Untitled - Symphony Healthcare, Inc. In Ocala, Florida

202 S.W. 17th Street, Suite A
Ocala, Florida 34471
PHONE #629-5939 FAX 629-7833
MEDICAL HISTORY
DATE: ________________
Patient Name_____________________________________Date of Birth_________________________
Females Only
Total number of: Pregnancies______ Births_____ Miscarriages_____
Complications of Pregnancy and Labor if any___________________________________________
Menstrual Cycle: Date of last cycle _______________ Regular? ___y/n___
Type of Birth Control used________________________________________________________
When did you last have:
_____Pap Smear _____Mammogram
_____Bone Density
_____Colonoscopy
_____Annual Screening Labs
_____Tetanus Vaccine
_____Pneumonia Vaccine _____Shingles Vaccine
_____Hepatitis Vaccine
_____HPV Vaccine
_____Dental Exam
_____Eye Exam
_____Pulmonary Function Test (for smokers, asthmatics, or lung disease pts)
_____Annual Physical
_____Prostate Exam
_____Colonoscopy
_____Tetanus Vaccine
_____Pneumonia Vaccine _____Shingles Vaccine
_____Dental Exam
_____Eye Exam
Males Only
When did you last have:
_____Annual Screening Labs (PSA)
_____Hepatitis Vaccine
_____HPV Vaccine
_____Pulmonary Function Test (for smokers, asthmatics, or lung disease pts)
Which of the following conditions are you currently being treated or have been treated for in the past (please check)
□Heart disease / Murmur / Angina □Shortness of breath
□High cholesterol
□Asthma
□High blood pressure
□Lung problems / cough
□Low blood pressure
□Sinus problems
□Heartburn (reflux)
□Seasonal allergies
□Anemia or blood problems
□Tonsillitis
□Swollen ankles
□Ear problems
□Eye disorder / Glaucoma
□Seizures
□Stroke
□Headaches / Migraines
□Neurological problems
□Depression / Anxiety
□Psychiatric care
□Diabetes
□Kidney / Bladder problems
□Liver problems / Hepatitis
□Arthritis
□Cancer
□Ulcers/colitis
□Thyroid problems
Please list any other medical treatment or condition not listed above:
Surgeries (Include date and doctor that performed)
Medication Allergies. Please list all medication allergies:
Medications
Dose
Instructions
Doctor that prescribed
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Social and Preventive History
Do you currently smoke or chew tobacco? Yes No
How many packs per day? _______________________
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If no, have you in the past?
□Yes □No
Do you drink alcohol, beer, or wine? Yes No
How many drinks per week? ______________________
If no, have you in the past?
□Yes □No
Do you currently drink coffee and/or tea?
If yes, how many cups per day? ________________________
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Do you exercise daily/weekly?
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□Yes □No
□Yes □No
Family History
Living
□Yes □No
Father □Yes □No
Sisters □Yes □No
□Yes □No
□Yes □No
Brothers □Yes □No
□Yes □No
□Yes □No
Age (or age at death)
List serious illnesses
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Mother
Has any member of your family (including children and parents) had any of the following illnesses:
Illness
Which family member?
Anemia or Blood disease
Cancer
Diabetes
Glaucoma
Heart disease
High blood pressure
HIV disease / AIDS
Mental Illness / Depression
Stroke
Other serious illness
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Specialists. Do you see any other doctors or specialists?
