HealthCare Partners Medical Group REGISTRATION FORM PATIENT INFORMATION

Transcription

1 New Patient Forms Welcome to HealthCare Partners, a DaVita Medical Group! We thank you for choosing us as your partner in health. To help you save time, we have the following forms available for you to complete and bring to your new patient appointment. As a new HealthCare Partners' patient, please visit MoreCareForPatients.com to learn about all the tools and resources available to you.

2 Today s Date: HealthCare Partners Medical Group REGISTRATION FORM PATIENT INFORMATION Doctor: Patient s Last Name: First: MI: SSN: (Office Use) MRN: New Is this your legal name? If not, what is your legal name? (Former Name): Birth Date: Age: Yes No / / Sex: M F Marital Status Driver s License Number: Street Address: Apt. Number City: State: ZIP Code: Established Home Phone: Mobile Phone: Work Phone: Preference of Contact X Home Work Cell Address*: Race: African-American Asian Caucasian Hispanic Other: Ethnicity: Hispanic, Latin, Spanish Not Hispanic, Latino, Spanish Primary Language Spoken: Religious Affiliation (Optional): Reason for Visit: Referring Physician: Primary Care Physician: How did you hear about our office?: Have you ever been a patient in any HealthCare Partners Facility Before? If yes at which doctor and location Yes No IN CASE OF EMERGENCY Name of local friend or relative (not living at same address): Home phone : Alternate Phone: Relationship to Patient: EMPLOYMENT Employer: Employer Street Address: Employer City: State: Zip: Employer Phone: GUARANTOR INFORMATION Guarantor Last Name: First: MI: SSN: Home Phone: Guarantor Address: Guarantor Employer: Occupation: City: State: Zip: Guarantor Employer Address: Work Phone: City: State: Zip: INSURANCE INFORMATION (PLEASE HAVE THE RECEPTIONIST COPY YOUR INSURANCE CARDS) Primary Insurance Company: Insurance Company Phone: Address: City: State: Zip: Subscriber Name: Subscriber SSN: Subscriber Birth Date: Policy Number: / / Group Number: Effective Date: Relationship to Patient: Subscriber Employer: / / Secondary Insurance Company: Insurance Company Phone: Address: City: State: Zip: Subscriber Name: Subscriber SSN: Subscriber Birth Date: Policy Number: / / Group Number: Effective Date: Relationship to Patient: Subscriber Employer: / / The above information is complete and correct. I authorize treatment of the above named patient. I hereby authorize release of information necessary to file a claim with my insurance company and I assign benefits otherwise payable to me to the doctor group indicated on the claim. All professional services rendered are charged to the patient. The Patient is responsible for all fees, regardless of insurance coverage. In the event of collection proceedings due to lack of payment on my part, I agree to pay any and all collection fees that may be added to my account in order to recover monies due the doctor. A copy of the signature is as valid as the original. Patient Signature Date Guarantor Signature Date Registered By: *You do not have to supply your address, but we are collecting this information because HealthCare Partners is working on ways to use the internet to better communicate with our patients. We do not sell or provide our patients phone numbers, addresses or addresses to any other organization. Like your medical records, all of the information you supply us is held in the strictest confidence. Form: CHI HB4L V

3 PATIENT HISTORY Name: Medical Record Number: Date of Birth: PAST MEDICAL HISTORY: Have you ever been diagnosed with any of the following? PATIENT HISTORY FAMILY HISTORY High Blood Pressure Yes No Yes No Diabetes Mellitus (sugar) Yes No Yes No Angina Pectoris (Chest Pain) Yes No Yes No Heart Attack Yes No Yes No Irregular Heart Beats Yes No Yes No Hypertension Yes No Yes No High Cholesterol Yes No Yes No Blood Clots Yes No Yes No Anemia (low blood count) Yes No Yes No Stroke Yes No Yes No Emphysema / COPD Yes No Yes No Asthma Yes No Yes No Other Breathing Problems: Yes No Yes No Hepatitis Yes No Yes No Hypothyroidism (Low Thyroid) Yes No Yes No Arthritis Yes No Yes No Kidney Stones Yes No Yes No Rheumatic Fever Yes No Yes No Ulcers (Bleeding) Yes No Yes No Cataract Yes No Yes No Glaucoma Yes No Yes No TB / Positive Skin Test Yes No Yes No Mental Health Treatment Yes No Yes No Please Specify: Other, please specify: Cancer: Yes No Yes No What kind: When? What kind: When? What kind: When? Page 1 Revised 07/2016

4 OBSTETRICS AND GYNECOLOGY HISTORY: PATIENT HISTORY Last Menstrual Period: Are you sexually active? Yes No Please specify, if any, irregularities about your period: Child Birth: Abortions, miscarriages, stillbirths, C-sections: WHAT OTHER PROVIDERS DO YOU SEE? or HAVE YOU SEEN IN THE PAST? Name: Name: Address: Address: Phone Number: Phone Number: Specialty: Specialty: Name: Name: Address: Address: Phone Number: Phone Number: Specialty: Specialty: PAST SURGICAL HISTORY: Have you ever had any of the following operations? If so, when? Appendectomy (Appendix) Yes No Date / Year Tonsillectomy (Tonsil Removal) Yes No Date / Year Cholecystectomy (Gallbladder) Yes No Date / Year Hysterectomy (Uterus) Yes No Date / Year Mastectomy (Breast Single or Bilateral) Yes No Date / Year Bypass Surgery (Heart) Yes No Date / Year Cataract Laser Yes No Date / Year Hemorrhoidectomy (Hemorrhoids) Yes No Date / Year Colectomy (Colon Removal) Yes No Date / Year Hernia Repair Yes No Date / Year Anesthesia Complications Yes No Date / Year Other, please specify: Recent ER Visit/Hospitalization? Yes No Date Date: Reason: Page 2 Revised 7/2016

5 PATIENT HISTORY PRIOR EXAMS and IMMUNIZATIONS: DATES DATE OF DOSE (mm/dd/yy) Exam Vaccine Periodic Health Exam Polio EKG Cholesterol Test Chest X-ray Pap Smear Mammogram (Breast Exam) Prostate Exam Colonoscopy Sigmoidoscopy Stool Test (FOBT) Bone Mineral Density Test Diabetic Eye Exam Dental Exam Glaucoma Screening DTP DT or Td MMR HIB Meningitis Mumps Rubella Measles Chicken Pox Tetanus HPV Pneumovax Hepatitis Zostavax Do you need any immunizations today? Yes No CURRENT MEDICATIONS: *Add additional medications to the back of this form Page 3 Revised 7/2016

6 ALLERGIES: PATIENT HISTORY Seasonal Yes No Animals Yes No Medication Yes No Medicine: Type of Reaction: Medicine: Type of Reaction: Medicine: Type of Reaction: SOCIAL HISTORY: Do you smoke? Yes No How much/how long? If stopped, how long ago? Do you drink Alcohol? Yes No How much? If stopped, how long ago? Substance Abuse? Yes No How much? If stopped, how long ago? Do you exercise regularly? Yes No How much? Are you on any special diet? Yes No What diet? Do you need any special assistance? Have you traveled outside of the country recently? Yes No What kind? Yes No What kind? Do you live in more than one location throughout the year? Yes No ***Please remember to provide us with any alternate contact and provider information Do you have Advanced Directives / Living Will Yes No ***Please bring a copy for your provider DATE PATIENT SIGNATURE Page 4 Revised 7/2016

