allcare medical centers, pc patient information/authorization to treat

ALLCARE MEDICAL CENTERS, P.C.
PATIENT INFORMATION/AUTHORIZATION TO TREAT
PATIENTS NAME
DATE OF BIRTH
MAILING ADDRESS
CITY
)
HOME PHONE (
CELL PHONE (
AGE
ZIP
)
SEX: M OR F
DRIVER'S LICENSE#
PATIENT SSN
MARITAL STATUS: SINGLE PARTNERED MARRIED SEPARATED DIVORCED WIDOWED
PATIENT EMPLOYER
WORK PHONE (
)
EMAIL ADDRESS
HOW DID YOU HEAR ABOUT US?
PRIMARY PHYSICIAN
PERSON TO CONTACT IN CASE OF EMERGENCY
RELATIONSHIP
FIRST AND LAST NAME
PHONE(
)
**IF PATIENT IS A MINOR PLEASE PROVIDE US WITH THE FOLLOWING INFORMATION:
PARENT/GUARDIAN NAME
DO YOU PLAN TO VACCINATE/IMMUNIZE YOUR CHILD?
INSURANCE
POLICY #
please present card @ time of service
GROUP#
NAME OF PERSON INSURED
DATE OF BIRTH
PHONE (
)
RELATIONSHIP
EMPLOYER
WAS THIS A MOTOR VEHICLE ACCIDENT
A WORKMEN'S COMPENSATION CLAIM
**PLEASE INITIAL THE FOLLOWING:
I HEREBY AUTHORIZE ALLCARE MEDICAL CENTERS, P.C. TO PROVIDE TREATMENT
AS PRESCRIBED BY MY PHYSICIAN.
I HEREBY ASSIGN ALL INSURANCE BENEFITS FOR SERVICES RENDERED TO BE PAID
DIRECTLY TO ALLCARE MEDICAL CENTERS, P.C..
I UNDERSTAND THAT IF MY INSURANCE CO/THIRD PARTY PAYER DENIES PAYMENT OR
MAKES PARTIAL PAYMENT I AM RESPONSIBLE FOR THE BALANCE DUE.
I HEREBY AUTHORIZE THE RELEASE OF MEDICAL RECORDS TO ALLCARE MEDICAL
CENTERS, P.C. AND ANY PERTINENT INFORMATION CONCERNING THE PATIENT
FOR THE PROVISION OF CARE AND FOR OBTAINING INSURANCE REIMBURSEMENT.
I UNDERSTAND THAT I AM LEGALLY RESPONSIBLE FOR PAYMENT OF ALL SERVICES
RENDERED BY ALLCARE MEDICAL CENTERS, P.C. INSURANCE IS BEING BILLED
AS A COURTESY. I AM RESPONSIBLE FOR PAYING ANY DEDUCTIBLE OR CO-INSURANCE
AMOUNTS. I UNDERSTAND THAT CO-PAYMENTS ARE DUE AT THE TIME OF SERVICE.
SIGNATURE OF PATIENT/PARENT/GUARDIAN
DATE
Telephone (941) 388-9887
Fax (941) 306 -5876
E mail: allcaremedicalcenters.com
Allcare Medical Centers
8209 Natures Way Suite 115-117
Lakewood Ranch, Florida 34202
-
Two Way Authorization to Release Confidential Information
In accordance with the Federal and State statutory requirements concerning confidentiality of records, I
request and give my permission to release/exchange information about the following individual:
(Please Print)
Patient Name:
Date of Birth :
I hereby request that medical information which may include chemical dependency information be release
between:
Allcare Medical Centers
and
8209 Natures Way Suite 115-117
Lakewood Ranch, Florida 34202
The specific information to be released/exchanged is:
Psychiatric/Psychological Information
Medical History, Lab, X-Ray Date, Etc...
Psychological Testing Information
Chemical Dependency Assessment/Evaluation
All Available Information
at my request.
This information is to be used for the purpose of
of Two Way
Revocation
a
requesting
by
time,
any
at
revoked
be
may
I understand that this consent
Authorization form. In any event, if not previously revoked this consent will expire upon
or 1 (one) year from the signature date.
Signature of Patient:
Date:
Signature of Responsible Party:
Date:
Signature of Witness:
Date:
NOTE: a photocopy or fax of this release is as good as the original
Allcare Medical Centers will not condition treatment, payment, enrollment, or eligibility for benefits on this
authorization.
Allcare Medical Centers notifies you of the potential that this information, once forwarded to the other
party, could be redisclosed and no longer protected by the rule.
AilCare Medical Centers, P.C.
DATE OF BIRTH/AGE:
OMALE
OFEMALE
MARITAL STATUS:
NAME:
S M D W SEP
HONE: (H):
PHONE:
(W):
NAME ADDRESS AND PHONE NUMBER OF PREFERRED PHARMACY:
1 VACCINE:
ALLERGIES:
•
.
•
'
TEST/
YEAR OF
LAST
EXAM
LAST
„,
-
1-
,.
--,,
:iv - ''"
YEAR OF
1
.--_,
,
tz..
Tetanus/TD
Physical
Influenza (Flu)
Cholesterol
Pneumonia
Eye
Hepatitis B
PAP
Tuberculosis Skin Test
Mammogram
Zoster
Gardasil
Prostate/PSA
Colonoscopy
MEDICATION LIST: Please include all prescriptions, Over the counter, and herbal medications.
Dose
Medication
Frequency
New Med(w/in 3 mon.) Reason for medication
Last fill
SOCIAL HISTORY: PLEASE ANSWER THE FOLLOWING BY CHECKING(4) THE BOX AND FILL IN THE BLANK.
, ri Smoke
oz per week
'_-_. Drink alcohol
cups per day
I__ Drink coffee/tea
i use seat belt
E'
Drug history - Marijuana
Ecstasy opium
_ History of sexual abuse
Exercise:
1- Current sexual abuse
Sedentary (no exercise)
Diet: L Normal
rl
ri Any other tobacco?
ri Are you interested in quitting?
Li
L High fiber/veggy
E High salt
'I
L High fat
Are you interested in quitting?
LSD
ILLNESS OR OPERATION
Heroine PCP Meth.
Li Quit
__ Current spousal abuse
Occasional vigorous exercise
C. High cholesterol
HOSPITAL ADMISSION (not including pregnancies) USE BACK OF SHEET IF YOU NEED TO ADD MORE.
MON/YEAR
Cocaine
Currently using
History of Spousal abuse
Mild (climb stairs, walk 3 blocks, golf)
years years quit
#cig/day
- Herbal diet
•
AllCare Medical Centers, RC
Women Health Questions
Check ('I) problems you have or have had in the past.
❑
Abnormal PAP smear
❑ Extreme menstrual pain
❑ Painful intercourse
❑
Bleeding between period
❑ Hot flashes
❑ Urinary problems
❑
Bleeding with intercourse
❑
Irregular periods
❑ Vaginal discharge
❑
Breast lump
❑
Nipple discharge
❑ Vaginal infections
At what age did you menstrual period began?
How often does your periods occur?
Date of last menstrual period
How long do they last?
How many days of heavy flow?
Are you sexually active? ❑ yes ❑ no
More than one partner? Oyes Ono
Are you using condoms? Oyes Ono
Are you using contraception, if so what kind?
If you have breast implants, do you have Silicon ❑ Saline 0 ? Did you have the implant insert in the US? ❑ yes
Have you had a cone(cutting) 0
❑
No
LEEP(burning) ❑ cryo (freezing) 0 on your cervix before?
Results of your last PAP?
Date/Result of your last Bone Density?
PREGNANCIES
_
,-
„.;;---
_
MM/DD/YY
HOSPITAL/DOCTOR
# of children now living
VAG/C-SECTION
# of miscarriages/stillbirths
COMPLICATION
SEX OF CHILD
WEIGHT OF CHILD
# of elective terminations
Men Health Questions
Do you usually get up to urinate during the night? ❑ no
❑ yes, if so, # of time
Do you feel pain or burning with urination? ❑ no
D yes
Any testicle pain/swelling? ❑ no
Do you have discharge from your penis? ❑ no
❑ yes
Date of last prostate and rectal exam?
Has the force of your urination decreased? ❑ no
❑ yes
Have you thought of a vasectomy? Eno ❑yes❑ Had it
Any difficult with erection or ejaculation? ❑ no
❑
yes
Have you had any kidney, bladder, or prostate infections within the last year?
❑
no
❑
yes
❑ yes
AilCare Medical Centers, P.C.
FAMILY HEALTH HISTORY: LIST SIGNIFICANT HEALTH PROBLEMS NOT LISTED BELOW
„ ,Aade
ra,...;J3.•.,...-...,
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AGE
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'"41.6441661111461M11111111111111111111MMMIII1
SIGNIFICANT HEALTH
Father
Mother
Siblings
Children/s
Paternal grandparents:
Maternal grandparents:
MEDICAL HISTORY
IF ANY BLOOD RELATIVE HAS SUFFERED ANY OF THE FOLLOWING- PLEASE PLACE A 'I IN THE BOX & INDICATE WHICH
RELATIVE AND AGE OF DIAGNOSIS. CIRCLE THE WORD IF IT APPLIES TO YOU AND DATE OF DIAGNOSIS.
❑ DEMENTIA
❑ TUBERCULOSIS
❑ DIABETES WITH PND
❑ GOUT
❑ ALZHEIMERS
❑ PNEUMONIA
❑ PERIPHERAL ARTERY DIS.
❑ DISC DISEASE
❑ PARKINSONS DIS
❑ GERD
❑ AMPUTATION
❑ HEMORRHOIDS
❑ MENTAL ILLNESS
❑ CVA
EBREAST CANCER
❑ OVERACTIVE BLADDER
❑ DEPRESSION
❑ HEART FAILURE
❑ STOMACH CANCER
❑ HPV
:ALCOHOLISM
❑ HYPERTENSION
❑ LIVER DISEASE
❑ HERPES
❑ CHEMICAL DEPENDENCY
❑ ATRIAL FIBRILATION
❑ CHRONIC HEPATITIS B
❑ HSV
❑ SEIZURE
❑ HEART DISEASE
❑ HIV
❑SLEEP APNEA
❑ HEADACHE
❑ HEART ATTACK
❑ HYPERLIPIDEMIA
❑ IMPOTENT
❑ MIGRAINE
L
❑ISTABLE ANGINA
❑ KIDNEY DISEASE
❑ 13PH
❑ CATARACTS
❑ UNSTABLE ANGINA
❑ RENAL DIALYSIS
TIPROSTATE CANCER
❑GLAUCOMA
❑ STROKE
:BLEEDS EASILY
❑COLON CANCER
❑ HYPERTHYROIDISM
❑ PACEMAKER
❑ BLOOD TRANSFUSION
❑ 0VARIAN CANCER
❑ HYPOTHYROIDISM
❑ PREVIOUS STENT
❑ TRANSPLANT
❑ CERVICAL CANCER
EASTH MA
❑ PREVIOUS CABG
DOSTEOARTHRITIS
❑ UTERINE CANCER
❑ COPD
❑ DIABETES TYPE 1
❑ OSTEOPOROSIS
❑ ANEMIA
❑ LUNG CANCER
❑ DIABETES TYPE 2
❑ RHEUMATOID ARTHRITIS
❑ HAYFEVER
AliCare Medical Centers, P.0
REVIEW OF SYSTEM: Check Mend indicate how long you have had any of the following symptoms:
❑ Heartburn/reflux
❑ Rectal bleeding
❑ Memory loss
■ Headaches
❑ Angina(armpain/shoulder/jaw)
■ Impotence
❑ Light headed
❑ Eye pain
I High blood pressure
❑ Pain in the testicles
❑ Fatigue/lethargy
❑ Loss of vision
■ Breast pain
❑ Loss of libido
❑ Increased thirst
❑ Double Vision
■
Breast discharge
■ Vaginal discharge
❑ Insomnia
❑ Ringing in ears
■
Breast Mass/lesion
❑ Vaginal mass/lesion
❑ Dizziness/fainting
❑ Pain in ears
II Abdominal pain
■ Hot flashes
• Heat intolerance
❑ Hoarseness
■
❑ Rash
❑ Cold intolerance
❑ Coughing up blood
■ Constipation
❑ Pain with walking
❑ Weight loss
❑ Nasal congestion
■ Change in bowel habit
111 Swelling of joint
❑ Weight gain
❑ Nose bleed
❑ Diarrhea
❑ Stiffness of joints
❑ Anxiety
❑ Trouble chewing
❑ Back pain
❑ Ankle swelling
❑ Depression
❑ Trouble swallowing
■
Urine frequency
■
■ Nervousness
❑ Sore throat
■
Painful urination
❑ Morning stiffness in joint>lhr
❑ Suicidal
❑ Neck stiffness/pain
■
Increase urination
❑ Muscle pain
■ Hallucinations
■ Cough
❑ Blood in urine
■ Athralgia (joint pain)
■ Cpap machine
■ Shortness of breath
■
Decrease in urine flow
❑ Numbness of extremities
❑ Snoring
■ Wheezing
■
Urine leakage
❑ Foot ulcer
111 Daytime sleepiness
■ TB exposed
❑ Recent chills
■ Toe pain
❑ Increase hunger
■ Vomiting blood
■
Recent fevers
❑ Vomiting
II Easy bleeding
■ Chest pain
■
Black/tarry stools
■ Nausea
❑ Easy bruising
❑ Palpitation
■ Stool incontinence
❑ Tremors
■ Fractures
❑
glasses/contacts
Loss of appetite
Loss of strength
Risk Assessment for Lynch Syndrome and Hereditary Breast and Ovarian Cancer Syndrome
Physician:
Today's Date:
Patient Name:
Date of Birth:
This is a screening tool for cancers that run in families. Please consider these family members when completing the
form:
Mother/Father/Sister/Brother/Children = 1st Degree Relatives
Aunt/Uncle/Grandparent/Niece/Nephew = 2" Degree Relatives
Cousin/Great Grandparent = 3rd Degree Relatives
Have you or any of your relatives been tested for hereditary cancer (BRCA/Colaris) in the past? YES
NO
YOUR RELATIONSHIP TO FAMILY
COLON AND UTERINE CANCER (Lynch Syndrome/Colaris)
MEMBER w/ CANCER
SELF
MOTHER'S SIDE
EXAMPLE: Two or more relatives with a Lynch syndrome
cancer; one under age 50
0
Y
Y
N
N
FATHER'S SIDE
Aunt-colon
Sister-uterine
AGE AT
DIAGNOSIS
47 y
yrs
60 yrs
Have YOU been diagnosed with uterine (endometrial) or
colorectal cancer before age 50
Two or more relatives on the same side of the family w/ any
of the following, one diagnosed before 50 (please circle):
colon, uterine/endometrial, ovarian, stomach, small bowel,
brain, kidney/urinary tract, ureter and renal pelvis
Y
N
Y
N
Three or more relatives on the same side of the family w/
any of the following diagnosed at any age (please circle):
colon, uterine/endometrial, ovarian, stomach, small bowel,
brain, kidney/urinary tract, ureter and renal pelvis
Family member has a known Lynch syndrome mutation
BREAST AND OVARIAN CANCER (HBOC/BRACAnalysis)
YOUR RELATIONSHIP TO FAMILY
MEMBER w/ CANCER
SELF
MOTHER'S SIDE
Y N
Breast cancer at age 45 or younger
(in self, first or second degree family members)
Y
N
Ovarian cancer at any age
(in self, first or second degree family members)
Y
N
Two relatives on the same side of the family with breast
cancer—with one under the age of 50
Y
N
Three relatives on the same side of the family with breast
cancer at any age
Y
N
Multiple breast cancers in the same person (in the same
breast or in both breasts)
Y
N
Male breast cancer at any age
Y
N
Ashkenazi Jewish ancestry with breast, ovarian or pancreatic
cancer in the same person or on the same side of the family
Y
N
Pancreatic cancer with breast or ovarian cancer in the same
person or on the same side of the family
Y
N
Triple Negative breast cancer under age 60
(ER, PR and Her2 negative receptor status)
Y
N
A family member with a known BRCA mutation
FATHER'S SIDE
Is there any other cancer in you or any family members not listed above provide site, relationship and age):
Patient's signature:
Date:
AGE AT
DIAGNOSIS
jAllCare Medical Centers, P.C.
Patient Authorization for Use and Disclosure of Protected Health Information
5 By signing, I authorize AllCare Medical Centers, P.C. to use and/or disclose certain protected
health information (PHI) about me to
10
This authorization permits AllCare Medical Centers, P.C. to use and/or disclose the following
individually identifiable health information about me (specifically describe the information to be
used or disclosed, such as date(s) of services, type of services, level of detail to be released,
origin of information, etc.):
The information will be used or disclosed for the following purpose:
(If disclosure is requested by the patient, purpose may be listed as "at the request of the
individual.")
15
The purpose(s) is/are provided so that I can make an informed decision whether to allow release
of the information. This authorization will not expire until I designate an expiration or it will
expire
whichever comes first.
The Practice will receive payment or other remuneration from a third party in exchange for using
or disclosing the PHI.
20
25
I do not have to sign this authorization in order to receive treatment from AllCare Medical
Centers, P.C. In fact, I have the right to refuse to sign this authorization. When my information
is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the
recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to
revoke this authorization in writing except to the extent that the practice has acted in reliance
upon this authorization. My written revocation must be submitted to the privacy officer at:
AllCare Medical Centers, P.C.
8209 Nature's Way, Suite 115-117
30 Lakewood Ranch, FL 34202
Signed by:
Signature of Patient or Legal Guardian
Relationship to Patient
Print Patient's Name
Date
35
40
Print Name of Patient or Legal Guardian, if applicable
Patient/guardian must be provided with a signed copy of this authorization form.
45
AlICare Zleclical Centers,
— HIPPA Form
AllCare Medical Centers, P. C.
8209 Natures Way Suite 115-117
Lakewood Ranch, Florida 34202-4218
941-388-8997 Fax 941-306-5876
OFFICE POLICY
Dear Patients,
We consider it a privileged responsibility to be chosen as your health care providers. This is a trust that does not come easily, and
we will make every effort to ensure that your trust is well placed and your confidentiality be protected. To that end, we agree:
•
•
•
•
To provide you with the best care we can, in a timely and cost effective manner with every effort to minimize
waiting time.
To return your calls as quickly as possible, and to take adequate time to understand your specific problems and
when necessary, arrange for all referrals to specialists and testing facilities.
To bill your insurance company in a timely, to be as accurate as possible with our billing procedures, and to
efficiently answer any billing questions you may have.
To be responsive to your constructive criticism in an attempt to continuously improve our services.
In return, and to help us meet the above goals, we ask of our patients the following:
•
•
•
•
•
•
•
Co-pays must be paid at every visit. We do not bill for co-pays. There will be a $2.00 Service Charge on all
payments using Credit and Debit Cards
Your Account balance past 30 days must be paid prior to the next visit. If you cannot pay, other options may be
evaluated. Please speak to the front office staff.
A monthly late fee charge of $35.00 will be applied to your account if you have not made your minumim
monthly payment.
Self-Pay patients are required to pay for their visit in full at the time of service unless other arrangements have
been made.
Please inform the front office of any change of personal information. For example: phone number, address,
marital status, and insurance information, etc.
Please keep all appointments. Any No Show or Late Cancel appointments may be charged as follows:
First Time — No Charge
Second Time — Half price of the Visit scheduled.
Third Time — Full Price of the Visit scheduled.
If your account balance remains past due after 90 days, we will notify you that without a response from you; we
may use a collection agency or our attorneys to obtain payment in full.
IF YOU ARE SEEN OUTSIDE OF OUR NORMAL BUSINESS HOURS THERE WILL BE A AN EXTRA
CHARGE OF $30.00 TO BE PAID BY THE PATIENT — INSURANCE WILL NOT COVER THIS
Thank you for the opportunity to serve you.
The staff at AllCare Medical Centers, P. C.
I agree to abide by the policies and procedures of the AllCare Medical Centers office.
Date:
Patient's Signature:
Patient's Name:
DOB:
Witness Signature: