Patient Registration Form

Transcription

1 Patient Registration Form Name: Last Name First Name MI (Previous Last name) SSN #: Address: Date of Birth: Sex: o M o F Home phone: Work phone: Cell phone: Race: o Caucasian o Hispanic o Bi-racial o African/American o Asian o Other o Decline Ethnicity: o Hispanic o Non-Hispanic o Decline Preferred Language: o English o Other Marital Status: o Single o Marrried o Widow o Divored Student Status: o Full Time o Part Time Referring Physician (if applicable): Phone: How did you hear about us? (If not referred by physician.) If we need to leave a message with medical personal information, what number may we use? Who is your emergency contact? Relationship: Phone: Who is your employer? Main phone: Employer s Address: INSURANCE INFORMATION Primary Insurance: Group#: ID#: Subscriber: Relationship to Subscriber: Effective Date: Subscriber s Date of Birth: Subscriber s SSN #: Secondary Insurance: Group#: ID#: Subscriber: Relationship to Subscriber: Effective Date: Subscriber s Date of Birth: Subscriber s SSN #: IF RELATED TO WORK OR INJURY Type o Worker s Comp o Auto Accident o Legal/Employer o Personal Injury o Other Claim #: Date of Injury or Accident: State of Injury/Accident: Worker s Comp/Auto Accident Insurance Carrier: Phone: Address: City: State: Zip Code: Case Contact Person: Phone: Attorney Practice Name: Phone: Address: City: State: Zip Code:

2 Medical History Name: Sex: o M o F Date of Birth: Age: Address: Home phone: Work phone: Cell phone: Marital Status: o Married o Divorced o Widowed o Separated If married, spouse s name: Your Occupation: SSN #: Children s names and ages Emergency contact information Name: Phone: Referred by: Allergies to Medications, X-Ray Dyes, or Other Substances: o Yes o No If yes, please list name of medication/substance and type of reaction: Medication/Substance Reaction Past Medical History & Review of Symptoms: (Please circle if you have any problems or are presently complaining of any of the following.) High blood pressure Lightheadedness Hay fever Ulcers Head or neck radiation Blood disorders Diabetes Frequent urination Abdominal discomfort Change in bowel habits Headache Venereal diseases Cancer Rheumatic fever Indigestion Unexplained weight gain/loss Kidney diseases Anxiety Heart disease Asthma Nausea Hemorrhoids Kidney stones Depression Chest pain/chest tightness Bronchitis Vomiting Gall bladder disease Difficulty urinating Anemia Shortness of breath Pneumonia Constipation Colitis Arthritis Alcohol abuse Swollen ankles Persistent cough Diarrhea Hepatitis or jaundice Low back problems Drug abuse Palpitations T.B. Blood in stool Thyroid disease Skin diseases Gout Gynecologic and Obstetric History: Age at onset of periods: Frequency: Length of period: Pregnancies: Births: Miscarriages: Prolonged or abnormal bleeding: o Yes o No Please describe: Leakage of urine: o Yes o No Please describe: Pelvic pain: o Yes o No Please describe: Abnormal discharge: o Yes o No Please describe: History of abnormal pap smear: o Yes o No Type of treatment:

3 Please list and provide dates for the following: Operations: Hospitalizations other than for surgery: Immunization History Have you had: Hepatitis B o Yes o No When? Pneumovax Immunization o Yes o No When? Flu Immunization o Yes o No When? Tetanus Immunization o Yes o No When? Other o Yes o No When? When was your last: Pap smear: Mammogram: Breast exam: Cholesterol Check: Stool check for blood: Prostate exam: Family History: Has any member of your family (including parents, grandparents, and siblings) ever had the following? Illness Which family members? Approx. age when diagnosed: Cancer (describe type) Hypertension (high blood pressure) Diabetes Strokes Mental disease (anxiety, depression etc.) Drug or alcohol addiction Glaucoma Bleeding disorders Other: Medications: (Prescriptions, over-the-counter, vitamins, herbs, etc.) Drug Dose Drug Dose

4 Prevention: Do you wear a seatbelt? o Yes o No If no, why not? Do you wear a bike helmet? Do you smoke? Do you drink alcoholic beverages? Do you drink coffee? Do you drink tea? o Yes o No o Yes o No If yes, how many packs per day? o Yes o No If yes, how much per week? _ o Yes o No If yes, how many cups per day? o Yes o No If yes, how many cups per day? If there is a gun in your home, is it out of children s reach and unloaded? o Yes o No Do you use drugs? (marijuana, cocaine, crack, etc.) o Yes o No If yes, explain: Have you ever engaged in any activity which has put you at risk of getting AIDS? o Yes o No If yes, explain: Do you wish to be tested for AIDS? o Yes o No Have you ever worked with chemicals, paints, asbestos, or other hazardous materials? If yes, explain: Are you in a relationship in which you have been physically hurt (e.g. slapped, kicked, punched, bruised) by your partner? o Yes o No Do you ever feel afraid of your partner? o Yes o No Do you have a living will? o Yes o No Do you have a donor card? o Yes o No Method of birth control? ***I hereby authorize Dr. Karmazin to release any medical information that may be necessary for either medical care or my insurance company.*** Signature:

