New Patient Adult Information Revised

FOREST FAMILY CARE, INC.
ADULT PATIENT INFORMATION
Patient Name:
(Please Print)
Date
Last
First
Home Address:
City:
Phone: Home (
Work: (
)
Social Security # Patient
Sex:
Male
Language:
-
Female
Marital Status:
Race:
Middle
Single
White
English
-
State:
)
)
Cell: (
Age
Zip:
Birth Date:
Transgender
Married
Hispanic
Hispanic
Widowed
Black
Other
Divorced
Separated
Other
Veteran
Email:
Employer:
Primary Insurance Co.
Insurance ID #
Group #
Policy Holder SS #
Secondary Insurance Co.
Insurance ID #
Group #
Policy Holder SS #
-
-
-
-
Emergency Contact:
Phone : (
)
Preferred Pharmacy:
Phone: (
)
I Understand the FINANCIAL POLICY OF THIS OFFICE IS AS FOLLOWS: Payment to be made prior to service. Co-pay's,
deductible and non-covered services are to be paid at time of service. I understand that my signature is valid for the
purpose of filing me or my child's insurance and I authorize payment of benefits to Forest Family Care, Inc.
PLEASE GIVE YOUR INSURANCE CARD(S) TO RECEPTIONIST TO COPY. THANK YOU.
Patient's signature:
Date:
FOREST FAMILY CARE, INC.
1785 W. Lee Hwy
(276) 228-6499—Phone
Wytheville, VA 24382
(276) 228-6145—Fax
STATEMENT OF PATIENT FINANCIAL RESPONSIBILITY
Forest Family Care appreciates the confidence you have shown in choosing us to provide for your health care
needs. The service you have elected to participate in implies a financial responsibility on your part. The
responsibility obligates you to ensure payment in full of our fees. As a courtesy, we will verify your coverage and bill
your insurance carrier. We expect these payments at time of service. Many insurance companies have additional
stipulations that may affect your coverage. You are responsible for any amounts not covered by your insurer. If your
insurance carrier denies any part of your claim or if you or your physician elects to continue past your approved
period, you will be responsible for your balance in full.
I have read the above policy regarding my financial responsibility to Forest Family Care for providing services
to me. I certify that the insurance and demographic information I have supplied to this office is, to the best of my
knowledge, true and accurate.
Date:
Patient/Guarantor Signature:
CO-PAY POLICY
Some health insurance carriers require the patient to pay a co-pay for services rendered. It is expected at the time
the service is rendered for the patient to pay his/her co-pay at EACH VISIT. Thank you for your cooperation in this
matter.
Patient/Guarantor Signature:
Date:
UN-INSURED (SELF PAY) POLICY
If un-insured, I agree to pay Forest Family Care $100.00 (or the full balance of the office visit, whichever is less) on
the office visit, and then pay $50.00 per month on the remaining balance of the account until the account is paid in
full.
I agree if payments are not made in the full amount stated above/or payments are not received on time, the entire
balance will be considered delinquent and balance due in full.
Patient/Guarantor Signature:
Date:
FOREST FAMILY CARE, INC.
1785 W. Lee Hwy
(276) 228-6499—Phone
Wytheville, VA 24382
(276) 228-6145—Fax
AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION
DOB:
PATIENTS NAME:
ZIP:
CITY:
ADDRESS:
SOCIAL SECURITY NUMBER:
I herby authorize :
(Physician From Whom You Are Requesting Records)
To Provide Confidential Information Contained Within My Medical Record To:
FOREST FAMILY CARE
Information To Be Released Should Include:
n COMPLETE HEALTH RECORD
r7 Office Notes n Discharge Summary' 1History & Physical Exam
n Consulting Reports n Progress Notes n Laboratory Test Results In X - Ray Reports I I
7 X-Ray Films/Images 71 Immunization Record I I Demographic/Insurance Information
Itemized Bill
The Purpose Of This Request Is:
I-1 Treatment and/or Consultation! I At The Request Of The Patient 710ther:
The Following Dates Of Service Should Be Included In This Request:
El ALL DATES OF SERVICE El From (Date):
To (Date):
I, the undersigned, have read and authorize the staff on the disclosing facility named to disclose information as
herein contained. I understand the information disclosed by this authorization may be subject to redisclose by the
recipient and will no longer be protected by the Health Insurance Portability and Accountability Act of 1998. The
facility, its employees, officers and physicians are hereby released from any legal responsibility or liability for
disclosure of the above information to the extent indicated and authorized herein. I understand that I do not have to
sign this authorization, and my treatment or payment for services will not be denied if I do not sign this form unless
specified about under "Purpose of Request". I can inspect or copy the protected health information to be used or
disclosed. Except to the extent that action has been taken in compliance with this request, this authorization may be
revoked by me at any time, by submitting a notice in writing to the Privacy Office at Forest Family Care. Unless
revoked, this authorization will expire In six months unless otherwise specified, or in the event of
Signature
Initial
Date
I acknowledge and hereby consent to such, that the released information may contain alcohol abuse,
psychiatric, sexually transmitted disease, Hepatitis B or C, HIV testing, HIV results or AIDS information.
FOREST FAMILY CARE, INC.
1785 W. Lee Hwy
(276) 228-6499—Phone
Wytheville, VA 24382
(276) 228-6145—Fax
ADULT HISTORY
PATIENT NAME:
DOB:
AGE:
TO HELP US MEET ALL OF YOUR HEALTHCARE NEEDS, PLEASE FILL OUT THIS FORM COMPLETELY. THIS IS A
CONFIDENTIAL RECORD OF YOUR MEDICAL HISTORY AND WILL BE KEPT IN THIS OFFICE.
Today's date:
When was your last physical exam?
1. CURRECT MEDICATIONS/VITAMINS/SUPPLEMENTS
Drug Name:
•
•
How Often:
Dose:
Have you been seen in the past for chronic pain management? Circle One: Yes or No
Current medication you are presently out of? (Please provide medications in space
below)
2. Please check any of the following MEDICAL problems that you have had.
YES
Abnormal Weight Gain
Abnormal Weight Loss
Excessive Fatigue
Insomnia
Anemia
Cancer
Tumor
NO
YES
Hearing Loss
Ear Problems
Ringing in Ear
Dentures
Dental Problems
Sores in Mouth
YES
Gout
Broken Bones
Breathing Problems
Frequent Bronchitis
Emphysema
Pneumonia
Asthma
Rash
Hives
Glasses/Contacts
If so, please specify:
Glaucoma
Cataracts
NO
Heart Attack
High Blood Pressure
Heartburn
Ulcer Disease
Gallbladder Disease
Blood in Stool
Hepatitis
Diarrhea, Constipation,
or other changes in
bowel habits
Hemorrhoids
Abdominal Pain
Colon Polyp
If so, when was last
colonoscopy?
Seizure
TIA
Stroke
Numbness
Weakness
Memory Loss
Headaches
Depression
Anxiety/Panic Attacks
Suicide Attempt
Physical Abuse
Sexual Abuse
NO
YES
YES
NO
Angina
Frequent Chest Pain
Irregular Heartbeat
Heart Murmur
Arthritis or join pain
Rheumatic Fever
High Cholesterol
Heart Failure
3.
NO
Mental Illness
Diabetes
Thyroid Disease
Abnormal Pap Smear
Breast Lump
Please list any food or drug ALLERGIES you have had:
Date of Occurrence:
Reaction:
Name of drug/food:
4.
YES
NO
Urinary Frequency
Bladder Infections
Prostate Problems
Urinary Incontinence
Kidney Problems
Please check or list all of the SURGERIES you have had:
Year
Type of Surgery
Year
Type of Surgery
Hysterectomy
Knee or Hip Replacement
Mastectomy or Lumpectomy
Polyp Removal (colon)
Tonsillectomy/Adenoidectomy
Tubal Ligation or Vasectomy
Plastic Surgery
Other (specify)
Appendectomy
Arthroscopy (joint)
Back or Neck Surgery
Cataract Surgery
Cesarean Section
Gallbladder Removal
Heart Surgery (specify)
Hemorrhoids
Hernia
5. Please list any HOSPITALIZATIONS you have had in the past 3 years.
Type of Surgery
Year
Type of Surgery
6. For WOMEN
Last menstrual period
Last pap smear - n/a
Last mammogram - n/a
/
/
/
/
/
/
Last bone density
/
/
Age of first period
# of days in cycle
# of days in flow
Are you menopausal
Age at onset of
menopause
YES or NO
# of pregnancies
# of live births
# of
miscarriages
# of abortions
# of living
children
Year
7. Have any of your FAMILY members had any of the following?
Family Member
Diabetes
Hypertension
Heart
Di ease
Stroke
Mental
Illness
Cancer
Daughter
Father
Son(s)
Mother
Paternal
Grandfather
Paternal
Grandmother
Maternal
Grandfather
Maternal
Grandmother
Sibling(s)
Children
8. SOCIAL HISTORY
•
Do you smoke currently?
o
YES NO
•
If no, did you smoke in the past?
•
Are you exposed to smoke?
•
Any other tobacco use?
o
YES
YES
YES
NO
NO
NO
If so, what type?
•
Do you drink caffeine?
YES
NO
•
Do you drink alcohol?
YES
NO
o
#of years smoking
cig/d
If so, how much?
drinks/day
If so, how much?
YES NO
•
Have you ever used drugs?
•
Do you exercise?
•
Do you wear a seatbelt?
•
Is there concern for your safety (emotional, physical, or sexual abuse)?
YES NO
YES NO
YES NO
Unknown
FOREST FAMILY CARE, INC.
1785 W. Lee Hwy
(276) 228-6499—Phone
Wytheville, VA 24382
(276) 228-6145—Fax
NOTICE OF DEEMED CONSENT
TESTING FOR BLOOD BORNE INFECTIONS
Should an employee of Forest Family Care be exposed to my blood or bodily fluid in a way
that might allow transmission of infection due to blood borne disease (i.e. HIV, Hepatitis B,
Hepatitis C, etc) or other communicable diseases, then I understand that according to
Virginia State Law, for the safety, health and possible treatment of the employee, samples
of my blood or bodily fluid may be tested for evidence of infectious diseases.
Likewise, I also understand that Forest Family care employees and physicians are obligated
to submit to blood tests for certain infectious diseases if I am inadvertently exposed to their
blood or bodily fluid during the course of my treatment.
Routine testing of blood for HIV and other blood borne infection is not performed. Testing
for such will only be performed as outlined above unless I am specifically informed and
counseled otherwise.
Patient Name: (Please Print):
Signature of Responsible Party:
Date of Birth:
Date:
FOREST FAMILY CARE, INC.
1785 W. Lee Hwy
(276) 228-6499—Phone
Wytheville, VA 24382
(276) 228-6145—Fax
Acknowledgment of Receipt of Privacy Notice and Patient Consent to the Use and Disclosure of Health Information
for Treatment, Payment, or Health Care Operations. Consent for photograph.
1.
I acknowledge that I have been provided with Forest Family Care Notice of Privacy Practices that provides a
more complete description of information uses and disclosure. I understand that I have the right to review
the Notice of Privacy Practices prior to signing this consent. I understand that Forest Family Care reserve the
right to change its Notice of Privacy Practices and prior to implementation may mail a copy of any revised
3.
notice to the address I have provided.
I understand that I have the right to request restrictions as to how my health information may be used or
disclosed to carry out treatment, payment, or health care operations, and the Forest Family Care is not
required to agree to the restrictions requested, but if it does, it is bound by such restrictions.
I understand that I may revoke this consent in writing, except to the extent that Forest Family Care has
4.
already taken action in reliance thereon.
By signing this form, I consent to Forest Family Care use and disclosure of my health information for
5.
treatment, payment, and health care operations.
I understand and consent for the patient's photograph to be taken either via camera or valid picture ID, as
2.
part of my medical record.
{Optional}
I request the following restriction to the use or disclosure of my health information:
❑
Restrictions Accepted
❑
Restrictions Denied
Employee Signature/Title:
I hereby give my permission to the person(s) listed below to authorize treatment and to receive information about
the care of the patient named below:
RELATIONSHIP
NAME
In order for the person(s) listed above to obtain information by telephone, the party calling the practice must provide
the following Patient Identifier:
Responsible Party
Print Patient Name:
Signature of Patient or Responsible Party:
Signature of Employee:
Date of Birth:
Date:
FOREST FAMILY CARE, INC.
1785 W. Lee Hwy
(276) 228-6499—Phone
Wytheville, VA 24382
(276) 228-6145—Fax
Controlled Medication Agreement
This agreement is between the patient and Forest Family Care. We are committed to doing all we can to treat
medical conditions. In some cases, narcotic pain medicines and/or potentially addictive nerve medications may be
necessary to treat your condition. These medications are strictly regulated by both Federal and State Agencies. This
contract is designed to protect both you and your physician by establishing guidelines, within the laws for proper
controlled medication use. It is agreed that controlled medication will be given by Forest Family Care to the patient
ONLY if the following terms are met:
1.
By signing a contract for controlled administration, the patient indicated that he/she understood the
discussion about the use of controlled medications, including side effects and is agreeable to start this
2.
3.
The patient has the chance to ask questions regarding alternative to the use of controlled medications.
Forest Family Care should be the ONE AND ONLY SOURCE of controlled medications unless written
4.
permission is given by a FFC physician for the patient to get controlled prescriptions from another physician.
ONLY ONE PHARMACY will be used for filling controlled prescriptions.
treatment under the terms set by FFC.
Pharmacy Name
5.
If it is found that the patient received prescriptions for controlled medications from a source other than a FFC
physician, without written permission, FFC may void this agreement and discontinue any prescriptions of
controlled medications to the patient.
6.
The patient agrees to have urine test for medications done randomly at the physician's request.
The patient must agree to follow the FFC physician to communicate with the referring physician and any
pharmacists regarding the patient's use of controlled substances.
7.
8.
The patient must supply documentation of treatment by other physician for co-existing, or relating condition,
including psychiatric conditions.
9.
The patient understands that FFC will NOT replace any lost or inaccessible controlled prescriptions or
controlled medications, for ANY REASON.
10. The patient must take the controlled medications as instructed by a FFC Physician.
11. Any unauthorized increase in the dose of controlled medication may be viewed as a cause for discontinuation
of the treatment with controlled medications.
12. If the patient demonstrates unacceptable behavior patterns, the FFC physician may discontinue prescribing
the controlled medications for the patient.
13. The patient must keep all regular follow up appointments as recommended by the FFC physicians. Failure to
comply may cause discontinuation of controlled prescriptions.
14. The patient must comply with all aspects of the treatment plan, including, but not limited to, Physical
Therapy, Behavioral Management and self-help programs,
15. All prescriptions must be picked up by the patient himself/herself. If the patient is too debilitated or sick, an
exception may be allowed.
16. NO controlled prescriptions will be refilled on weekends or over the phone.
17. Controlled medications WILL NOT be refilled early.
18. The patient understands the benefit of the controlled medications will be evaluated periodically using the
following criteria of pain relief, increase in general functions, increase in exercise, completion of
rehabilitation program, return to work, maintenance of job, etc.
19. The patient understands the controlled medications can be discontinued immediately, at the treating
physician's discretion, if the patient does not fulfill the terms of this agreement. Medications can also be
discontinued if there is evidence of rapid tolerance, loss of effectiveness or if significant side effects develop.
20. The patient certifies or agrees to the following:
a)
That he/she is not currently abusing illicit or prescription drugs.
b)
That he/she has never been involved in the sale, illegal possession, diversion or transport of controlled
substances (controlled, sleeping pills, nerve pills or pain killers).
c)
That she is not pregnant and that she will use appropriate contraception during her course of treatment.
d)
Sharing your controlled medications is strictly prohibited. Any sharing will result cancellation of your
prescription refills.
21. Evidence of medication hoarding, increasing the amount of the medication without communication to your
FFC physician, refilling your prescription too frequently, getting the medication from multiple physicians,
increasing the amount of medication despite significant side effects, altering prescriptions, medication sales,
unapproved use of other drugs (alcohol, sedatives or using non-prescription, medications inconsistent with
drug labeling) during controlled analgesic treatment or other unacceptable behavior will result in tapering
and discontinuing of controlled therapy.
22. If the patient is no-compliant or un-cooperative with the Physician or Office Staff we reserve the right to
discharge you at any time.
I fully understand the explanations regarding the benefits and the risks of this method of treatment.
This has been fully explained to me, I have read it or have had it read to me, and I understand it. I have had the
opportunity to ask questions, and have received acceptable answers. I agree to the terms of this contract.
DATE:
Patient Name (Print):
Patient Signature: