PATIENT REGISTRATION

Transcription

1 PATIENT REGISTRATION Last Name First Name Middle or Maiden Mailing Address City County State Zip Physical Address (if different) Telephone: Home( ) Cell ( ) Work ( ) Preferred Contact: Home Cell Text Message Date of Birth / / Gender Marital Status SSN / / Race Ethnicity Preferred Language Do you have an Advanced Directive? Yes / No If yes, please specify: Living Will DNR Healthcare Power of Attorney EMPLOYER INFORMATION Employer Name Employer Address Work Phone ( ) Ext Can We Contact You at Work? EMERGENCY CONTACT Emergency Contact Name Relationship Address City County State Zip Home Phone ( ) Alternate Phone ( ) RESPONSIBLE PARTY / INSURED INFORMATION Name of Insured (if different than patient) Relationship SSN / / Date of Birth / / Work Phone ( ) Person Responsible for Bill Relationship Address (if different than patient or insured) City County State Zip OTHER INFORMATION Family Physician Name Office Phone ( ) Pharmacy Name City Telephone ( ) MEDICAL RECORDS ACCESS You may access your medical record using our secure patient portal online. To enroll, please provide us with your personal address: ***Once enabled, you will receive a secure with your user name and password. Due to HIPAA Regulations, we are unable to provide patient information to anyone other than the patient. ( In somes cases, this also pertains to the information of a minor.) If you want someone other than yourself to obtain information from your medical record, please notify the receptionist.

2 I hereby authorize the staff of Greensboro Rheumatology to provide those medical treatment(s) and procedure(s) that I agree to accept after they have been explained to me. Furthermore, I authorize the use of any facilities and services of Greensboro Rheumotology which may be regarded as necessary or beneficial in the performance of said procedure(s). I further agree to abide by the rules and regulations of this practice, including observance of office hours and office policies. I authorize the taking of and use of my photograph for inclusion in the medical record that is retained by the clinic. I understand this photograph will be used for the purpose of identification and familiarization by the staff and the physician(s). I authorize the Greensboro Rheumatology physician(s) to release any information acquired in the course of examination and treatment in connection with this office visit for the purpose of insurances, Medicare, and/or other benefit payments. I further authorize the Greensboro Rheumatology to release information to my doctor(s) and to agents of my health plan who are engaged to review my care. I further authorize my medical benefits providers to make all payments related to this visit/procedure directly to Greensboro Rheumatology, Greensboro, NC. I authorize the Greensboro Rheumatology to act in my behalf in ( the collection of benefits from any responsible third party through whatever means may be deemed necessary; and ( in the endorsement of benefit checks made payable to myself and/or Greensboro Rheumatology. I authorize the refund of overpaid insurance benefits in accordance with my insurance policy conditions, where my coverages are subject to a co-ordination of benefits clause. I understand I may be billed for self-administered drugs as determined by my insurance carrier. Where Medicare or Medicaid benefits are applicable, I certify that the information given by me in applying for payment under Title XVIII or XIX of the Social Security Act is correct, and request that said payment of authorized benefits be made on my behalf as stipulated in the above assignment of benefits. I understand that my insurance is an agreement between the insurance company and myself. I hereby guarantee payment of all charges of the patient, and am aware that I am not relieved of any liability by any extension of time granted for the payment of these charges, nor by the acceptance by Greensboro Rheumatology of a note from the patient or any third person. Payments of the uninsured amount where such amount can be reasonably estimated, are due upon registration. I also agree to pay all expenses incurred in collecting this account, including reasonable attorney's fees, in case this account is not paid as stated above. Balances remaining unpaid after 90 days may be subject to interest charges and/or collections activities. I understand and acknowledge that services such as bloodwork and x-rays are billed by an outside third party. I consent to receive these services. NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION I acknowledge that I have been given a copy of the privacy practices of Greensboro Rheumatology. I have the right to a copy of the privacy practices of Greensboro Rheumatology at any time. I understand that I can ask for a copy of the notice at any time. I also understand that should I choose to receive this notice electronically, I am still entitled to a paper copy of this notice. Patient Name (Printed) Patient Signature Date

3 E-PRESCRIBING CONSENT eprescribing is defined as a physician s ability to electronically send an accurate, error free, and understandable prescription directly to a pharmacy from the point of care. Congress has determined that the ability to electronically send prescriptions is an important element in improving the quality of patient care. eprescribing greatly reduces medication errors and enhances patient safety. The Medicare Modernization Act (MMA) of 2003 listed standards that have to be included in an eprescribe program. These include: Formulary and benefit transactions - Gives the prescriber information about which drugs are covered by the drug benefit plan. Medication history transactions Provides the physician with information about medications the patient is already taking to minimize the number of adverse drug events. Fill status notification - Allows the prescriber to receive an electronic notice from the pharmacy telling them if the patient s prescription has been picked up, not picked up, or partially filled. By signing this consent form you are agreeing Greensboro Rheumatology can request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payers for treatment purposes. Understanding all of the above, I hereby provide informed consent to Greensboro Rheumatology to enroll me in the eprescribe Program. I have had the chance to ask questions and all of my questions have been answered to my satisfaction. Patient Signature/Date

4 Greensboro Rheumatology New Patient Form Name: Date of Birth: Primary Care Physician: Referring Physician: Describe briefly your symptoms: Medications (Please include all over the counter medications and supplements) Drug Name Dose How Often Medical History Medical Diagnosis Year Diagnosed Allergies Medications + Reaction: Foods/Other + Reaction: Surgical History Surgery Year Doctor

5 Family History of Medical Conditions Mother: Sisters: Father: Sons: Brothers: Daughters: Other Family with Rheumatic Condition: Social History Occupation: Marital Status: Single Married Divorced Widowed Children: Yes No If Yes, How Many? Do you smoke? Yes No Previous Packs per day For how long? Year Quit Do you use illicit drugs? Yes No Do you consume alcohol? Yes No If yes, how often? Do you exercise? Yes No How often? Date of last Tuberculosis test: Result: Review of Systems Please check if you are experiencing any of the following: Fatigue Mouth sores Irregular heartbeat Joint stiffness Loss of strength Fever Dry mouth Abdominal pain Muscle aches Anxiety Headache Cold intolerance Constipation Painful joints Depressed mood Weight gain Weakness Diarrhea Swollen joints Other (please list): Weight loss Shortness of breath Nausea/vomiting Hair loss Hives Cough Easy bruising Rash Itching Chest pain Prolonged bleeding Sun sensitivity Decreased vision Dizziness Blood in urine Tingling/numbness Dry eyes Fluid accumulation in legs Difficulty urinating Color changes in hands or feet in the cold I certify that the information I have given above is correct to the best of my knowledge. Patient s Signature: Date: Signature and Relationship of person filling out form: