia Aponte or our Physicians Assistant Katherine Major. Please keep in mind most of the time Dr. Diaz is booked two weeks in advanced, therefore, same day appointments are seen by our other providers. In addition, the following will help us remain on schedule. There are rare instances in which it is appropriate to come in before calling. A life-threatening situation is not one of these instances. Anytime you feel that a life-threatening medical condition is present, the appropriate course of action is to immediately call 911. EMT s responding can assess the situation and provide emergency care and transport to the Emergency Room for further evaluation. It is not appropriate to come into the office in such situations; this will delay adequate medical evaluation and treatment and may put you in dangerous situation. If you arrive at our office without an appointment, we will have out staff evaluate and determine the urgency of you illness. We will then triage to an appropriate appointment time or refer you accordingly. You may be asked to return at another day or time. Please note that while we do all we can to reduce your wait time; it is often unavoidable in quality healthcare. Our providers will see each patient in order of appointment time (or sometimes severity). Each provider will have several different patients in exam rooms at any given time, therefore you may not be seen in the order that you are signed in. Our staff will be happy to assist you as best as they are able in determining you wait time. Due to circumstances outside of our control it is possible that we may need to request that you see a different provider other than the one you are scheduled with. Phone ahead to make an appointment for extra family members that want to be seen. Finally, we ask for your patience and understanding when we are running behind schedule. When this happens we try to get back on schedule as quickly as possible. APPOINTMENT/CANCELLATIONS A routine appointment is not designed to exceed 15 minutes; therefore the allotted time for each appointment is 15 minutes. In order for us to stay on schedule, we ask that you do not exceed more than three problems/issues per appointment. If you are scheduled for a physical, general medical exam or preventative exam and you are sick at the time of the visit or want to be seen for another problem, we will treat you for the sickness or the problem only. You must schedule another appointment for the physical. Per insurance guidelines, these visits must be billed separately. Exceptions can be made upon doctor s approval. Patient should arrive 15 minutes prior to their scheduled appointment time. Late arrivals in excess of 20 minutes past appointment time will be worked back into schedule or may be asked to re-schedule the appointment.

9 We ask that you kindly provide a 12 hour notice if you need to cancel or reschedule an appointment so that we may offer your time slot to another patient that need to be seen. If you do not cancel your appointment, your account may be charged a missed appointment fee, the current fee is $ If you miss or cancel more than 3 appointments in advanced notice, we reserve the right to notify your insurance company and/or dismiss you as a patient of Arizona Medical Institute. AFTER HOURS/WEEKENDS/HOLIDAYS Please be aware that our providers do not have access to medical records and can only provide basic medical information when our office is closed. They cannot diagnose or treat illness over the phone. We do not phone in antibiotics or refill medications after hours. If you have a medical emergency, please call 911 or go to the nearest Emergency Room for treatment. MEDICATIONS/REFILLS Prescriptions are a professional service and a part of your treatment plan. Please bring back an updated list of all medication you are taking or bottles for this medication with you to each appointment. Ongoing medical evaluation of benefits and risks of each medication requires regular office visits. It is important to notify us of all medication (prescription, over-the-counter and herbal) that you are taking in order to avoid drug interactions. Refills will be handled at the time of your office visit. Please check prior to your appointment to see if you are running out. Medication refills are a predictable event. Please check your bottles and plan ahead. If you are require a refill of your medication, outside your normal office visit, the fastest, most efficient way to obtain your prescription is to contact your pharmacy (including prescriptions with zero refills ). Your pharmacy will contact us via fax to request the refill. Please allow 48 hours to process the request. If your refill is denied, please call our office to schedule appointment. Please call our office and schedule appointment if you need a change of medication or a 90 day mail order refill. State law requires appropriate assessment and documentation prior to writing a prescription. We do not replace lost or stolen narcotics (controlled substances). It is against the law to obtain narcotics (controlled substances) from multiple physicians without notifying the physicians in question. Any patient engaging in illegal activities will be discharged from the practice. PHONE CALLS WITH PROVIDERS Because our providers spend most of their day in patient care and usually cannot be called away to talk to patient on the phone, we ask you leave a detailed message with the receptionist when trying to reach your doctor. The medical assistants are trained to handle your phone questions initially. This allows them time to review your record prior to returning your call (they usually try to return your call that evening or the next business day) or they may recommend that you come in for an appointment. Emergencies will be expedited and/or given to the doctor for immediate attention. CELL PHONES As a courtesy to other patients and staff, we ask that cell phones be turned off prior to entering the building. MINOR AND/OR FULL TIME STUDENTS All patients under the age 18 must be accompanied by a parent, legal guardian, or have signed /legal guardian consent for treatment. The individual who is requesting the medical treatment is responsible for the payment of the

