PATIENT REGISTRATION

Transcription

1 PATIENT REGISTRATION Last / First / M.I. Patient Information Address / APT# City / State / Zip Phone # SSN: DOB Male Female Marital Status: Occupation Patient Address Assignment and Release I hereby authorize my insurance benefits be paid directly to the physician and I am financially responsible for non-covered services. I also authorize the physician to release any information required in the processing of this claim and all future claims. If my account is sent to a collection agency, I agree to pay all collection and attorney fees. Signature (Patient or, if minor Signature of parent or guardian) Date Primary Doctor/Family Doctor Referring Doctor In Case of Emergency Contact Other Information Phone # Relationship: Pharmacy Telephone Address PATIENT REGISTRATION 1.1

2 NEW PATIENT MEDICAL HISTORY Patient: Medical History: Please check box if you have ever had any of the following: Asthma Angina/ Chest Pain Anemia Arthritis Glaucoma Cancer Chronic Bronchitis Cirrhosis Clotting Disorder Diabetes Emphysema Epilepsy Fractures Gallstones Heart Attack Heart Murmur Headaches Hepatitis High Blood Pressure High Cholesterol HIV +/ AIDS Kidney Disease Kidney Stones Migraines Positive TB Rheumatic Fever Stroke Thrombophlebitis Thyroid Disease Tuberculosis Ulcers Other- Please List Below Family History: If any blood relatives has ever had any of the following, please check box and indicate relationship. Please indicate the age and either living or deceased for each of the following: Bleeding Tendency Cancer Diabetes Heart Attack Heart Disease High Blood Pressure Kidney Disease Liver Disease Migraine Headaches Stroke Tuberculosis Operations and/or Hospitalizations: List below with approximate date: Reason Date Reason Date NEW PATIENT MEDICAL HISTORY 2.1

3 Patient: Allergies to Medications: Current Medication and Supplements: Habits: Smoking Packs Daily How Long? Interested in stopping If you quit, when did you quit? How long did you smoke? Do you exercise routinely? (Y/N) How Often? 1-2 wk 3-5+week What do you do for exercise? Coffee Sleep Cups Daily Snoring Other Caffeine: Daytime Drowsiness Alcohol Difficulty Falling Asleep Type: Continuity Disturbances Frequency: Early Morning Awakening Amount: Other: Diet Salt Intake Fat Intake How would you rate your overall diet? Have you ever used illegal drugs? (Y/N) If so, what drugs? How often? Patient Height Patient Weight Pa tient Blood Pressure Patient Race NEW PATIENT MEDICAL HISTORY 2.2

4 NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT Patient Name Date of Birth Social Security Number Notice of disclosure: On occasion we use testing from Genetic Direction to assist in the personalization of diet, weight loss and anti-aging. Dr. Rudman has made a small monetary investment in this company. I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions. Patient Signature Date Personal Representative Signature (if applicable) Relationship to Patient NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

5 ASSIGNMENT OF BENEFITS, ASSIGNMENT OF RIGHTS TO PURSUE ERISA OR OTHER LEGAL AND ADMINISTRATIVE CLAIMS ASSOCIATED WITH MY HEALTH INSURANCE AND /OR HEALTH BENEFIT PLAN (INCLUDING BREACH OF FIDUCIARY DUTY) AND DESIGNATION OF AUTHORIZED REPRESENTATIVE Assignment of Insurance Benefits Appointment as Legal Authorized Representative I hereby assign all applicable health insurance benefits and all rights and obligations that I and my dependents have under my health plan to the Provider and the Provider s representatives ( My Authorized Representatives ) and I appoint them as my authorized representative with the power to: File medical claims with the health plan File appeals and grievances with the health plan Discuss or divulge any of my personal health information or that of my dependents with any third party including the health plan Institute any necessary litigation and/or complaints against my health plan naming me as plaintiff in such lawsuits and actions if necessary (or me as guardian of the patient if the patient is a minor) I certify that the health insurance information that I provided to Provider is accurate as of the date set forth below and that I am responsible for keeping it updated. I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my bills for professional services from Provider are paid in full. I also understand that I am responsible for all amounts not covered by my health insurance, including co-payments, co-insurance, and deductibles. Authorization to Release Information I hereby authorize My Authorized Representatives to: (1) release any information necessary to my health benefit plan (or its administrator) regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims. This order will remain in effect until revoked by me in writing. Authorization I hereby designate, authorize, and convey to My Authorized Representatives to the full extent permissible under law and under any applicable insurance policy and/or employee health care benefit plan: (1) the right and ability to act as my Authorized Representative in connection with any claim, right, or cause of action including litigation against my health plan (even to name me as a plaintiff in such action) that I may have under such insurance policy and/or benefit plan; and (2) the right and ability to act as my Authorized Representative to pursue such claim, right, or cause of action in connection with said insurance policy and/or benefit plan (including but not limited to, the right and ability to act as my Authorized Representative with respect to a benefit plan governed by the provisions of ERISA as provided in 29 C.F.R (b)(4) with respect to any healthcare expense incurred as a result of the services I received from Provider and, to the extent permissible under the law, to claim on my behalf, such benefits, claims, or reimbursement, and any other applicable remedy, including fines. This constitutes an express and knowing assignment of ERISA breach and/or fiduciary duty claims and other legal and/or administrative claims. I authorize communication with the Provider and its authorized representatives by and my address I understand I can revoke this authorization in writing at any time. A photocopy of this Assignment/Authorization shall be as effective and valid as the original. Patient Date ASSIGNMENT OF BENEFITS AUTHORIZATION 5.1