Endocrinology of the Rockies, PC. PATIENT REGISTRATION FORM E. 9th Ave. Ste. 245, Denver, CO 80220

Transcription

1 1 PATIENT REGISTRATION FORM E. 9th Ave. Ste. 245, Denver, CO Patient Name (Last, First, M.I.): Prefer to be called: Address: City: State: Zip: Home phone: ( ) Work phone: ( ) Day phone: ( ) Marital Status: DOB: Gender: F M Race: American Indian or Alaskan Native or Other Pacific Islander White Patient Refusal Asian Asian Black or African American Hawaiian Ethnicity: Hispanic or Latino Not Hispanic or Latino Patient Refusal Primary Care (First & Last Name): Referring Physician (if different from PCP): **GROUP HEALTH INSURANCE INFORMATION (All copays due at the time of service) (Although we have copied your insurance card, we still need you to complete all of the insurance information below) PRIMARY INS: Eff. Date: Policy Holder Name: DOB: M/F: Policy Holder Employer: Relationship to Policy Holder: Policy Holder ID: Group #: *********************************************************************** SECONDARY INS: Eff. Date: Policy Holder Name: DOB: M/F: Policy Holder Employer: Relationship to Policy Holder: Policy Holder ID: EMERGENCY CONTACT INFORMATION Group #: Emergency Contact Name: _ Relationship to Patient: Home phone: ( ) Work phone: ( ) Alt phone: ( ) Patient/Responsible Party Signature: Date: Thank You.

2 2 Financial Policy Financial Policy In order to reduce confusion and misunderstanding between our patients and the practice, we have adopted the following financial policy. We are dedicated to providing the best possible care and service to you and regard your complete understanding of our financial policies as an essential element of your care and treatment. Unless other arrangements have been made in advance by yourself or you health coverage carrier, full payment for office services are due auth the time of service. For you convenience, we accept VISA, MasterCard, Discover, as well as cash or check. Health Insurance You Insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you. If your insurance company does not pay the practice within a reasonable period, we will have to look to you for payment. If we later receive a check from your insurer, we will refund any overpayment to you. Participating Health Plans We have made prior arrangements with many insurers and other health plans to accept an assignment of benefits. We will bill those plans with which we have an agreement and will only require you to pay the co-payment at the time of service. All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be not covered, you will be responsible for the complete charge. Payment is due upon receipt of statement from our office. It is your responsibility to verify that this office participates with your insurance. If we do not participate with your insurance, you will likely be responsible for all charges out of pocket. By signing below, I acknowledge that I have read and understand the financial policy of the practice and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time-to-time by the practice. Signature Printed name if signed on behalf of patient Date Relationship to Patient

3 3 General Policies This is a brief explanation of how we run the office. We hope that this will open communication and prevent confusion. Payment: If you have a copay or co-insurance amount, that amount is expected at the time of service. We accept credit cards, checks, and cash. No Show and Cancellation Policy: We recognize that in today's busy world, adhering to a schedule is important in order to maximize time and meet the demands of daily life. With this in mind, we have developed a No Show/Cancellation policy that is fair to both our patients and our practice. We are committed to seeing our patients on time and respecting their time. Late cancellations (less than 24 hours notice), missed appointments, and late arrivals are disruptive to our schedule and other patients. In order to maintain our schedule, we request 24 hours notice for cancellations or rescheduling of appointments. In the instance of a missed appointment, late arrival or late cancellation (less than 24 hours notice), there may be a $45.00 No Show/ Cancellation Fee. Late Cancellations: (less than 24 hour notice) will be considered a "NO SHOW. Patient Signature Date Check In: We respect and value your time. We request that all of our patients arrive 10 minutes prior to their appointment for check in. If you are more than 15 minutes late, we may need to reschedule your appointment. We apologize for any inconvenience this may cause you, but we hope that in the end, everyone will be served in a more timely and efficient fashion, while still receiving the highest quality possible. For our Diabetic Patients: To EVERY VISIT, make sure you bring your blood sugar records, and your meter. If you have been keeping food records, bring those too! Patient Signature Date Insurance Referrals: It is my responsibility to understand the requirements of my insurance policy. If a referral is needed prior to seeing Dr. Haas, it is my responsibility to obtain one through my primary care doctor. If I choose to be seen WITHOUT a valid referral in place, I understand that I am responsible for any charges not covered by my insurance company. Patient Signature Date

4 4 Patient Consent Form I, the undersigned, hereby consent to the following treatment: Administration and performance of all treatments Performance of such procedures as may be deemed necessary or advisable in the treatment of this patient Use of prescribed medication Performance of diagnostic procedures/tests and cultures Performance of other medically accepted laboratory tests that may be considered medically necessary or advisable based on the judgement of the attending physician or their assigned designees I fully understand that this is given in advance of any specific diagnosis or treatment. I intend this consent to be continuing in nature even after a specific diagnosis has been made and treatment recommended. The consent will remain in full force until revoked in writing. I, the undersigned, acknowledge that Endocrinology of the Rockies, P.C. will use and disclose my information for the purpose of treatment, payment, and healthcare operations as described in the Notice of Privacy Practices. A photocopy of this consent shall be considered as valid as the original. Medicare Patients: I authorize to release medical information about me o the Social Security Administration or its intermediaries for my Medicare claims. I assign the benefits payable for services at Endocrinology of the Rockies, P.C. I acknowledge that I have been given the Endocrinology of the Rockies, P.C. Notice of Privacy Practices. I understand that if I have any questions or complaints that I should contact the Privacy Official. I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. Patient (or Responsible Party) Signature Date Patient s Printed Name

5 5 Telephone and Messaging Consent Frequently, someone at Endocrinology of the Rockies will need to contact you by telephone regarding your health and/or your protected health information. In order to best protect your privacy, as well as provide excellent patient care, we ask that you complete the following consent. This provides us with specific direction as to where we may contact you, ad with whom we may speak to on your behalf regarding health information. I permit Endocrinology of the Rockies to leave phone messages at the following telephone numbers candor with the following individuals. I acknowledge that only the individuals listed on this form will be able to discuss any issues related to my healthcare with physicians or staff of Endocrinology of the Rockies. I agree that this consent will remain valid until revoked in writing by me or by an authorized designee (i.e., durable power of attorney). Patient Name: Date of Birth: Contact Numbers May we leave a detailed message? Preference (1, 2, or 3) Home: Y/N Cell: Y/N Work: Y/N To whom may we speak with on your behalf: Name: _ Relationship: Phone Number: Name: _ Relationship: Phone Number: Patient Signature Date

6 6 Medical Information Form 1. Please list any drug allergies and reactions. 2. Please list all medications and doses. 3. Medical History. Please indicate if you have any of the following chronic illnesses. a. Diabetes Y N If yes, what year was it diagnosed? Have you ever been hospitalized for a high or low sugar? Y N Do you have diabetic eye disease? Y N Last eye exam? Do you have kidney disease? Y N Do you have numbness and tingling in your hands or feet? Y N b. High Blood Pressure Y N c. High Cholesterol Y N d. Thyroid Problems Y N Please Specify: e. Heart Disease Y N Please Specify: f. Stroke Y N g. Kidney Stones Y N h. Cancer Y N Please Specify: i. Osteoporosis Y N j. Asthma/Lung Disease Y N k. Liver Disease Y N l. Kidney Disease Y N m. Pituitary Disease Y N n. Other Chronic Illness Y N Please Specify: 4. Surgical History. Please list all major surgeries with dates.

7 7 5. Family History. Please list any illnesses of the following family members. Please include if they have diabetes, thyroid disease, cancer, heart disease, high blood pressure, or kidney stones. a. Mother: a. Father: b. Siblings: c. Grandparents: 6. Social History. a. What is your marital status? b. Do you have children? If so, how many and ages? c. What is your occupation? d. Do you smoke currently? Y N Packs per day: e. Do you drink alcohol? Y N Drinks per week: f. Have you ever used intravenous drugs? Y N g. Do you exercise regularly? Y N If so, please describe: 7. Menstrual History. a. When was your last period? b. Are or were your periods regular? Y N How often? c. Number of pregnancies? Number of living children? d. What do you use for contraception? 8. Please indicate if you have any of the following symptoms. Unexplained weight loss or gain Y N Chest Pain Y N Fever, chills, night sweats Y N Palpitations Y N Rashes, easy bruising Y N Constipation Y N Double vision Y N Diarrhea Y N Dental disease Y N Nausea Y N Hoarseness, trouble swallowing Y N Stomach pain Y N Cough, shortness of breath Y N Hair loss Y N Frequent urination Y N Depression Y N Trouble urinating Y N Irregular periods Y N Temperature intolerance Y N Fatigue Y N Joint or muscle pain Y N Leg swelling Y N Nipple milk secretion Y N Headache Y N Change in shoe or ring size Y N Acne Y N