NEW PATIENT INFORMATION

Transcription

1 PATIENT INFORMATION NEW PATIENT INFORMATION LAST NAME FIRST NAME PREFERRED NAME MIDDLE INITIAL DATE OF BIRTH SS# GENDER PRIMARY LANGUAGE MAILING ADDRESS CITY/STATE ZIP CODE CELL PHONE HOME PHONE WORK PHONE CIRCLE ONE: Y/N ADDRESS EMPLOYER RACE/ETHNICITY HISPANIC ORIGIN? EMERGENCY CONTACT NAME PHONE NUMBER RELATIONSHIP TO PATIENT INSURANCE INFORMATION INSURANCE COMPANY SUBSCRIBER NAME MIDDLE INITIAL GROUP NUMBER SUBSCRIBER NUMBER INSURED DATE OF BIRTH SECONDARY INSURANCE SUBSCRIBER NAME MIDDLE INITIAL GROUP NUMBER SUBSCRIBER NUMBER INSURED DATE OF BIRTH PREFERRED PHARMACY PHARMACY NAME LOCATION/ADDRESS PHONE NUMBER HOW DID YOU HEAR ABOUT BRIO?

2 P A T I E N T P R I V A C Y F O R M PATIENT S NAME DATE OF BIRTH SHARING INFORMATION Please list who has permission to receive information from Brio Internal Medicine other than the patient. Name of person that has permission to receive the above patient information Relationship to patient Name of person that has permission to receive the above patient information Relationship to patient COMMUNICATION I authorize Brio Internal Medicine to provide information regarding: Check ONLY ONE All information including appointments, general information, updates, billing, etc. Appointment information ONLY On my: Cell Phone Number Home Phone Number Brio will send appointment reminders, healthcare updates, & newsletters, via . Please check here if you DO NOT wish to receive these s. Please check here if you DO NOT wish to receive s about aesthetic services offered at Brio. RIGHTS OF THE PATIENT I understand that I have the right to revoke this authorization at any time by sending notification to Brio Internal Medicine 9 Hawthorne Park Ct. Greenville, SC I understand that a revocation is not effective in cases where the information has already been used or disclosed, but will be effective going forward. I understand that information used or disclosed as a result of this authorization may result in re-disclosure by the recipient and may no longer be protected by federal or state law. Information received by this office is for our own use and will continue to be protected by our Privacy Policy. I understand that I have the right to inspect or copy the protected health information disclosed as described in this document. I can do this by written notification to: Brio Internal Medicine 9 Hawthorne Park Ct. Greenville, SC I understand that I have the right to refuse to sign this authorization: I have read and received a copy of the Notice of Privacy Practices for Brio Internal Medicine. Signature Date Relationship if not patient

3 RESPONSIBLE PARTY ACKNOWLEDGEMENT RESPONSIBLE PARTY The Responsible Party is the person who is FINANCIALLY responsible for the patient s account(s) and who will receive all account statements to their address. By signing, I underdstand that I am the responsible party and will adhere to the requirements outlined in the policies provided to me for the following patient(s) as well as future patients registered in my name at Brio Internal Medicine. If you are 18 or older, you are your own responsible party. NAME OF RESPONSIBLE PARTY (Please Print) RELATION TO PATIENT(S) WAIVER OF LIABILITY Responsible Party Initials I understand that the treatment/service from the providers and physicians at Brio Internal Medicine for the patient(s) listed above may not be a covered treatment/service or may not be covered at 100%. I agree to be personally and fully responsible for any balance due. PAYMENT POLICY Responsible Party Initials Brio Internal Medicine is committed to providing the best treatment for our patients. Our pricing structures are representative of the ususal and customary charges for our area. Thank you for adhering to our payment policy. Signing below indicates that you are the responsible party which means you are financially responsible for this patient and have read and understand the payment policy and agree to abide by its guidelines. RESPONSIBLE PARTY ACKNOWLEDGEMENT I understand that I am the responsible party for the patient(s) listed above and any future patient(s) registered in my name at Brio Internal Medicine and I agree to the terms of the Waiver of Liability and Payment Policy. I have been given a copy for review and I am aware of the availability of these documents in the office of Brio Internal Medicine as well as online at Signature of Responsible Party Date NEW PATIENT APPOINTMENTS I understand that the typical new patient visit is a consultation in which your new provider will take the time to get to know you personally as well as your medical issues. Devoting this extra time at your initial visit allows us to gain a solid foundation of your health information that will result in us providing you with the highest quality care. After your initial consultation, we will together determine when labwork, additional testing, and/or a physical are needed. Signature of New Patient Date