10 medical bills. Co-pays will be collected from the attending parent//guardian at the time of service. We will not be responsible for billing or collecting from another party, i.e. divorced or separate spouses. LAB TESTING We draw blood in the office as staffing permits. There is a charge for phlebotomy and specimen processing. If you do not wish to pay the additional fee you may request an order and proceed to your participating laboratory for the lab draw. Please make sure we are using the correct lab to process your laboratory specimen. It is important that you update your personal and insurance information prior to being seen. We have an established relationship with LABCORP and SONORA QUEST. If you prefer a different lab we will give you an order to take to the lab of your choice. If you have questions regarding you laboratory bill, please contact the billing laboratory directly. OFFICE TESTING/RESULTS A member of our staff will contact you about your test results either by phone or mail. Most test results take approximately 72 hours, however some testing takes longer. Please allow 5 to 7 business days after your blood draw or other testing before you call our office. For STAT (urgent) testing, please allow 24 hours before calling our office. Due to faulty testing or circumstances beyond our control, you may be asked to repeat the test. REFERRALS AND AUTHORIZATIONS Referrals require medical evaluation to confirm condition and appropriateness of referral. Please call our office and schedule an appointment. Referral for routine GYN, Podiatric, Dermatologic and Chiropractic care is subject to state laws and limited visits may be obtained without a referral. Please review our policy. Referrals can be time consuming and may require the review of medical records or authorization from your insurance company, therefore, we request that you allow 10 to 14 business days before calling our office regarding the status of your referral. All urgent or STAT referrals will be done within 24 hours. It is your responsibility to call and schedule your appointment with the specialist or facility. We will provide you with the information necessary to do so. We will forward a referral request via fax to the selected provider or facility along with any pertinent office notes and test results. If you have a preference for a specific specialist or facility, please notify our staff. Please verify provider participation with our insurance plan prior to being seen. Your policy clearly states that the patient should verify provider participation prior to being seen. Please review your policy if you have any questions. Authorizations are frequently required for MRI, CT, PET, and NUCLEAR IMAGING, some specialist, certain injections or high cost medications, hospitalizations and other outpatient procedures. We will call and get authorization as required by your insurance company. It is your responsibility to verify authorization has been obtained prior to being seen. Such authorizations are not a guarantee of payment. Authorizations are based on INSURER guidelines for payment and may not be concordant with medical necessity as determined by your doctor based on your healthcare needs. Please review policy or contact your insurance company if you have any questions.

11 FORMS/DISABILITY PAPERWORK Our doctors would be happy to complete forms or disability paperwork for you. Usually, an office visit is required to discuss your current condition; however, expectations can be made upon the doctor s approval. There is an $80 fee to complete a form outside of an office visit. CONDUCT Patients and their families are required to maintain acceptable conduct at all times. Any patient who is disrespectful to any staff or other patients will be asked to leave practice and seek future medical care elsewhere. Any verbal or physical thereat, no matter how small, will be reported to law enforcement. Parents are responsible for the conduct of their children. Children under the age of 13 cannot be left alone. Children should not be excessively noisy or disruptive to other patients. These policies are designed to give you a better understanding of our medical practice for the purpose of establishing and maintain a successful and comfortable patient-physician relationship. Your comments and suggestions regarding the care you received are important and we encourage you to take an active part in your health care. We feel this will enable us to serve you more effectively. Thank you.

12 Arizona Medical Institute Notice of Privacy Practices and Office Policies I have received a copy of Arizona Medical Institutes notice of Privacy Practices and Office Policies. I consent to the release of Protected Health Information (PHI) that is required to carry out treatment, payment, activities, and healthcare operations on my behalf. My signature below signifies my understanding and willingness to comply with these policies. Signed: Date: Witness: Date: Arizona Medical Institute Aviso de conocimiento de las Practicas de Privacidad y Politicas de la Oficina He recibido una copia de las Prácticas Privadas y Políticas de la Oficina. Doy mi consentimiento para la divulgación de información médica que se requiere para realizar el tratamiento, actividades de pago y operaciones de atención médica en mi nombre. Mi firma abajo significa mi entendimiento y la voluntad de cumplir con estas politicas. Firma: Fecha: Testigo: Fecha: