SKINNER FAMILY PRACTICE 1

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Transcription:

SKINNER FAMILY PRACTICE 1 Health History Patient Name: DO YOU HAVE A PERSONAL HISTORY OF DIABETES (E11.9) COPD (J44.9) BLOOD PRESSURE (I10) CROHNS DISEASE (K50.10) HEART DISEASE (I51.9) TUBERCULOSIS (A15.9) DIVERTICULITIS (K57.90) KIDNEY STONES (N20.2) HEART ATTACK (I21.3) LIVER DISEASE (K76.9) ULCERATIVE COLITIS(K51.90) SEIZURES (R56.9) HIGH CHOLESTEROL (E78.5) THYROID DISEASE (E07.9) ASTHMA (J45.998) AIDS/HIV (B20) STROKE (I63.9) HEPATITIS (K71.6) MIGRAINES (G43.009) CHRONIC PAIN* (G89.29) CANCER (C80.1) BACK INJURY (S39.92XA) ULCERS (K12.1) KIDNEY DISEASE (N28.9) History of surgeries (please include year): Medication Allergies: Do you use tobacco? Type and amount: Do you drink alcohol? Amount and frequency: Have you ever been treated for drug or alcohol abuse? FAMILY HISTORY (PLEASE LIST ANY SIGNIFICANT HEALTH CONDITIONS) FATHER: MOTHER: GRANDPARENTS: SIBLINGS: *PLEASE NOTE: SKINNER FAMILY PRACTICE DOES NOT PROVIDE PAIN MANAGEMENT. PLEASE INITIAL HERE INDICATING YOUR UNDERSTANDING OF THIS: DATE:

SKINNER FAMILY PRACTICE 2 DEMOGRAPHIC INFORMATION First: MI: Last: Preferred Name: Maiden name: Social Security #: Date of Birth: Gender: Marital Status: Ethnicity (optional): Home Address: City: State: Zip: Phone: Mobile: Other: Emergency Contact: Relationship: Phone: Preferred pharmacy: Please list other family members that are patients at Skinner Family Practice: RESPONSIBILITY OF PAYMENT: Please list the person responsible for your medical bills. If your insurance is not in your name, this section is mandatory. Name: Social Security #: Date of Birth Gender: Address: City: State: Zip: Relationship:

Patient Name: SKINNER FAMILY PRACTICE 3 INSURANCE INFORMATION Please provide a copy of your card for our files. If you have NO insurance, please indicate by initialing here:. By initialing, you accept responsibility for all amounts billed for services provided. Payments are due at the time of service. If other services are provided, billing may be delayed and therefore payment will be expected upon receipt of the final bill. Primary Insurance: Name of insured: Insured date of birth: Insured SS#: Relationship to insured: Self/ Spouse / dependent / other Secondary Insurance: Name of insured: Insured date of birth: Insured SS#: Relationship to insured: Self/ Spouse / dependent / other Authorization and assignment: I hereby authorize Skinner Family Practice to furnish any information to my insurance carrier(s) and health care administrators or agents concerning my illness and/or treatment. I hereby assign to Skinner Family Practice all payments for services rendered to me/my covered dependents. I understand that I AM RESPONSIBLE FOR ANY AMOUNTS NOT COVERED BY INSURANCE AND THAT MY COPAYMENT IS DUE AT THE TIME OF SERVICE. I further understand that Skinner Family Practice is filing my insurance as a courtesy and convenience for me and that I am ultimately responsible for all billed amounts for services provided. Signature: Date:

Patient Name: SKINNER FAMILY PRACTICE 4 HIPPA PRIVACY ACT By signing below, I acknowledge that I have been notified of the availability of the Notice of Privacy Practices and a copy has been made available to me by Skinner Family Practice. I also authorize Skinner Family Practice and any authorized staff members to share pertinent protected health information with those listed below. I also understand that, with written request, I can amend or withdraw any names listed below at any time and that it is my responsibility to ensure the persons listed below do not divulge or use the information provided in any way without my authorization. Please list below any individuals to which health information may be freely shared without further notification. Please DO NOT list other physicians of medical facilities. By initialing here, I am requesting that NO ONE receive health information about me without advanced notice by me. Initials: Date: The following individuals may freely receive any information regarding my health without further notice Signature: Date:

SKINNER FAMILY PRACTICE 5 MEDICATION LIST Medication Name: Dosage: How taken:

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