5 PATIENT SIGNATURE ON FILE FORM CONSENT FOR TREATMENT Name: Date of Birth: I am either the patient who is seeking treatment or I am the person who is authorized to seek treatment for the patient. I consent to medical treatment and diagnostic procedures as provided by Virtua, its associated physicians, clinicians, and other personnel. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me as a result of treatment or examination at Virtua MEDICARE I request that payment of authorized Medicare benefits be made to either me or on my behalf to Virtua Health for any services furnished to me by their physicians. I authorized any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to myself or the party who accepts assignment. In order to comply with Medicare regulations, please answer the following questions: Are you or your spouse employed? Y N Has treatment been authorized by the VA? Y N Do you or your spouse have other insurance? Y N Are you covered under the Black Lung Program? Y N Are you disabled or have end stage renal disease? Y N Is there Medigap coverage secondary to Medicare? Y N Is illness/injury the result of an auto accident? Y N Is there Insurance coverage primary to Medicare? Y N Did illness/injury occur at work? Y N Is there employer supplemental coverage secondary to Medicare? Y N MEDIGAP (MEDICARE AND SECONDARY INSURANCE) I request that payment of authorized Medigap benefits be made to either me or on my behalf to Virtua Health for any services furnished to me by their physicians. I authorize any holder of Medicare information about me to be released to (Name of Medigap Coverage) any information needed to determine these benefits payable for related services. COMMERCIAL ASSIGNMENT OF BENEFITS I authorize payment directly to Virtua for medical benefits including any Major Medical benefits otherwise payable to me under the terms of my policy, but not to exceed the balance due to the physicians. I understand and agree that I am financially responsible to the above party for charges not paid under my policy. I permit a copy of this authorization to be used in place of the original. GENERAL RELEASE OF INFORMATION Virtua may disclose any or all parts of my clinical records to any insurance company or companies, or in the case of Worker s Comp claims, to my past or present employer(s), for purposes of satisfying charges billed by Virtua Health. This authorization does not cover requests from other parties seeking information regarding my account. I acknowledge receipt of and/or the opportunity to review the Virtua Joint Notice of Privacy Practices which explains how protected health information will be used and disclosed. I give consent to access all of my electronic medication information in connection with providing a list of current medications. I give consent to access all of my electronic immunization information in connection with providing my complete list of vaccinations. GUARANTEE OF ACCOUNT For and in consideration of services rendered by Virtua Health to the below and named patient, the undersigned (jointly and several if more than one) guarantee payment of all charges incurred by all said patient in accordance with the policy of payment of such bills. PATIENT BILL OF RIGHTS The patient Bill of Rights has been made available for me to review. I acknowledge receipt of the Health Information Exchange brochure. You may not discuss my medical care with anyone other than me. THE UNDERSIGNED CERTIFIES THAT EACH HAS READ AND UNDERSTANDS THE ABOVE TERMS AND CONDITIONS. Patient Signature Patients Agents Representative/Guarantor Signature Date

6 Medical Group ACKNOWLEDGEMENT OF RECEIPT FORM Health Insurance Portability and Accountability Act, [HIPAA] AUTHORIZATION TO RELEASE HEALTH INFORMATION Patient Name (Please Print) Date of Birth: By signing below, I acknowledge receipt of or the opportunity to review the Notice of Privacy Practices of Virtua Medical Group. In addition, by signing below, I authorize Virtua Medical Group to disclose my health information in conformance with the provisions of the Notice of Privacy Practices. Signature: Date: Phone Authorization Yes, you have my permission to leave medical information on my answering machine. Please let us know which daytime telephone number is best to do so. ( ). No, you do not have my permission to leave medical information on my answering machine. To whom, other than yourself, may we speak regarding your medical condition? Name Relationship Phone# Name Relationship Phone# I have the right to withdraw or revise my permission at any time in writing. Signature: Date: For Office Use Only: INABILITY TO OBTAIN ACKNOWLEDGEMENT To be completed if no signature is obtained. If it is not possible to obtain the individual s acknowledgement, indicate the reason why the acknowledgement was not obtained. Individual refused to sign. An emergency situation prevented us from obtaining the acknowledgement. Signature of Virtua Representative: