MEDICATION LIST. Name: DOB: Date:
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1 OBSTETRICS & GYNECOLOGY CARE, CORAL MEDICATION LIST Name: DOB: Date: For the quality of your healthcare, we will need the following detailed medication information in addition to what you have listed in your digichart online history. Please complete this list with ALL MEDICATIONS to include prescribed medications, non-prescribed herbs, vitamins and home remedies. Your provider will need this list at the time of your appointment. Medication/Vitamins Herbs/Home Remedies Doses Why Taken How Long You Have Taken Who Prescribes Medication Allergies Please note at which Pharmacy you prefer to have your prescriptions filled. Pharmacy Name: Street Address: City, State: Phone #: Fax #: Mail Order Rx? Yes No
2 Patient Name: Birth Date: Please Print Please read the following and complete the information requested You have the right to identify individuals other than your health care providers who are involved in your care (family, friends, or others). We may verbally share your medical information to an individual you have identified as involved in your medical care. We may also give information to someone who helps pay for your care. EvergreenHealth will only share your health information with the individuals you designate, except as required or permitted by law. You may add or change this list at any time. Information related to Mental Health, Chemical Dependency, or HIV testing and/or therapy will only be shared with you unless specifi cally authorized below. (Sensitive Information) I DO NOT authorize EvergreenHealth to verbally share information with anyone. I authorize EvergreenHealth to verbally share medical information/billing information with the individuals listed below: Name Relationship to Patient Information to Share I agree I may be contacted for follow up information about my care at the primary telephone number I have designated. Is it OK to leave a detailed message at the primary telephone number designated? YES NO These designations will remain in effect indefinitely or until otherwise revoked by me in writing. Signature: Date: (if signed by a personal representative of the patient, please complete the following:) Personal Representative s Name: Relationship to Patient: Parent Legal Guardian* Holder of a Medical Power of Attorney* * Please attach Legal Documentation if you are the Legal Guardian or Holder of Power of Attorney Kirkland, WA INDIVIDUALS INVOLVED IN CARE FORM ID ADM 710 Approved 04/17 APPLY PATIENT LABEL HERE Original - Medical Record MR
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5 OBSTETRICS & GYNECOLOGY CARE, CORAL NE 130 th Lane, Suite 420 Kirkland, WA Phone: Fax: Information You Need to Know INSURANCE It is the patient s responsibility to be aware of your insurance coverage, co-pays and benefits, so we encourage you to contact your insurance company before your appointment. If your plan does not cover preventative care, or you do not have insurance, please contact our office to discuss payment options. If you are a Medicare patient, please be aware that your breast, pelvic and pap exam may only be covered every other year. You may incur an out of pocket expense. Remember to bring your insurance card to your appointment. COPAYS If you have a co-pay, it is due at the time of service. LAB WORK If your insurance plan is contracted with a particular lab, it is your responsibility to inform our clinical staff at the time of your appointment. If we are not informed and tests are sent out to a different lab, we will be unable to do anything about the incurred lab fees. NATIONAL CODING LAWS We must bill your annual well-woman exam as preventative care. We are unable to re-bill visits with changed procedure or diagnosis codes as this constitutes insurance fraud. IDENTIFY THEFT LAW Federal law now requires a photo ID for your visit. Please bring your drivers license or another photo ID to your appointment. We will be taking an office photograph of all patients in our system to be compliant with the current identity theft law. Thank you for your understanding in these matters. Your cooperation is greatly appreciated.
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