Your appointment is scheduled for at. Please complete this form and bring it with you at the time of your appointment. Last Name: First Name: M.I.

Transcription

1 Dear Patient: The following questions are designed to obtain some general information about your medical problems. As a result of answering these questions more time will be available for detailed discussion of your major medical problems. Please complete all pages. Your appointment is scheduled for at. Please complete this form and bring it with you at the time of your appointment. PATIENT INFORMATION (Please print or type) Last Name: First Name: M.I. Preferred Name: Date of Birth: / / Age: Address: City: State: Zip Code: Sex: M F Transgendered: M F address: Home Phone: Cell Phone: Marital Status: Single Married Partner Widowed Separated Divorced Language Preference: English Portuguese Spanish Russian Other: Race (insurance purposes): White Black Native American Asian Other: Decline to report Ethnicity (insurance purposes): Hispanic or Latino Not Hispanic or Latino Decline to report Preferred Pharmacy (name and address): Present Employer: Employer s Address: Employer s Phone: Years at employer: Position /Title: Spouse s Name: Spouse s Date of Birth: / / Spouse s Employer: Spouse s Employer s Address: Spouse s Employer s Phone: Spouse s Title: Nearest Friend or Relative Not Living With You: Address: Phone #: Relationship: 7/2015

2 Number of Children: Do you live alone? Yes No Person responsible for payments of your professional fees: Myself Other Person (Indicate name of other person, address, and telephone number): Referred by: List the names of all doctors you have seen in the last two years and the reasons why you have seen the doctor(s): INSURANCE INFORMATION Do you have hospitalization insurance? (Check one) Yes No Is your illness covered by Workers Compensation Insurance? Yes No If you have insurance coverage, please indicate the type(s): Medicare Medicaid Blue Cross/Blue Shield Pilgrim United Health Plans (Ocean State).... Health Advantage Other Insurance Coverage (List below): Medicare Number: Medicaid Number: Contract Number: Contract Number: Contract Number: Contract Number: Name of company or companies and contact numbers: MAJOR MEDICAL PROBLEM(S) OR QUESTION(S) Describe briefly the major medical problem(s) or question(s) that bother you the most: List below all the medications that you take regularly or have taken regularly in the past month (including aspirin products, vitamins, birth control pills, etc): Drug How often you take the Length of time you have Drug Strength drug each day taken the drug

3 Patients 65 or older, please answer the following questions: Have you had two or more falls in the past 12 months? Yes No Have you had any falls with injury in the past 12 months? Yes No Are you afraid that you will fall? Yes No Do you use a cane, walker, or other device to help you walk? Yes No Do you need medication refills today? Yes No If yes, please list below: Are you having problems affording your medications? Yes No PAST MEDICAL HISTORY Place a check mark in the box next to the illness or illnesses that you currently have or have had in the past: Anemia Glaucoma Liver disease Arthritis Gout Nervous stomach Asthma Heart attack Rheumatic fever Cancer Heart trouble Spastic colon Cirrhosis Hepatitis Stomach ulcers Depression or other mental illness High blood pressure Sugar diabetes Emphysema Kidney infections Thyroid trouble Gallstones Kidney stones Yellow jaundice Serious past injuries (describe the type of injury and approximate dates of occurrences): HEALTH MAINTENANCE When was your last tetanus booster? Have you received a flu (influenza) vaccine? When was your last eye exam? Have you ever had your hearing tested? Pneumonia vaccine? When was your last dental exam? Do you wear a seatbelt? WOMEN: Have you had a Pap smear in the last two years? Do you perform monthly breast self-examination? Have you had a change in your menstrual cycle? Have you ever had a mammography (breast X-ray)? Obstetrical History: Number of pregnancies: Number of deliveries:

4 Allergies: List any drug allergies (if any, briefly describe the reaction): Are you allergic to antibiotics (such as penicillin or sulfa)? Yes No Previous surgery (place a check mark in the box next to the type of surgery you have had and indicate the approximate date of surgery): Appendix Breast surgery Eye surgery Gallbladder Hemorrhoids Hysterectomy Open heart surgery Stomach or colon surgery Other surgery: Previous hospitalizations (other than surgery): Hospital Year Reason

5 FAMILY HISTORY Is your mother living? Yes No (cause of death and age at death ) Is your father living? Yes No (cause of death and age at death ) Have any family members, either living or dead, ever had any of the following diseases? If yes, place a check mark in the box next to the illness. In the space next to the illness put the name of the family member or the initial code letter of the family member that had the illness. The following code initials may be used: Mother [M] Brother [B] Aunt [A] Father [F] Child [C] Uncle [U] Sister [S] Grandparent [GP] Cousin [CS] (For example: If one of your grandparents and a cousin had tuberculosis: tuberculosis GP, CS ) (continued on next page) Family Member Alcoholism Cancer Breast cancer Colon cancer Ovarian cancer Colitis Diabetes Family Member Heart Attack At what age(s)? High blood pressure Kidney disease Osteoporosis Tuberculosis Other SOCIAL HISTORY AND HABITS Do you drink alcoholic beverages (wine, beer, liquor etc)? Yes No (If NO, skip to questions on smoking) Have you ever tried to cut down the amount of your drinking? Yes No Do you get annoyed when others comment on your drinking? Yes No Do you ever feel guilty about your drinking? Yes No Do you ever drink first thing in the morning? Yes No Place a check mark in the box that most closely approximates how much cigarette smoking you average each day: none less than a half pack more than a half pack but less than one pack one to two packs more than two packs Place a check mark in the box that closely approximates how many years you have been a cigarette smoker: 1-5 years 6-10 years years years more than 25 years Have you ever tried to quit smoking? Yes No

6 Place a check mark in the box that most closely approximates how much of the following beverages you drink each day: Coffee: None 1-3 cups or glasses 4-10 more than 10 Tea: None 1-3 cups or glasses 4-10 more than 10 Colas: None 1-3 cups or glasses 4-10 more than 10 Do you exercise regularly? Yes No Are you sexually active? Yes No What method of contraception do you use? Birth control pill condom diaphragm Other: Have you ever been diagnosed with a sexually transmitted disease? Yes No Place a circle around the highest level of education you obtained in school none Masters PhD Other : elementary high school college How do you prefer to learn new information? (circle one) Doing / Demonstration Reading / Written Materials Watching / Video or Presentations REVIEW OF SYMPTOMS What is your usual weight? What was your approx. weight one year ago? What is your present weight? YES NO 1. Have you lost five pounds or more in the last two months? [ ] [ ] 2. Are you frequently troubled with coughing? [ ] [ ] 3. Have you ever coughed up blood or blood streaked sputum? [ ] [ ] 4. Do you frequently get short of breath? [ ] [ ] 5. Have you recently had repeated episodes of chest pain? [ ] [ ] 6. Are you frequently bothered by abdominal pain? [ ] [ ] 7. Do you frequently have heartburn or indigestion or difficulty swallowing? [ ] [ ] 8. Are you frequently bothered by nausea or vomiting? [ ] [ ] 9. Have you ever vomited blood? [ ] [ ] 10. Have you ever passed blood in or on your stools? [ ] [ ] 11. Are you frequently bothered by diarrhea? [ ] [ ] 12. Are you frequently bothered by constipation? [ ] [ ] 13. Do you experience pain or burning when you urinate? [ ] [ ] 14. Do you have difficulty getting your urinary stream started? [ ] [ ] 15. Do you awaken frequently during the night to urinate? [ ] [ ] 16. Do your joints frequently bother you? [ ] [ ] 17. Do you have frequent headaches? [ ] [ ] 18. Have you ever had a stroke, convulsion, or paralysis? [ ] [ ] 19. Do you have recurrent feelings of anxiety or fear? [ ] [ ] 20. Have you recently felt sad, depressed, or down in the dumps? [ ] [ ] 21. Have you recently had crying spells or felt like crying for no particular reason? [ ] [ ] 22. Do you have difficulty falling or staying asleep? [ ] [ ]

7 ASSIGNMENT OF INSURANCE BENEFITS Except where my plan provides for automatic payment of benefits to the provider of services, I authorize payment of benefits, otherwise payable to me, for services rendered by Coastal Medical, Inc. I UNDERSTAND THAT I AM ULTIMATELY RESPONSIBLE TO THE PROVIDER FOR CHARGES NOT COVERED BY MY BENEFIT PLAN. / / Signature Date Have you designated anyone to function as your legal guardian or decision maker (by completing a living will or power of attorney form) in the event that you are unable to make decisions regarding your health care? If YES, please write the name, address, phone number, and relationship of that individual: Name: Address: Relationship to you: Phone: If NO, please ask your physician about this. I have reviewed the information in this questionnaire and verified that the information is accurate. Patient s signature If questionnaire was completed by someone other than the patient: Relationship to patient: Patient s signature PHYSICIAN S NOTES:

8 Patient Financial Policy It is the policy of Coastal Medical, Inc. to provide you with information related to our billing processes and your financial responsibilities as our patient. This policy helps us in our mission to provide you with exceptional medical care in the most cost-effective manner. Things to bring with you to each visit: 1) Current insurance card(s) 2) Photo identification 3) Your preferred method of payment for any cost shares due at the time of service Insurance Companies: Participation and Billing 1) While Coastal Medical, Inc. participates with the majority of third-party insurance plans available in our area; it is your responsibility to verify that your physician is currently participating with your plan and that you have obtained all necessary referrals PRIOR to your scheduled appointment. You are responsible to designate your physician as the PCP with your insurance plan. Failure to do so may result in your responsibility for any incurred charges. 2) You will be asked to provide your insurance card(s) at every visit. This is to ensure that the information we have on file is correct, and that your plan is current. 3) The Practice will submit claims to your primary and secondary insurance companies whether we participate or not, as a courtesy to you. 4) Except where my plan provides for automatic payment of benefits to the provider of services, I authorize payment of benefits, otherwise payable to me, for services rendered by Coastal Medical, Inc. I understand that I am ultimately responsible to the provider for charges not covered by my benefit plan. 5) Due to the wide range of insurance plans, we are unable to quote specific plan benefits. To fully understand your individual insurance plan, please contact your insurance company directly to discuss your plan s benefits. Time of Service Payments 1) Co-payments, deductibles and coinsurance are part of the contractual agreement between you and your insurance company. Your insurance company requires us to collect your co-payment in full at the time of service. If your plan also has a deductible and/or coinsurance that hasn t been met, we may collect a deposit of $ (since we can only estimate the future amount due) at the time of service. 2) Patients without medical insurance coverage (self-pay patients) are responsible for any and all charges that result from professional or medical services provided by our physicians. Payment is due when services are rendered, unless other payment arrangements have been approved. Collections 1) The practice reserves the right to consider delinquent patient accounts for external collection efforts in accordance with state and federal regulations. By signing below, I acknowledge that I have read, understand, and accept the policy. Print Name: Date of Birth: / / mm dd yyyy Signature: Date: / / Revised 05/07/2015

9

10

11

12

13 Notices of Privacy Practices Protected Health Information (PHI)/ Electronic Health Record (EHR) Acknowledgement Coastal Medical has provided me with a copy of its Notice of Privacy Practices with respect to PHI and their EHR. I have reviewed this document and all questions I had have been answered. Patient Name (Please Print) Date of Birth Signature Date

14 COASTAL MEDICAL EMERGENCY CONTACT FORM In the event you are involved in an accident or other emergency, we urge you to complete the information requested. * * * * * PLEASE PRINT ALL INFORMATION * * * * * Name D.O.B. / / Primary Contact Person: Name D.O.B. / / Relationship to Patient Are They a Coastal Medical Patient? Yes No Home phone # Work phone # Cell phone # Secondary Contact Person: Name D.O.B. / / Relationship to Patient Are They a Coastal Medical Patient? Yes No Home phone # Work phone # Cell phone #

15 PERMISSION TO DISCUSS I, hereby give Coastal Medical permission to discuss my medical information with: Name #1 Relationship Home Phone: Cell: Work: Name #2 Relationship Home Phone: Cell: Work: Please list any exclusions: Signature: Date: / / Date of Birth: / / ****************************************************************************** It is the patient s responsibility to notify our office of any changes. This permission expires 1 year from signature. 6/2016

16 AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION Patient: Date of Birth: SSN: Address: Telephone: Transfer the following information: To:* C oastal Medical From: Abstract of last 2 years for continuation of care** Complete record Other Consultation notes Laboratory Studies X-ray reports This authorization includes allowing the transfer of information regarding: AIDS (Acquired Immunodeficiency Syndrome), HIV (Human Immunodeficiency Virus), psychiatric disorders, and history of treatment for drug or alcohol abuse. Have you seen a behavioral health specialist in our office? Yes No If yes, what is the provider s name? Do you authorize the release of these records as well? Yes No I understand that this authorization may be revoked at any time prior to an actual release of records made in good faith that occurred in reliance on this authorization. This authorization will automatically expire 90 days from the date below. The purpose of this request is: Signed: Witness: Patient/Legal Guardian Date: THIS AUTHORIZATION DOES NOT ALLOW AN AGENCY RECEIVING RECORDS FROM FURTHER DISTRIBUTING THEM WITHOUT ADDITIONAL WRITTEN CONSENT OF THE PATIENT. * Requests for the patient's records will be billed to the patient according to state regulations. You may have a personal copy delivered to you electronically upon request. **Abstract includes progress notes, laboratory and other testing results, telephone encounters, and consultation documents from the last two years; additional preventive immunizations and most recent mammogram, colonoscopy and cardiac testing results will be forwarded if present. 9/9/2015