7 AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION Patient Name: MRN: DOB: / / Address: City: State: Zip: Phone:( ) - HealthCare Partners and its entities will not condition treatment, payment, enrollment or eligibility for benefits on providing, or refusing to provide this authorization. This authorizes the following HealthCare Partners clinic(s)/affiliate(s): to disclose information as specified below for the following purpose(s): Personal Legal Insurance purposes Continued medical care Other HealthCare Partners may disclose this information to: Check if same as above (disclosure to patient) Recipient Name: Address: City: State: Zip: Phone:( ) Fax:( ) Copies of records or medical record information within the following dates: to Medical office/clinical records Hospital records All records for specified physician or facility/clinic Records limited to a specific provider or Department: X-ray films X-ray digital images Laboratory results Billing/Claims information Note: Hospital and medical office records may include disclosure of information related to mental health, alcohol/drug, and HIV references contained within those records as part of this authorization. The actual treatment records from restricted or sensitive health information are specifically protected, and will not be disclosed unless you sign below. Mental/behavioral Health records Alcohol/drug dependency treatment records HIV testing results/aids treatment Sexually transmitted disease (STD) Genetic testing/test results Signature: Signature: Signature: Signature: Signature: Media type: Electronic Paper Delivery preference: /secure portal/encrypted US Mail Pickup Duration: This authorization shall remain in effect for one year from the date of signature unless a different date is specified here / / (date). Revocation: Patient or Personal Representative can revoke this authorization upon written request. If you revoke, it will not affect information disclosed before the receipt of the written request. Re-disclosure: Once this health information is disclosed, how the recipient further discloses it may no longer be protected under federal privacy law (HIPAA). California recipients are required to obtain your authorization before disclosing this information. Fee disclaimer: Federal and state laws permit HealthCare Partners to charge a reasonable fee for copying/releasing records. State regulated fees for labor and supplies may apply. You will be notified in advance regarding any fees and payment as required. A copy of this authorization is as valid as an original. I have the right to receive a copy of this authorization. Date Signature If not the patient, print your name and relationship. Verification of Right to Request, if not patient, e.g. legal documentation, required. Office use only: Date received: / / Received by (Print name/initial): /

8 HIPAA CONTACT DISCLOSURE I, (DOB), give Dr. and staff, authorization to disclose my protected health information to the following family, friends and/or caregivers: In the event HealthCare Partners of Nevada may need to give your test results or medical information, may we (check all that apply) Leave a detailed message Call you on your cellular phone, the number is Call you at work, the number is Speak to you directly. ONLY Certain Sensitive health information (treatment / testing) are specifically protected and will not be disclosed outside of the clinic setting without specific authorization. This includes the following: Mental / behavioral Health records Sexually transmitted disease (STD) Alcohol / drug dependency treatment Genetic testing / test results HIV testing results / AIDS treatment allow I allow HealthCare Partners to share sensitive health information as noted above per the communication options checked on this form. (Patient Signature) HealthCare Partners to share sensitive health information as noted above. I (Patient Signature) I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to information shared in the process of treatment, payment or healthcare operations as sighted in the Notice of Privacy Practices. Unless, otherwise revoked, this authorization will expire on the following date, event or condition: If I fail to specify a date this authorization will expire one (1) year from the signature on this form. Date Signature of Patient Date Signature of Guardian or Personal Representative Date Signature of HealthCare Partners of Nevada Employee 2

9 By signing below, I acknowledge that HealthCare Partners and/or a facility operated by, managed by or affiliated with HealthCare Partners or any of its affiliates or subsidiaries has/have My Rights. I have the right to: Get a copy of my paper or electronic medical record File a complaint if I believe my privacy rights have been violated My Choices. Assists in disaster relief efforts Treat you Bill for our services Help with public health and safety issues Do research Comply with aplicable laws Work with a medical examiner or funeral director acknowledgement. ns. Date Property of HealthCare Partners Page 1 of 2

10 (check one): Other (list reasons why acknowledgement was not obtained): Facility Name and Address: Employee Signature Date Property of HealthCare Partners Page 2 of 2