4 Controlled Substances Policy of Brio Internal Medicine Patient Name: SSN: Your physician believes that a drug, which is a controlled medication, is indicated for your current or possible future pain relief or similar medical issue. Controlled medicine can be dangerous and habit forming. These medicines must be taken only as prescribed by your doctor. Please read this policy thoroughly and ask questions you may have. If you are in agreement and fully understand the benefits and risks sign and date below. I understand that the medication I am being prescribed may cause addiction, but my physician feels it is necessary for treatment of my condition: I agree to accept this risk. I agree to take this medication only as prescribed by my physician. I agree to attend all scheduled appointments with my physician or PA. I understand refills will not be given early. After initiation of treatment, the patient will follow up every 90 days prior to the issuance of refills of medication prescribed for the treatment. The patient will not be permitted to schedule past 90 days unless extenuating circumstances. Merely scheduling a follow-up appointment does not satisfy this requirement. Medication prescriptions cannot be mailed, faxed or called into the pharmacy. The prescription must be picked up at Brio Internal Medicine by the patient and picture ID must be shown. I will not seek controlled substances from any other physician. I understand that it is illegal for me to seek controlled substances from more than one doctor at the same time. I understand that these medications are for my personal use only and only for the relief of the pain. I agree not to share my medications with somebody else. I agree to keep my medications away from children and not to share my medications with family or friends. I agree to safely dispose of my medications if necessary. I understand that it is illegal to give or sell my medications to others. I agree to not use any illegal substances, including but not limited to, marijuana, cocaine, or any other street drugs. Patient initial: Scanned by: Date:

5 I understand that is illegal for me to use medications prescribed to other people. I understand that I am responsible for my own medication. Lost or stolen medications will not be replaced. Brio Internal Medicine is to be promptly notified in the event that the medication prescription or prescribed medication is lost, stolen or rendered unusable. Such an occurrence will be thoroughly evaluated by the physician prior to the issuance of a replacement prescription. I give up the right to privacy in this matter. The physician or her staff may talk with other medical doctors, pharmacists or family members to confirm appropriate medication use. I agree to random drug screening test when ordered by my physician, and I will be responsible for payment of the test. If requested of me, I agree to bring my pill bottle(s) to the office for the purpose of a pill count. I understand that I may obtain my controlled substances from only one pharmacy, and I agree to provide the following information and update Brio Internal Medicine of any changes. I understand these medications may interfere with my ability to drive and/or operate heavy machinery. I agree to immediately notify my physician if I experience any symptoms or side effects. Give your current pharmacy information below. Advise of updates on each visit. You must provide a daytime telephone number where you can be reached during normal business hours. I have read the above Controlled Substance Policy. I understand that failure to follow the above guidelines after one occurrence may result in being discharged from Brio Internal Medicine. Patient Signature Date Witnessed by: Home: Cell: Work: Pharmacy Name: Phone#/Location Patient initial: Scanned by: Date:

6 Patient Name: DOB: LABS. Did you know? At Brio Internal Medicine we pride ourselves in offering the best healthcare possible to our patients. By doing this, our providers may at times desire for you to have labs drawn, whether for preventative or diagnostic care. Although we feel like these labs are a very important part of your healthcare, these labs may not be covered by some insurance companies. In the event that your labs are not covered by your insurance company you will receive a bill from Brio Internal Medicine, LabCorp, or both. For any lab bill you receive from Brio Internal Medicine that is not covered by insurance, you will be given a 20% discount on that lab bill (this does not include bills from LabCorp). By signing this form, you are accepting responsibility for any uncovered expenses associated with these labs. Patient Signature Date

