~ PLEASE PRINT CLEARLY ~ LAST ADDRESS FIRST MI HOME PHONE SOCIAL SECURITY # EMPLOYER WORK PHONE DATE OF BIRTH JOB/ PROFESSION: CELL PHONE MARITAL STATUS SPOUSE S SPOUSE S SOCIAL SECURITY # (If under spouse s medical insurance) EMERGENCY CONTACTPHONE: SPOUSE S JOB or PROFESSION EMAIL ADDRESS: INSURANCE INFORMATION: PRIMARY INSURANCE COMPANY SUBSCRIBER S RELATIONSHIP SECONDARY INSURANCE COMPANY SUBSCRIBER S RELATIONSHIP OTHER INFORMATION: PRIMARY PHYSICIAN PREFERRED PHARMACY SPECIALISTS Circle what pain meds you have taken and tolerate: Vicodin/Norco/Lortab Tramadol/Ultram Darvocet/Darvon Other: I attest that everything I stated in these intake forms is true and correct to the best of my knowledge. 1
PATIENT HISTORY FORM Please list medical problems: Do you have a history of cancer? Yes No If yes, please list cancer type, year of diagnosis, treatment(s): Please list any prior surgeries: Do you have any allergies to any medication, Latex, or any substance (e.g. tape)? Yes No If yes, please list: Please list the medications that you are currently taking and dosages: Have you ever experienced any problems with anesthesia? Yes No What medical conditions/cancers/diseases run in your family?: If female, number prior pregnancies:, live births: Could you be pregnant now? Are you, or did you ever smoke? Yes No If so, how many packs per day for how many years? packs per day, for years. Do you drink alcohol? Yes No Mo/year of last colonoscopy:, Mo/year of last abdominal CT scan:, Mo/year of last abdominal ultrasound:. Please circle any symptoms or conditions you have or have had: General: Tiredness, inability to exercise, fever, weakness, night sweats, new weight loss or gain. Head: Changes in your vision, glaucoma, taking eye drops, dizziness, sensitivity to noise, ear pain, ringing sounds in ears, impaired ability to smell, hoarseness, difficulty swallowing, pain with swallowing. Heart: Heart attacks, heart surgery or stents, chest pain or pressure, palpitations or irregular heart beat, heart murmurs, heart failure, heart attacks, high blood pressure. Breathing: Cough, shortness of breath, coughing up blood, breathing problems, wheezy or noisy breathing, smoking, asthma, tuberculosis, breathing problems. Gastrointestinal: Abdominal pain, heartburn, nausea, vomiting, abdominal swelling/distension/gassiness, changes in bowel habits, constipation, diarrhea, ulcers, liver or pancreas diseases, hepatitis, jaundice (yellow skin), gallstones, blood in vomit or bowel movements, unusually dark, light, or narrow stool. Genitourinary: Kidney or bladder diseases, problems with urination, frequent urination at night. Bones, Muscle & Skin: Weakness, limitations on walking or exercise, arthritis, bone or joint surgery, chronic back pain, muscle cramping, twitching or pain, scars, moles, open wounds, skin cancers. Nervous System: Stroke, head injury, seizures, passing out, memory loss, changes in balance or coordination, depression, mood changes, anxiety, do you see a therapist/psychologist/psychiatrist? Endocrine: Diabetes, thyroid conditions, have you ever taken steroids or prednisone? Blood: Anemia (low blood count), tendency to bleed easily, easy bruising, previous blood transfusions. Immune: Disorders of the immune system such as HIV or AIDS, autoimmune conditions, scleroderma, lupus, rheumatoid arthritis. Signature: Print Name: Date: 2
PATIENT ACKNOWLEDGMENT OF PRIVACY PRACTICES As the laws regarding patient privacy are changing and new procedures are being put into effect, it is our responsibility to notify you as well as receive feedback from you about how your records are handled. Patient s Bill of Rights and our office s Policies are available to read here in the office and I may receive a copy upon request to take with me. The staff will identify themselves as Dr. Lee s office when confirming upcoming appointments and returning calls. I understand that test results or other medical information will not be left on voice mail unless I grant prior authorization. I authorize the following person,, ( a spouse, family member, or friend) to have access to my medical information, such as being able to receive my test results, take advice regarding my condition, and make my appointments. I may change this at any time by signing a new form. Dr. Lee s makes it a practice to keep your primary care physician notified of your progress. They will receive a letter from Dr. Lee regarding your visit, findings and treatment plan. Any doctor you list as your primary or specialty physician will get this letter. The staff will release pertinent records to any physician they refer me to for further care. Unless a new Patient Acknowledgment form is signed and dated with changes made by me, the above information goes into effect immediately. ** Please note, that in any case of releasing medical records or information, even to those you have agreed may have access, it is our policy to release the minimum amount necessary to avoid misuse of your information. I give my physician or physician s office permission to: Leave a message with medical information: YES NO Communicate via email or text message: YES NO NOTICE TO CONSUMERS: Medical doctors are licensed and regulated by the Medical Board of California, (800) 633-2322, www.mbc.ca.gov. Dr. Crystine M. Lee is a licensed Physician & Surgeon by the Medical Board of California (Lic. #A065187) and also Board Certified by the American Board of Surgery. 3
FINANCIAL POLICIES (1) Insurance Billing Please present your current insurance card at each visit. As a courtesy to you, we will bill your insurance directly for medical services rendered. Payment is ultimately the responsibility of the patient regardless of third party involvement. If problems arise regarding coverage issues, we will work with you and your insurance company to help resolve them. We will bill most insurance plans, but that does not mean we are in network for all plans. You should check with your insurance prior to being seen to ensure you are not following your specific company s guidelines for service. We require front and back copies of your insurance card. We are members of the Marin IPA HMO medical group. It is your responsibility to obtain a referral prior to being seen. Failure to do so may result in you being responsible for payment of the visit. If you belong to another HMO group, you will be considered private pay, and payment will be expected at the time of service, unless you bring with you an out of network referral. Please note: We do not bill Tricare for Life. If Medicare is your primary, and they automatically forward the billing to Tricare, we will receive the payment. However, if the billing is not forwarded, you will be responsible for the balance, and can submit to them directly for reimbursement. Operations or procedures will be pre-authorized by our office if the insurance company requires us to do so. I hereby authorize the processing of the medical insurance either by electronic or manual method by Dr. Crystine Lee. My signature below authorizes payment of all major and or surgical benefits to which I am entitled from the listed insurer (listed above) to pay Dr. Crystine Lee. I further authorize assignee to release all medical and or insurance claim information necessary to secure payment(s). I recognize that it is my financial obligation of any co-insurance, deductible, and non-covered services. This agreement will remain in effect until revoked by me in writing. If appropriate, I request that payment of authorized Medicare benefits (if applicable) be made on behalf of Dr. Crystine Lee, M.D. for any services furnished to me by the listed provider/ supplier. I authorize any holder of medical information about me to release to Health Care Finance Administration and its agents any information needed to determine these benefits payable to related services. I understand that my signature below requests that payments be made and authorizes release of medical information necessary to process my claim. If other health insurance is indicated in Item 9 of HCFA-1500 form, or elsewhere on other approved claim forms or assigned cases, the provider or supplier agrees to accept the charge determined by Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered items. Co-insurance and the deductible are based upon the charge determination of the Medicare carrier. Please be advised that you are ultimately financially responsible for payment of medical services rendered. 4
FINANCIAL POLICIES (2) Medical Fraud To combat medical fraud, photo ID may be checked at any visit. Co-payments/Prior balances A co-payment for each visit may be required, as determined by your coverage under your medical insurance policy. We accept payment in cash or check at the time of service. Any previous unpaid balance due will be billed to you. Payment at time of service Payment at time of service is required for patients who do not have medical insurance. For patients who have a financial hardship, special payment arrangements may be made prior to services being rendered. Please inform the receptionist when making the appointment, so an estimate may be given. Medi-Cal patients will be expected to pay any unmet share of cost at the time of service. Miscellaneous Services Charges The California Health and Safety code and California Business and Profession Code state that Medical Offices may assess reasonable charges for the following: *No Show appointments/ Cancellations without 24 hours notice: $25 office visits *No Show appointments/ Cancellations without 72 hours notice: $200 surgery Collection Proceedings Any balance due is considered late 30 days after the date on the statement. If payment is not made in full, the account will be referred to a collection agency. This can result in a blemish on your credit report, and should be handled like any other balance due. Our goal is to avoid sending an account to collections, and we will work with you to do so. I HAVE READ THE TWO ABOVE PAGES OF FINANCIAL POLICIES AND UNDERSTAND THE FINANCIAL POLICIES OF THIS MEDICAL OFFICE. I ALSO AUTHORIZE MY INSURANCE BENEFITS TO BE PAID DIRECTLY TO THE PHYSICIANS. I FURTHER AUTHORIZE THE RELEASE OF MY INFORMATION REQUIRED TO PROCESS AN INSURANCE CLAIM. Signature: Print Name: Date: 5