Doctors Name
Specialty
Phone Number
Date last seen
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WEIGHT LOSS QUESTIONNAIRE Name ______________________________________________________________________ Date __________________________________ Please complete this questionnaire, which will help you and your physician develop the best management plan for you. 1. Is there a reason you are seeking treatment at this time? ___________________________________________________________________ 2. What are your goals about weight control and management? ______________________________________________________________________________________________________________________________________ 3. Your level of interest in losing weight is: Not interested 1 2 3 4 5 Very interested 4. Are you ready for lifestyle changes to be a part of your weight control program? Not ready 1 2 3 4 5 Very ready 5. How much support can your family provide? No support 1 2 3 6. How much support can your friends provide? No support 1 2 3 4 5 Much support 4 5 Much support 7. What is the hardest part about managing your weight? _____________________________________________________________________ ______________________________________________________________________________________________________________________________________ 8. What do you believe will be of most help to assist you in losing weight? ______________________________________________________________________________________________________________________________________ 9. How confident are you that you can lose weight at this time? Not confident 1 2 3 4 5 Very confident ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Weight History 10. As best as you recall, what was your body weight at each of the following time points (if they apply)? Grade school ______ High school______ College______ Age 20‐29______ 30‐39______ 40‐49______ 50‐59______ 11. What has been your lowest body weight as an adult?______ Your heaviest as an adult?______ 12. At what age did you start trying to lose weight?______ 13. Please check all previous programs you have tried in order to lose weight. Include dates and length of participation. Program Date Weight (lost or gained) Length of participation TOPS
________________ ___________________________ ___________________________ Weight Watchers ________________ ___________________________ ___________________________ Overeaters Anonymous ________________ ___________________________ ___________________________ Liquid diets (Optifast, etc) ________________ ___________________________ ___________________________ Diet pills: Meridia, Xenical ________________ ___________________________ ___________________________ Diet pills: phen‐fen, Redux ________________ ___________________________ ___________________________ NutriSystem / Jenny Craig ________________ ___________________________ ___________________________ OTC diet pills ________________ ___________________________ ___________________________ Obesity surgery ________________ ___________________________ ___________________________ Registered dietitian ________________ ___________________________ ___________________________ Other ________________ ___________________________ ___________________________ 14. Have you maintained any weight loss for up to 1 year on any of these programs? ______ Yes ______ No 15. What did you learn from these programs regarding your weight? _________________________________________________________________________________________________________________________________ 16. What did not work about these programs? ____________________________________________________________________________ 17. Have you been involved in physical activity programs to help with weight loss? ______ Yes ______No Which ones or in what way? ____________________________________________________________________________________________ ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ DEBORA DONAHUE, ARNP-BC
202 S.W. 17th Street, Suite A
OCALA, FL 34471
352-629-5939~~352-629-7833 FAX
AUTHORIZATION TO RELEASE MEDICAL INFORMATION
I, ___________________________________SS#____________________________DOB______________
(Please Print)
HEREBY AUTHORIZE DEBORA DONAHUE,ARNP-BC TO: OBTAIN
RELEASE___________
Doctor/Facility
PHONE#
FAX NUMBER
____________________________
____________________/_______________________
____________________________
___________________/________________________
____________________________
____________________/_________________________
THE PATIENT RECORDS IN YOUR POSSESION:
~LABORATORY STUDIES_______ ~DIAGNOSTIC/TESTING_______ ~OTHER_______________________
CONCERNING MY ILLNESS AND/OR TREATMENT DURING THE PERIOD FROM__________TO____________
THE PURPOSE OF REQUEST
(PLEASE MARK)
CONCURRENT CARE_______ MOVING_______ TRANSFERRING______ SELF______ INSURANCE_____
I specifically consent to the release of any material in your possession, including, if any, existing results of HIV (AIDS) test and any which
might address chemical dependence, depression, or other psycho emotional issues.
I request the provider named above promptly honor this request for medical information and/or copies of medical records. A copy of this
request is as valid as the original. This authorization and request is valid for a period of one year from the date signed below, unless I request
in writing to have this authorization revoked. I do, however, understand that any action already taken in reliance on this authorization cannot
be reversed, and my revocation will not affect those actions. I also understand the information used or disclosed pursuant to this authorization
may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPPAA Privacy Rule. I may inspect and obtain a
copy of any information disclosed. I may be charged a fee of $1.00 per page up to 25 pages and $0.25 for each additional page plus a
$10.00 processing fee for personal copies.
PATIENT SIGNATURE(X)_____________________________________________________________DATE__________
______________________________________________________________________________________________
Address
City
Zip
_______________________________________________________________________________________________
Telephone Number
Other
Faxed by:________________________Date___________________
Debora Donahue, ARNP-BC
202 S.W. 17th Street, Suite A
Ocala, FL 34471
352-629-5939 Fax 352-629-7833
PERMISSION TO SPEAK TO FAMILY MEMBERS
I give Debora Donahue, ARNP-BC and staff permission to speak to:
_____________________________________________and they can be reached at:
_____________________________________________.
Can we leave messages on your voicemail?
__Y/N__
Can we contact you via text message?
__Y/N__
Can we contact you via the e-mail you have provided with information
regarding your Protected Health Information and Appointments?
__Y/N__
Patient Name__________________________________________
Signature_____________________________________________
Date__________________________________________________
FINANCIAL POLICY
INSURANCE:
We have made prior arrangements with many insurers and health plans. We will file claims with those
plans with whom we have an agreement with. We will collect any required co-payment, co-insurance, or
deductible at time of service. In the event your health plan determines services to be “not covered,” you
will be responsible for the complete charge. We do not file secondary insurance unless there is an
automatic cross-over from Medicare. We do not file nor accept Medicare HMO plans.
MINOR PATIENTS:
For all services rendered to minor patients, the adult accompanying the patient is responsible for payment
in full at time of service regardless of who is legally responsible.
MISSED APPOINTMENTS:
In order to provide the best possible service and availability to all our patients, it is our policy to charge at
$30.00 fee for any appointments not canceled within 24 hours in advance AND a $60.00 fee for any
physical appointments. We attempt to make a “courtesy” call to remind you, but this is not a guarantee.
MEDICAL RECORDS:
Medical records may be released with a signed consent from the patient only and may be charged $1.00 per
copy page up to $25.00 and $0.25 per page thereafter.
COMPLIANCE:
In an effort to maintain optimal health, each patient is expected to comply with the provider’s advice
regarding your health care needs. Failure to do so may result in our inability to continue providing your
health care.
FINANCIAL AGREEEMENT:
We will gladly discuss your proposed treatment and do our best to answer any questions relating to your
insurance. You must realize that:
1. Your insurance is a contract between you and your insurance company. The patient has the
ULTIMATE responsibility to know their benefits. We are not a party to that contract.
2. Not all services we order may be a covered benefit in your contract. You will need to check
with your insurance company directly.
3. You MUST notify us which lab and imaging company your insurance is contracted with.
We must emphasize that as your medical car provider, our relationship and concern is with you and your
health; not your insurance company. All charges are your responsibility from the date services are
rendered. For your convenience, we accept Visa, Mastercard, American Express, Discover, Personal
Checks, and Debit cards. There is a $25.00 charge on all returned checks. On accounts past 60 days,
collection action will be taken. If it becomes necessary to collect any sum due through an agency or
attorney, you agree to pay all reasonable costs of collection.
I have read and understand the policies of the practice. I understand and agree that such terms may be
amended from time to time by the practice.
______________________________________________________________________________________
Signature of Patient/Guarantor
Date
Debora Donahue, ARNP-BC
202 SW 17th Street, Suite A
Ocala, FL 34471
Phone: 352-629-5939 Fax: 352-629-7833
WE DO NOT PRESCRIBE ANY NARCOTIC PAIN MEDICATIONS. WE ALSO LIMIT THE USE OF
OTHER CONTROLLED MEDICATIONS TO SHORT TERM PERIODS ONLY. We will be happy to assist
you with a referral to a specialist to manage any chronic needs.
Here at Symphony Healthcare, Inc. our goal is to provide the best care possible. For that reason, we have designed this
Medication and Appointment Policy to help you understand and to show you how you can help us provide you with the
highest quality health care available. Please read all of this information carefully. Ask your provider if you have any
questions. These are for your protection and will be enforced. You will be asked to sign a contract stating that you
agree to follow these terms.
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Medicines can have side effects. Combining other medications with opioids may cause drowsiness,
intoxication, or death. Some of these medications are tranquilizers, stimulants, diet pills, sleeping pills,
alcohol, or other street drugs. If you should suffer a side effect, it is your responsibility to notify us
immediately so that corrective action can be taken.
Medication must be taken only as prescribed by our provider and must not be taken with any other
medication from any other provider without the consent of this office.
Refills will only be filled during regular office hours. THERE ARE NO EXCEPTIONS.
Any medication that is lost, misplaced, stolen, destroyed, or finished early will not be replaced for any
reason.
We require at least 48-72 hours notice to refill your prescription. It is your responsibility to monitor your
medication and request a refill in a timely fashion.
Prescriptions lost in the mail cannot be replaced.
All prescriptions should be obtained from the same pharmacy when possible. Should the need arise to
change pharmacies; our office must be notified in writing.
You must not share, sell, or otherwise permit others to have access to your medications.
The prescribing doctor and staff have permission to discuss diagnosis and treatment details with dispensing
pharmacists and other professionals who provide your healthcare for the purpose of medication
accountability. We retain the right to discuss your treatment with law enforcement officials during any
official investigation.
You must keep your scheduled appointments. If you fail to appear for an appointment, your medication may
not be refilled and you may be required to pay a fee of $30 to reschedule. If you fail to appear for more than
2 appointments, you may be dismissed from our practice. You must provide us with 24 hour notice to cancel
appointment. If you fail to provide this notice, you will be considered as failure to appear and may be subject
to the fee and limitation of refills as described above.
If you are unable to tolerate any medication, you must return the unused portion of the medication (in the
appropriate amount) to our office before you are given a different prescription.
A random urine drug screen may be requested. Presence of unauthorized substances or abnormal results may
result in discontinuation of your controlled medications or dismissal from the practice.
I have read and agree to the terms of this contract. I understand that controlled medication can be addictive.
This means my body may begin to depend on the medication and I may experience withdrawal such as
nausea, shakes, sweating, rapid heart rate, diarrhea, high blood pressure, pain and severe nervousness if I
suddenly stop taking the medication. I understand that taking more medication than prescribed may lead to
overdose and this could result in impaired breathing, brain injury, coma, or death. I understand that the use
of this medication may also be associated with other risks such as decreased mental & physical effectiveness,
physical dependence, confusion, itching, difficulty urinating, allergic reactions, drowsiness, nausea, vomiting,
addiction, trouble driving or operating machinery, and adverse interaction with other medications. After
carefully reading and understanding these terms, I request treatment by Symphony Healthcare, Inc. and
promise to follow the terms of this contract.
______________________________________________________________________________
Pharmacy Name
Telephone Number
______________________________________________________________________________
Patient Name (Please Print)
Signature
Date
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU
MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices describes how we may use and disclose your protected health
information (PHI) to carry out treatment, payment or health care operations (TPO) and for other
purposes that are permitted or required by law. It also describes your rights to access and control
your protected health information. “Protected health information” is information about you,
including demographic information, that may identify you and that relates to your past, present or
future physical or mental health condition and related health care services.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Your protected health information may be used and disclosed by your physician, our office staff
and others outside of our office that are involved in your care and treatment for the purpose of
providing health care services to you, to pay your health care bills, to support the operation of the
physician’s practice, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or
manage your health care and any related services. This includes the coordination or
management of your health care with a third party. For example, your protected health
information may be provided to a physician to whom you have been referred to ensure that the
physician has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your
health care services. For example, obtaining approval for a hospital stay may require that your
relevant protected health information be disclosed to the health plan to obtain approval for the
hospital admission.
Healthcare Operations: We may use or disclose, as-needed, your protected health information
in order to support the business activities of your physician’s practice. These activities include,
but are not limited to, quality assessment, employee review, training of medical students,
licensing, fundraising, and conducting or arranging for other business activities. For example, we
may disclose your protected health information to medical school students that see patients at our
office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to
sign your name and indicate your physician. We may also call you by name in the waiting room
when your physician is ready to see you. We may use or disclose your protected health
information, as necessary, to contact you to remind you of your appointment, and inform you
about treatment alternatives or other health-related benefits and services that may be of interest
to you. We may use or disclose your protected health information in the following situations
without your authorization. These situations include: as required by law, public health issues as
required by law, communicable diseases, health oversight, abuse or neglect, food and drug
administration requirements, legal proceedings, law enforcement, coroners, funeral directors,
organ donation, research, criminal activity, military activity and national security, workers’
compensation, inmates, and other required uses and disclosures. Under the law, we must make
disclosures to you upon your request. Under the law, we must also disclose your protected
health information when required by the Secretary of the Department of Health and Human
Services to investigate or determine our compliance with the requirements under Section
164.500. Other Permitted and Required Uses and Disclosures will be made only with your
consent, authorization or opportunity to object unless required by law. You may revoke the
authorization, at any time, in writing, except to the extent that your physician or the physician’s
practice has taken an action in reliance on the use or disclosure indicated in the authorization.
YOUR RIGHTS
The following are statements of your rights with respect to your protected health information. You
have the right to inspect and copy your protected health information (fees may apply) –
Under federal law, however, you may not inspect or copy the following records: Psychotherapy
notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or
administrative action or proceeding, protected health information restricted by law, information
that is related to medical research in which you have agreed to participate, information whose
disclosure may result in harm or injury to you or to another person, or information that was
obtained under a promise of confidentiality. You have the right to request a restriction of your
protected health information – This means you may ask us not to use or disclose any part of
your protected health information and by law we must comply when the protected health
information pertains solely to a health care item or service for which the health care provider
involved has been paid out of pocket in full. You may also request that any part of your protected
health information not be disclosed to family members or friends who may be involved in your
care or for notification purposes as described in this Notice of Privacy Practices. Your request
must state the specific restriction requested and to whom you want the restriction to apply. By
law, you may not request that we restrict the disclosure of your PHI for treatment purposes. You
have the right to request to receive confidential communications – You have the right to
request confidential communication from us by alternative means or at an alternative location.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have
agreed to accept this notice alternatively i.e. electronically. You have the right to request an
amendment to your protected health information – If we deny your request for amendment,
you have the right to file a statement of disagreement with us and we may prepare a rebuttal to
your statement and will provide you with a copy of any such rebuttal. You have the right to
receive an accounting of certain disclosures – You have the right to receive an accounting of
all disclosures except for disclosures: pursuant to an authorization, for purposes of treatment,
payment, healthcare operations; required by law, that occurred prior to April 14, 2003, or six
years prior to the date of this request. You have the right to obtain a paper copy of this notice
from us even if you have agreed to receive the notice electronically. We reserve the right to
change the terms of this notice and we will notify you of such changes on the following
appointment. We will also make available copies of our new notice if you wish to obtain one.
COMPLAINTS
You may complain to us or to the Secretary of Health and Human Services if you believe your
privacy rights have been violated by us. You may file a complaint with us by notifying our
Compliance Officer of your complaint. We will not retaliate against you for filing a complaint.
We are required by law to maintain the privacy of, and provide individuals with, this notice
of our legal duties and privacy practices with respect to protected health information. We
are also required to abide by the terms of the notice currently in effect. If you have any
questions in reference to this form, please ask to speak with our HIPAA Compliance
Officer in person or by phone at our main phone number. Please sign the accompanying
“Acknowledgment” form. Please note that by signing the Acknowledgment form you are
only acknowledging that you have received or been given the opportunity to receive a
copy of our Notice of Privacy Practices.
Patient/Guarantor Signature
Date