7 Patient Center Medical Home FACT SHEET What is a patient centered medical home? The Medical Home is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care. At Brio, we understand the importance of having a consistent medical home. This means that we work together as a team to provide the most comprehensive care for every patient. Our team includes our Brio providers, nurses, medical assistants, and staff, as well as other external referred resources and specialists, and the most important member the patient! We act as a central hub of information and care to ensure that all areas (physical, psychological, emotional, and developmental, etc.) are being addressed and monitored over the long term. This is a proven way to detect any areas of concern as well as build trust and establish a long-term relationship with the patient as part of the Brio family. As a Medical Home we will also help find needed information and resources, such as information about: We will also: Specialists Health conditions/latest treatments Home care, equipment, and vendors Supports and respite services for your family Other key local services Take care of every patient when he or she is sick or well and help promote wellness Help plan the patient s care and/or set goals for care, now and for the future Talk with patient and family about any testing or treatment that is needed Work with patient and family and other care providers to coordinate care For more information please reference this website: Link to video about Patient Centered Medical Home:

8 P R I V A C Y N O T I C E HIPAA POLICY STATEMENT Brio Internal Medicine P.A. s Privacy Notice to Patients THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED BY BRIO INTERNAL MEDICINE AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY. Effective Date: October 5, 2015 Under the HIPAA Privacy regulations, Brio Internal Medicine and all similar health care providers are required by federal law to maintain privacy of your protected health information (PHI) and will abide by the terms in the Privacy Notice. Please be advised that Brio Internal Medicine may use your PHI in rendering treatment. For example, we are permitted to use your PHI in providing you with medical care/treatment when you visit our office or when we treat you in a hospital or nursing facility. Under federal law, we may disclose your PHI to you or we can disclose your PHI to third parties for treatment. For example, if we refer you to a specialist, we will forward your medical information to such specialists. We can disclose your PHI for payment purposes. For example, we will disclose your PHI to your insurance provider, your employer, Medicare, Medicaid, or other parties responsible for providing you with health insurance coverage in order for Brio Internal Medicine to be reimbursed for our services rendered to you. We will also use or disclose your PHI for health care operations. For example, we may use your PHI when we engage in quality assurance and medical chart reviews, which are part of our health care operations. We may also disclose your PHI, when required by the Secretary of the US Department of Heatlh & Human Services. Unless disclosure is requried under federal/state law, or certain other exceptions, including law enforcement, we are prohibited from disclosing your PHI without your authorization. Our practice may use or disclose your PHI in accordance with the specific requirements of the HIPAA rules without Brio Internal Medicine needing to obtain your authorization if the information is: 1. required by law 2. required for public health purposes 3. required disclosures about victims of abuse, neglect or domestic violence 4. required by health oversight agency for oversight activities authorized by law 5. required in the course of any judicial or administrative proceeding 6. required for a law enforcement prupose to a law enforcement official 7. required by a coroner or medical examiner 8. required by an organ procurement organization for research, and 9. necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. Additionally, if you are a member of the armed forces, Brio Internal Medicine is permitted to disclose your PHI without consent if deemed necessary by appropriate military command authorities to assure an appropriate military mission. We may also contact you via mail or phone to remind you of appointments with our office or to discuss treatment alternatives. If, for any reason, you do not wish to be contacted via mail or phone, our office personnel will note your request in your chart. In the event our practice wishes to disclose your PHI to another entity besides those referenced above, we are required to obtain your authorization. We would seek to obtain your authorization if Brio Internal Medicine decided to release your PHI for reasons other than treatment, payment, or for our practice s operations. For example, if we desired to participate in outside research or a drug study, we would need your written authorization prior to being permitted to release your PHI to such outside research facility or drug manufacturer. If you provide us with an authorization, you have the ability to revoke such authorization at any time by sending Brio Internal Medicine a written revocation. However, if we have already released such information pursuant to your prior authorization, the revocation will be effective for all future disclosures. Please be further advised that you have the ability to access, obtain a copy, inspect and request amendment to your medical information that we maintain. Additionally, if you desire, Brio Internal Medicine can provide you with an accounting of all disclosures for treatment, payment or healthcare operations pursuant to authorization. If you have a dispute with our practice regarding the use of your PHI or a disclosure by Brio Internal Medicine and believe that your primary rights have been violated, please contact Brio Internal Medicine to file a complaint or you may contact the Secretary of Health and Human Services. We welcome feedback from our patients through our website contact us form or via at info@briointernalmedicine.com. Please understand that Brio Internal Medicine will not retaliate against you in any way for filing a complaint. Lastly, please be advised that you have the right to designate a personal representative or request restrictions on certain uses and disclosures of your PHI to carry out treatment, payment or healthcare operations or disclosures by Brio Internal Medicine of your PHI to a family member, relative, or a close personal friend. However, we are not required by federal law to agree to your requested designation or restricition. If you request a copy of your PHI, you also have the ability to request that we send it to an alternative location (different address) and by alternative means. Additionally, if you have received this notice in an electronic form and you would like a paper copy, please contact Brio Internal Medicine s Privacy Contact. Brio Internal Medicine reserves the right to amend this notice as revised. Notices will be posted on our website ( and in our offices and provided to you upon your request. Thank you and if you have any questions, please contact Brio Internal Medicine at

9 PAYMENT POLICY P A Y M E N T P O L I C Y PROOF OF INSURANCE: All patients must complete our patient information forms before seeing the provider. We must obtain a copy of your current, valid insurance card for proof of insurance. If you fail to provide us with the correct insurance information at the time of service, you may be responsible for the balance of your claim. COPAYMENTS AND BALANCES DUE: All copayments and balance dues must be paid at the time of service. This arrangment is part of your contract with your insurance company. Failure on our part to collect copayments from patients can be considered fraud. Please help us in upholding the law by paying your copayment at each visit. CLAIM SUBMISSION: We will submit your claims to your insurance provider and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not a party to that contract. MONTHLY BILLING STATEMENT: After your insurance company pays Brio Internal Medicine, you will receive a monthly billing statement, which indicates your balance due and/or deductible due. These amounts are payable to Brio Internal Medicine. The balance due is payable in full within 10 days of receipt of the monthly billing statement. If you have questions about your account please call INSURANCE: We participate in most insurance plans. If you are not insured by a plan we do business with or do not have insurance, payment in full is expected at each visit. If you are insured by a plan we do business with but don t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Brio Internal Medicine will file to your primary and secondary insurance. COVERAGE CHANGE: If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If we cannot verify active coverage, the balance will automatically be billed to you. NON-PAYMENT: Partial payments will not be accepted unless otherwise negotiated with the billing department. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you may be discharged from this practice. You will be responsible for any collection or legal cost associated with collecting your account. If this is to occur, you will be notified that you have 30 days to find alternative medical care. During that 30 day period, our providers will only be able to treat you on an emergency basis. MISSED APPOINTMENTS: In order to achieve the best appointment availability for our patients, we have a policy for missed appointments. There will be a $50 charge added to the account for a missed appointment. Three missed appointments within a 12 month period will result in eligibility for discharge from the practice for the family. We understand the potential for unforeseen circumstances that can arise that may cause a late arrival or missed appointment. If this happens, please call us as soon as possible so we can change your appointment status accordingly and make it available for another patient. If the first New Patient Appointment is missed, the individual will no longer be eligible to stay with Brio as a patient of the practice. CANCELLATIONS: Our policy is to charge $25 for previously scheduled appointments that are canceled less than 24 hours prior to their scheduled time/date. These charges will be your responsibility and billed directly to you, and not your insurance company. Please help us serve you better by keeping your regularly scheduled appointments. NON-COVERED SERVICES: Please be aware that some-and perhaps all-of the services you receive may be non-covered or not considered reasonable or necessary by your insurance company. Since all insurance plans are different, please contact your insurance company or HR department for detailed information about what is covered or not covered including annual physical maximums, immunizations, etc. You will be billed and responsible for all non-covered services. We charge a $15 fee in order to fill out forms that are brought into the office outside of an appointment. FORMS OF PAYMENT: Brio Internal Medicine accepts payments by cash, check, money orders, Visa, MasterCard, American Express, Discover, and debit cards bearing these logos. Payment is expected at time of service.

10 M E D I C A L H I S T O R Y PATIENT S NAME DATE OF BIRTH MEDICAL INFORMATION PERSONAL MEDICAL HISTORY-Please circle existing medical problems. High Blood Pressure Diabetes Cholesterol Problems Stroke Reflux/Heartburn Anemia Heart Disease Menopause Osteoarthritis Allergies Osteoporosis Sinus Disease Cancer (Type ) Psoriasis Rheumatiod Arthritis Seizures Hypothyroidism Liver Disease Kidney Disease Migraines Headaches COPD/Asthma Diverticulosis Depression Irritable Bowel Syndrome Anxiety Bipolar Eczema PREVENTATIVE CARE-Please list the date of most recent procedures and immunizations. Pap Smear Tdap Mammogram Pneumovax Bone Density Prevnar Colonoscopy Zostavax SPECIALISTS-List any specialist you are currently seeing and the reason. Please circle any symptoms you have had recently. Significant Weight Loss/Gain Fever/Chills Night Sweats Excessive Fatigue Insomnia Loss of Appetite Headaches Blurred Vision Glasses/Contacts Double Vision Ringing in Ears Hearing Loss Sinus Drainage Sore Throat Hoarseness Chest Pain Palpitations Leg Swelling Short of Breath Cough/Sputum Wheezing Severe Heartburn Difficulty Swallowing Nausea Vomiting Constipation Diarrhea Bloody Stools Black Stools Abdominal Pain Painful Urination Blood in Urine Difficulty Voiding Breast Change/Discharge Menstrual Changes Hot Flashes Loss of Balance Dizziness Blackouts Prolonged Numbness Seizures Sexual Problems Depression Anxiety Tremor Rashes/Mole Changes Joint Pains/Swelling Easy Bruising

11 M E D I C A L H I S T O R Y PATIENT S NAME DATE OF BIRTH SOCIAL MEDICAL HISTORY Yes Yes Yes Yes Yes No Do you currently smoke or use tobacco products? If yes, how many per day? No Have you smoked or used tobacco products in the past? If yes how many per day? How many years have you smoked? No Do you drink caffeinated beverages? If yes, what type, how often/much? No Do you drink alcohol? If yes, what type, how often/much? No Do you exercise regularly? If yes, what type? How often and how long? SURGICAL & HOSPITALIZATION HISTORY-List all hospital admissions and operations. 1. Year 2. Year 3. Year 4. Year 5. Year 6. Year Did you have any problems with anesthesia? If yes, please describe: ALLERGIES-Please list all medication, environmental, and any other allergies. MEDICATIONS-Please list all medications you are currently taking. MEDICATION NAME DOSAGE FREQUENCY

12 F A M I L Y M E D I C A L H I S T O R Y PATIENT S NAME DATE OF BIRTH MEDICAL INFORMATION FAMILY MEDICAL HISTORY-Has anyone in your close family experienced the following: High Blood Pressure No Yes Who High Cholesterol No Yes Who Heart Disease No Yes Who Stroke No Yes Who Migraines No Yes Who Seizures/Convulsions No Yes Who Diabetes No Yes Who Bleeding/Blood-clotting Disorder No Yes Who Allergies No Yes Who Asthma No Yes Who Thyroid Problems No Yes Who Osteoporosis No Yes Who Pyschiatric Disorder/Mental Illness No Yes Who Alzheimer s/dementia No Yes Who Cancer-type: No Yes Who Other: No Yes Who Please list any other medical history that you consider important to share:

13 MEDICAL RECORDS RELEASE AUTHORIZATION Last Name First Name Date of Birth PLEASE RELEASE ALL MEDICAL RECORDS FOR TRANSFER OF PATIENT CARE FROM: Name of Practice Phone Fax TO: Name of Practice Phone Fax Please release a copy of all medical records, including but not limited to: all records, progress notes, operative notes, laboratory/x-ray results, and diagnostic tests. This authorization is valid from the date of this document and will expire 180 days after that date. BY MY SIGNATURE I AUTHORIZE RELEASE OF ALL MEDICAL RECORDS and agree that I have been offered a copy of this document as it is available in the office of Brio Internal Medicine as well as online at I am aware that some of this information may contain sensitive material with regard to alcohol and drug abuse, sexually transmitted diseases, behavior or mental health, HIV/AIDS, hepatitis, or other communicable diseases. Patient Signature: Date: Rights of the Patient: I understand that I have the right to revoke this authorization at any time by sending notification to Brio Internal Medicine 9 Hawthorne Park Ct. Greenville, SC I understand that a revocation is not effective in cases where the information has already been used or disclosed, but will be effective going forward. I understand that my treatment, payment, enrollment, or eligibility is not dependent on whether or not I sign this authorization. I understand that information used or disclosed as a result of this authorization may result in re-disclosure by the recipient and may no longer be protected by federal or state law. Information received by this office is for our own use and will continue to be protected by our Privacy Policy. I understand that I have the right to inspect or copy the protected health information disclosed as described in this document. I can do this by written notification to: Brio Internal Medicine 9 Hawthorne Park Ct. Greenville, SC I understand that I have the right to refuse to sign this authorization. BRIO INTERNAL MEDICINE 9 Hawthorne Park Court, Greenville, SC Phone: Fax: