TriValley Primary Care. First Appointment Checklist. Forms: Please download, complete and sign the following forms prior to your first visit.

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Download "TriValley Primary Care. First Appointment Checklist. Forms: Please download, complete and sign the following forms prior to your first visit."

Rosamund Cook
6 years ago
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1 First Appointment Checklist Forms: Please download, complete and sign the following forms prior to your first visit. Patient Registration Form Medical History form or Pediatric History form Financial Responsibility form Acknowledgment of Receipt of Notice form (Notice of Privacy Practices) (minors) Minor Release Form for Minors Please review instructions for completing these forms on the New Patient Forms tab of the TriValley website under Our Patient Services: Forms Disposition: Bring these completed forms with you to your first appointment; Or, drop them off at your TriValley office prior to your first appointment Request transfer of your records to your TriValley office prior to your appointment if possible: Obtain (transfer ) Records In form from your TriValley office s web page. Look for/click on the Transfer Records tab: Click on Our Practice. Click on your office. Or, if completing a transfer records form from your former practice, obtain the address of your TriValley office s Home page. Bring the following with you to your TriValley office at your first appointment: Photo identification (ID) only required for first visit Social Security Number Insurance card(s) please have available and show the receptionist each visit Funds to pay insurance co-payment or deductible cash, check, credit card * Advanced Directive (living will, durable power of attorney), if you have one Order/paperwork regarding custody/guardianship of a minor, if applicable Power of attorney for medical and financial decisions affecting an adult in your care Immunization record (for everyone but especially for minors) Bottles (container) of medications, vitamins and supplements, etc. you are taking Arrive 15 minutes early to finish the registration process. Your photo will be taken. You are encouraged to ask questions of your provider and the staff, as necessary, if you do not understand what is being discussed with you or if something has not been explained to your satisfaction. You are also encouraged to explore the TriValley website. Patient Portal Recommended: If you did not receive this via the Patient Portal, you are strongly encouraged to request access to TriValley s Patient Portal by informing the receptionist that you want access to the Patient Portal. More details are provided via the Patient Portal tab of the TriValley website under Our Patient Services: Welcome! The physicians and staff of TriValley Primary Care welcome you and hope that we exceed your expectations! */ Cards accepted: MasterCard, Visa, Discover (Novus), and Star card

2 Patient Registration Form IF THIS IS AN UPDATE TO PREVIOUSLY SUBMITTED INFORMATION, CHECK HERE To be completed by (or for) each patient. Prepare a new form for updated information. Always include Name and Birth Date on each form. Please print the information requested in the space provided. Thank you. PATIENT INFORMATION PHOTO ID REQUIRED Today s Date: LAST NAME PRIMARY CARE PHYSICIAN FIRST NAME M.I. DATE OF BIRTH PREVIOUS NAME ADDRESS 1 ADDRESS 2 MARITAL STATUS SOCIAL SECURITY NUMBER EMPLOYER Male Female S M D W STATE ZIP EMPLOYER ADDRESS HOME PHONE CELL PHONE EMPLOYER STATE ZIP WORK PHONE EXT EMPLOYMENT STATUS STUDENT STATUS RESPONSIBLE PARTY Check here if self EMERGENCY CONTACT LAST NAME LAST NAME FIRST NAME M.I. FIRST NAME M.I. ADDRESS 1 ADDRESS 1 ADDRESS 2 ADDRESS 2 STATE ZIP STATE ZIP HOME PHONE CELL PHONE HOME PHONE CELL PHONE WORK PHONE EXT WORK PHONE EXT RELATIONSHIP Male Female RELATIONSHIP Male Female PRIMARY INSURANCE (MUST PRESENT CARD) INSURANCE NAME SECONDARY INSURANCE (MUST PRESENT CARD) INSURANCE NAME SUBSCRIBER NUMBER CO-PAY SUBSCRIBER NUMBER CO-PAY INSURED NAME ADDRESS INSURED NAME ADDRESS STATE ZIP HOME PHONE STATE ZIP HOME PHONE Male Female Male RELATIONSHIP TO INSURED GROUP NUMBER RELATIONSHIP TO INSURED GROUP NUMBER Female STATISTICAL DATA: SOLICITED PER FEDERAL MEANINGFUL USE REGULATIONS (ARRA ) ETHNI RACE LANGUAGE REV 4/2011

3 MEDICAL HISTORY PLEASE PRINT THIS INFORMATION BECOMES PART OF YOUR CONFIDENTIAL MEDICAL RECORD PLEASE PRINT Name Type of Work Marital Status Religion Last First MI Education (years completed) Age Today s Date Grade High Vocational College Date of Birth Previous Physician PAST HISTORY (GIVE NAMES AND DATES) PREVIOUS SURGERY FRACTURES INJURIES PREVIOUS HOSPITALIZATIONS MAJOR ILLNESS CHRONIC CONDITIONS FAMILY HISTORY FATHER MOTHER BROTHERS NUMBER SISTERS NUMBER CHILDREN NUMBER AGE IF LIVING AGE AT DEATH NUMBER LIVING IN YOUR HOUSEHOLD : SMOKING PACKS PER DAY ALCOHOL NEVER OCCASIONAL NO. OF YEARS MODERATE HEAVY YEARS STOPPED ALCOHOL PROBLEM PIPE CIGAR CHEW YES NO PRESENT CONDITION OR CAUSE OF DEATH COFFEE CUPS PER DAY EXERCISE TYPE FREQUENCY CHECK IF ANY RELATIVES HAVE HAD DIABETES HEART TROUBLE HEART ATTACK HIGH BLOOD PRESSURE STROKE CANCER TUBERCULOSIS ULCERS ARTHRITIS OBESITY (OVER WEIGHT) EMOTIONAL PROBLEMS THYROID TROUBLE ALCOHOL OTHER: PRESENT WEIGHT LBS USUAL WEIGHT LBS WEIGHT AT AGE 20 LBS WEIGHT CHANGE LAST YEAR GAINED LBS LOST LBS HEIGHT Medications (Prescription, Over-the-Counter, Vitamins, Herbs, etc.) DRUG NAME DOSE DRUG NAME DOSE SPECIFY ANY DRUG REACTION OR ALLERGY: PLEASE COMPLETE OTHER SIDE

4 Past Medical History & Review of Systems Please circle if you have had problems with or are presently complaining of any of the following: 1. High Blood Pressure 14. Pneumonia 27. Unexplained Weight Loss/Gain 40. Skin Disease 2. Diabetes 15. Persistent Cough 28. Hemorrhoids 41. Blood Disorders 3. Cancer 16. T.B. 29. Gall Bladder Disease 42. Venereal Disease 4. Heart Disease 17. Hay Fever 30. Colitis 43. Anxiety 5. Chest Pain/Chest Tightness 18. Abdominal Discomfort 31. Hepatitis or Jaundice 44. Depression 6. Shortness of Breath 19. Indigestion 32. Thyroid Disease 45. Anemia 7. Swollen Ankles 20. Nausea 33. Head or Neck Radiation 46. Alcohol Abuse 8. Palpitations 21. Vomiting 34. Headache 47. Drug Abuse 9. Light-headedness 22. Constipation 35. Kidney Disease 48. Gout 10. Frequent Urination 23. Diarrhea 36. Kidney Stones Rheumatic Fever 24. Blood in Stool 37. Difficulty Urinating Asthma 25. Ulcers 38. Arthritis OTHER: 13. Bronchitis 26. Change in Bowel Habits 39. Low Back Problems Prevention Do you wear seatbelts? No Yes If No, Why Not? Do you wear a bike helmet? No Yes N/A If there is a gun in your home, is it out of children s reach & unloaded? No Yes N/A Do you use drugs? (Marijuana, Cocaine, Crack, etc.) No Yes If yes, explain: Have you ever engaged in any activity which has put you at risk of getting AIDS? Do you wish to be tested for AIDS? No Yes Have you ever worked with chemicals, paints, asbestos, or other hazardous materials? Are you in a relationship in which you have been physically hurt (E.G., slapped, kicked, punched, buised) by your partner? Do you feel afraid of your partner? No Yes Do you have a living will? No Yes Do you have a donor card? No Yes No Yes If yes, explain: No Yes If yes, explain: No Yes FOR WOMEN ONLY Number of Pregnancies Date Last Menstruated? Number of Miscarriages Period every Days. Birth Control Method (if any) Any Menstrual Problems? Yes No Date of Last Pap Smear Heavy Periods Check if you have had: Irregular Periods D&C Toxemia Infrequent Periods Hysterectomy Cesarean sec. Painful Periods Difficulty with pregnancy Spotting With labor Discharge With delivery

5 Financial Responsibility Policy Must be read and signed by all adults and emancipated minors. Please read each item carefully. Ver Patient Name: Date of Birth: Payment Policy: It is the policy of TriValley Primary Care to require payment in full on the day of service. This includes health plan co payments, co insurances, deductibles, and charges for non covered services. Responsible Party (Self Pay): I agree that I am responsible to pay for services rendered if I do not have insurance that covers such services, or if I must file a claim to my insurance company. Payment is due, payable, and expected on the day of service. Responsible Party (Insurance Coverage): I agree to pay on the day of service co insurances, co payments, and deductibles related to services rendered or to be rendered; as well as charges for non covered services, except as limited by law or contract. Furthermore, I agree to pay within thirty (30) days following notice to me that: (1) my coverage has denied payment; or, (2) my insurer has not paid within 60 days of the last claim submitted; or (3) there is a balance remaining after insurance payment, except as limited by law or contract. Failure to Pay: I understand that if I fail to pay any balance on my account within thirty (30) days of billing, my account will be delinquent and may be referred to an attorney or collection agency for collection. In the event of such default and referral for legal action, I agree to (i) pay interest on the delinquent account balance at the rate of 1.5% per month from and after the date of default through the date such balance is paid in full and (ii) pay all costs of collection, including reasonable attorneys fees and expenses, collection agency commissions, and court costs. Payment in full of any delinquent balance is required prior to future appointments. The provisions of this section apply to all current balances for which I am responsible that remain unpaid 30 days after the date I sign this document. Returned checks will be assessed a fee of not less than a $15. Minors, Dependents, and Wards: If the above named patient is a minor, dependent or ward, I represent that I am the parent or guardian of this patient and I agree to be responsible for payment for services rendered to this patient not otherwise covered by insurance or a health plan except where limited by law, court decree or contract. In the former case then, the terms of this policy apply to me as if I had been rendered the service. I agree that account credits in this patient s name may be applied to any account balance for which I or my spouse may be responsible, except where limited by law, court decree or contract. Transfer of Account Credits/Small Balance Forgiven: I agree that account credits in my name may be applied to any account balance for which I or my spouse may be responsible, except where limited by law, court decree or contract. I hereby disclaim a patient account credit of less than $2.00 in recognition that TriValley Primary Care shall forgive a patient account balance that I owe of less than $2.00. Note: By contract, $2.00 co pays (and all other co pays) must be paid. Release of Information: I authorize TriValley Primary Care to release any medical and non medical information 1) to my insurance company (or Medicare, or health maintenance organization, or a fiscal intermediary), needed to determine benefits, or the benefits payable for related services; 2) to my attorney as requested, and 3) to another physician's office, other practitioner, or diagnostic/treatment facility needed to support my care. This authorization will remain in effect until revoked by me in writing. Assignment of Insurance Benefits: I hereby assign all medical benefits, to include major medical benefits to which I am entitled; private insurance, and benefits from any other health plans, to TriValley Primary Care. This assignment will remain in effect until revoked by me in writing. My signature indicates that I have read the above statements, and fully understand and accept (and intend to be legally bound to) the terms and conditions as presented. A photocopy of this Agreement, including insurance benefit assignment, is as valid as the original, and therefore, may be used in lieu of the original. Date: Signature Patient's Signature (SEAL) or Parent/Legal Guardian/Responsible Party/Guarantor (SEAL)

6 Medicare Assignment of Benefits Medicare patients: Please read, complete and sign the form(s) below: Medicare Statement: Beneficiary s name: Health Insurance Claim Number: (Lifetime Assignment Authorization) I request payment of authorized Medicare benefits be made either to me or on my behalf to TriValley Primary Care for services furnished me by TriValley Primary Care. I authorize 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 service. Date: Beneficiary Signature If you have a Medigap policy, please read and sign the following form: Medigap Statement: (All Medicare Beneficiaries with a Medigap policy, please complete this section, too): Beneficiary s name: Medigap Insurer (Plan Name): I request payment of authorized Medigap benefits be made either to me or on my behalf to TriValley Primary Care for any services furnished me by TriValley Primary Care. I authorize any holder of medical information about me to release to the Medigap insurer shown above or on file and its agents any information needed to determine these benefits or the benefits payable for related service. Date: Beneficiary Signature Thank you for choosing a TriValley Primary Care physician.

7 Acknowledgment Of Receipt Of Notice IF THIS IS AN UPDATE TO PREVIOUSLY SUBMITTED INFORMATION, CHECK HERE I acknowledge that I have been provided TriValley Primary Care s Notice of Privacy Practices. Name of Patient (Please print) (for identification) Date of Birth (or personal representative) Signature of Patient Date of Receipt If signed by personal representative, please complete information below: Name of personal representative (Please print) (or other authority) Relationship to patient Alternate Communications Means or Location (See Note, below) Patients (or their personal representatives) may request alternate means to communicate with them or an alternate location. If TriValley incurs an expense to effect the alternate means/location, it must be borne by the patient, or it shall not be approved. Important: Two-way communication via is not possible, and will not be allowed. TTY/TDD communication is available only via a relay service unless the patient pays for the device(s). I hereby request that I be contacted as follows instead of by means of the information in my chart: Alternate Telephone Alternate Facsimile Alternate Mailing Address Not approved Not approved Authorization for Voice Mail Use Optional I authorize TriValley Primary Care staff to leave protected health information on an answering machine/voice mail at the following number: (void if blank). (or personal representative, as above) Signature of Patient Declaration of Personal Representative (See Note, below) The following is my personal representative for health matters. Important: Information passed to the personal representative is equivalent to communicating with the patient. Name Relationship Check here if continued on back.. Signature of Patient: Or Power of Attorney on File Date (office signature): NOTE: It is the patient s responsibility to keep this information current. A Community of Physicians for the Community Lower Salford*Pennridge*Upper Perkiomen*Franconia*Lansdale*Western Bucks*Indian Valley Version

Patient Registration Form

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: Email: Race: o Caucasian o Hispanic o Bi-racial