Document 6428029

SWEDISH COVENANT MEDICAL GROUP
AUTHORIZATION
I.
General Consent To Treatment:
I agree and consent to the performance of diagnostic and therapeutic procedures deemed
necessary by the patient's physician(s). I acknowledge that there are no guarantees,
expressed or implied, as to the results of any procedures or m~dical treatment.
II.
Release of Information:
I authorize physicians providing services on behalf of the patient to release all billing and
medical information (including information concerning mental health, genetic testing,
substance abuse and HIV status, if applicable) to physicians or institutions providing
follow-up care, the Social Security Administration, Medicare, Medicaid (or their various
intermediaries), and the insurance company, health maintenance organization, employer,
person acting on behalf of a preferred provider arrangement or third party named on this
patient information form (or any of their agents or representatives), when such information
is requested for payment, worker's compensation, utilization review, or coverage
determination purposes, I understand that this authorization will remain in effect unless
revoked by me in writing and delivered to this physician's office.
III.
Receipt of Notice of Privacy Practices
I acknowledge receipt of the Swedish Covenant Medical Group Notice of Privacy
Practices.
IV.
Assignment of Insurance or Third Party Coverage
A. I authorize any third party payor to pay directly to the physicians providing services
to the patient, all benefits due and payable as a result of services rendered.
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B.
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V.
I authorize assignment to the physician who has provided services to the patient the
insured's rights to penalties and attorney's fees in the event that the insurer fails to
timely pay such benefits in accordance with lllinois State Law.
Acknowledgement of Responsibility to Pay for Services
I understand that the physician will, as a courtesy, file claims with insurance carriers and
third party payors. However, I acknowledge and agree that, except as provided by law, and
in consideration of the services provided, I will pay any charges which, for any reason, are
not paid by any third party payor unless there is a specific written agreement to the contrary
between the physician and the patient or between the physician and the payor.
VI. Medicare Patients
I request that payment of authorized Medicare\Medigap benefits be made either to me or on
my behalf to
for any services furnished me by the
provider. I authorize any holder of medical information about me to release to the Centers
for Medicare and Medicaid Services or my Medigap insurance and its agents any
information needed to determine these benefits or the benefits payable for related services.
I understand that this authorization will remain in effect unless revoked by me in writing
and delivered to this physician's office.
DATE
SIGNATURE OF PATIENT/ REPRESENTATIVE
Relationship of Representative
SK Revised 02/21/12
SWEDISH COVENANT MEDICAL GROUP
AUTHORIZATION
I.
General Consent To Treatment:
I agree and consent to the performance of diagnostic and therapeutic procedures deemed
necessary by the patient's physician(s). I acknowledge that there are no guarantees,
expressed or implied, as to the results of any procedures or medical treatment.
II.
Release of Information:
I authorize physicians providing services on behalf of the patient to release all billing and
medical information (including information concerning mental health, genetic testing,
substance abuse and HIV status, if applicable) to physicians or institutions providing
follow-up care, the Social Security Administration, Medicare, Medicaid (or their various
intermediaries), and the insurance company, health maintenance organization, employer,
person acting on behalf of a preferred provider arrangement or third party named on this
patient information form (or any of their agents or representatives), when such information
is requested for payment, worker's compensation, utilization review, or coverage
determination purposes, I understand that this authorization will remain in effect unless
revoked by me in writing and delivered to this physician's office.
III.
Receipt of Notice of Privacy Practices
I acknowledge receipt ofthe Swedish Covenant Medical Group Notice of Privacy
Practices.
IV.
Assignment of Insurance or Third Party Coverage
A. I authorize any third party payor to pay directly to the physicians providing services
to the patient, all benefits due and payable as a result of services rendered.
B.
V.
I authorize assignment to the physician who has provided services to the patient the
insured's rights to penalties and attorney's fees in the event that the insurer fails to
timely pay such benefits in accordance with Illinois State Law.
Acknowledgement of Responsibility to Pay for Services
I understand that the physician will, as a courtesy, file claims with insurance carriers anQ
third party payors. However, I acknowledge and agree that, except as provided by law, and
in consideration of the services provided, I will pay any charges which, for any reason, are
not paid by any .third party payor unless there is a specific written agreement to the contrary
between the physician and the patient or between the physician and the payor.
VI. Medicare Patients
I request that payment of authorized Medicare\Medigap benefits be made either to me or on
my behalf to
for any services furnished me by the
provider. I authorize any holder of medical information about me to release to the Centers
for Medicare and Medicaid Services or my Medigap insurance and its agents any
information needed to determine these benefits or the benefits payable for related services.
I understand that this authorization will remain in effect unless revoked by me in writing
and delivered to this physician's office.
DATE
SIGNATURE OF PATIENT/ REPRESENTATIVE
Relationship of Representative
SK Revised 02/21112
SWEDISH COVENANT MEDICAL GROUP
PATIENT CONTACT INFORMATION
(6/29/Io)
Date:- - - - - -
Affix Patient Label Here
Please tell us how you prefer to have your medical care provider communicate Confidential Personal Heath
Information (PHI) to you.
(Check as many as you wish)
_Cell telephone number_ _ _ _ _ _ _ _ _ _ _ _ _ __
Best times- - - - - - - - - - -
_Home telephone number________________
Best times
_Work telephone number with extension_ _ _ _ _ _ _ _ __
-----------
Best times- - - - - - - - - - -
US Postal Service
May confidential PHI be left on phone voicemail? ___Y es_ _ _No
May we leave confidential PHI, including test results, with another person? ___Yes_ _ _N,o
If yes, with whom may we leave the message? Name_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Personal relationship to you_ _ _ _ _ _ _ _ __
Keep in mind that ifyou choose your cell, home, or work telephone as preferred choice, we cannot protect
confidential PHI!
It is your responsibility to notify this office if there is a change in address/telephone Thank you!
Patient/Guardian Signature_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
SWEDISH COVENANT MEDICAL GROUP
Personal Health History Form
Affix Patient Label Here
DATE: ______________
Patient N a m e : - - - - - - - - - - - - - Primary D o c t o r : - - - - - - - - - - - - -
Medications:
Referred B y : - - - - - - - - - - - - - - Reason for v i s i t : - - - - - - - - - - - - - - - - - - - - - - D Married (Living with domestic partner)
Personal Profile:
DSingle
DDivorced
Allergies:
DWidowed
Current or most recent occupation/date:
Have you recently traveled outside the U.S.?
YES
NO
Country Visited _ _ _ _ _ _ _D,ate______
GYNECOLOGICAL HISTORY
Date of last pap: __/__/__
Results:
Normal
Abnormal
(Please circle one)
If abnormal, explain: - - - - - - - - - - - - Have you ever had an abnormal Pap test? YES NO
Age of your first period:
First day of your last Menstrual Period:
Length of your period:
(Number of bleeding days)
____/_ _/_ _
Number of days between each period: _____
Date of last mammogram: __/__/__ Any Breast Biopsies: YES
NO
Date_/__/__
Last Bone Density Scan: __/__/__
Last Colonoscopy: __/__/_
Have you had any menstrual problems?
YES NO
If yes, e x p l a i n : - - - - - - - - - - - - - -
Do you bleed through your clothing or sheets? YES NO
Do you often wear a tampon AND a pad for more protection?
Do you ever stay home from work due to bleeding?
YES NO
YES NO
Does your bleeding affect your work, social, athletic or sexual activities?
YES NO
Are you in a sexual relationship?
YES NO
Are there any sexual problems?
YES NO If yes, explain: - - - - - - - - - - - - - -
Sexual Partners are:
Men
Age at first intercourse: _ __
Women
Both
Total number of sexual partners in your lifetime: _ __
Total number of sexual partner within the last year: ___
Method of birth control: Presently _ _ _ _ _ _ _ _ _ _ In the P a s t - - - - - - - - - - - - - - - -
OBSTETRIC HISTORY
Number
Number
Pregnancies
Miscarriages
Full term births
Abortions
Preterm births(< 37 weeks)
Ectopic/Tubal pregnancies
Vaginal Births
Complications:
Cesareans
Explain:
Number of living Children
Gestational Diabetes:
Yes
No
Yes
No
PAST MEDICAL HISTORY: please check off
Illness
NO
YES
Diabetes
High Blood Pressure
Sexually Transmitted Diseases (Gonorrhea,
Hepatitis B, Hepatitis C, Chlamydia or HIV)
YES
Seizures/Convulsions/Epilepsy
Asthma/TB/Iung disease
Kidney Infections/Stones
Ulcers/Reflux
Bowel Problems
Hepatitis/Liver Disease
Tuberculosis
Depression/Anxiety
Cancer
Blood Transfusions
Rheumatic Fever
Gall Bladder Disease
Lupus
None
NO
Stroke
Headaches/Migraines
Osteoporosis
Thyroid Disease
Urinary Tract Infections
Blood Clots in Lungs or Legs
Surgeries:
Illness
Heart Attack/Disease
Rheumatoid Arthritis
Adult Bone Fractures
Glaucoma
0
Date
Surgery
Any Complications
SOCIAL HISTORY
NO
YES
Tobacco (Present or past use)
Alcohol
Recreational Drug Use
Calcium Supplements
Have you ever been sexually, physically
or verbally abused?
Herbal or Alternative Medicines or
Therapies
FAMILY HISTORY
NO
YES
Packs per day:
Drinks per day:
Type of Drug:
Quantity:
By Whom?
Relationship
Breast Cancer
Colon Cancer
Ovarian Cancer
Uterine Cancer
Cancer Other
Blood Clots in Legs or Lungs
Osteoporosis
Diabetes
#of
Years:
Drinks per week:
How used:
Dose:
Currently?
NO
YES
Stroke (under age 50)
Heart Attack (under age 50)
Thyroid disease
High Cholesterol
Birth defects or Mental
Retardation
Alcoholism or Drug Abuse
Alzheimer's Disease
PATIENT SIGNATURE_ _ _ _ _ _ _ _ __
DATE____~/______/ _________
PHYSICIAN SIGNATURE _ _ _ _ _ _ __
DATE____~/_ ___:/_____
Revised 1/201 0
Relationship
.
(~
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.·
;
.•
PRENATAL HISTORY
1. When was Ute first day of your last menstruat period _ _ _ _ _ _ _ _?
2. Are you sure about thls date or just the month
3. Wa~
?
yOw- last period of nonnal amount and duration _ _ _ _ _ _ _ _?
4. Do you have regular monthly periods _____________,__?
5~ About how often do they come (i.e. every 28
days, 30 days) _ _ _ _ _?
6. Where you on birth controJ at the time of conception
?
7. Old you take a home pregnancy teat or blood test to confirm this pregnancy?
Yes or No. If yes, when did you take the test
?
8. Please list any past pregnancies (fast six):
Date
or
Blt1ll
GA
u:'
sa
Blrtll
WdJIIt
MIP
Labor
Ddlyery
'
\
~
A•a.
f'lae.oJ
l"w.
DtiiYerT
Ten~~
La..r
vm
Co -.
Co.......C.
,.,
..
\."
Past Medical History
Have you or anyone In your Immediate family ever had the following: •
·-·•order
Ytr
Or
No
uonnoealacL
Daft ct Treatmeat
Dbear............er
Yea
Or
No
IJemiliednd.
Datt & Treatment
16. Rh Seasitized
2. Hyporteusion
J1. P\J
(TB, Al1bma)
3. Heart Disease
18. Alleraiea
r
(Drup)
4.Auto
19. Breat
Disorder
· S.
-./ Dlleue
20.0ynecolop
Uriuuy Tract haC.
S\qery
6. •
·v
Epilepsy
22• .{
c
Complications
8. Hepatitiaf
2l.Hiltory ef
AboormaiPap
Livu Diseaso
9. v
.
24. UtaiPc
Anomalies
10. Thyroid
25. IDfedility
Dys1imctiOD
II. Thtumal
26.
Family Histo.ry·
Doaadc Violence
12. HistoJy of
Bloocl Tnalftuioa
ADIMDt Per Day
rre-Prepaaq
13. Ti
14.
·Amoat P'er Day
Number of Yean
DllliDc ilrepaaq
01l1se
. i
Genetic Screening/Teratology Counseling
lncludea patient. baby'a father, or anyone In either family with:
YES
YES
NO
J. Patient'a Age> 35 Yean
2. Th~l .
(Italian, <heok.
Medlteqaacan, or Allan Back·
NO
II. Huntfa&toa Olorea
12. Mental Rctardalionl Autism
Oround)
If yes, wu penon tested for
J. Neunl TUbe Oofectt
(Mcnfnaomyclocele, Spina Biftda
.
fragile X?)
or"
haly)
4. Conaoaital Heart Defect
13. Other blherited ocnodc or
Ovomoaomal Dflordor
5.Dowa~1
.e:..-
6. T..,~
~B.a. 1~ caJun
or French Canadian)
,.
· 7. Sictlc CeU DSMUe or Ttait
-
.
(Afiicaa)
8. Hemopbilia
9.
·u.~--.-Y
10. Cystic Fibrom
I 8. Aay OCher
INl'BCTION BJSroRY
1.~.0'
tB/
2.Livewida
:witlalB
·or ExpOIOd to 1B
3. Patic:At or Putuer hal • ._,_.1
of~ -•· ·Rape~
~~-
14. Matemal MoCabOiiC
(o.c. iAiuUil depoadeat
dfabofcl, PKU)
IS. Patialt or I!_~·· Fatbor HacJ
a Child with Birth Dcfectl Not
Listed Abovo
16. Rec:urrent Pregnaacy Loll,
or a Stillbirth
17. M
....Veet Dl'upl
Alcohol Since Lut MeDitnlal
Pcried
lfYes, Which Ones:
YES
NO
YES
4. Raila or ViraiiiiDc!el Silico
Last Me8struaJ Period
s. .
ofsn>, oc,
Cblamycti., HPV. Sypbilis
6:00.
NO
SWEDISH COVENANT MEDICAL GROUP
Financial Policy
Thank you for choosing us as your health care provider. We are dedicated to providing the best possible care for you, and we
want you to completely understand our fmancial policies. Please feel free to speak with our Operations Manager if you have
any questions about our fees or financial policy.
•
All new patients must complete our "Patient Registration Form" prior to seeing the provider. Please inform the receptionist
if any of this information changes, especially a name change, address change, or phone number change.
•
It is the patient's responsibility to provide us with current insurance information and photo I.D., prior to seeing the
provider. We will need to see your insurance card at each visit.
•
Our Practice accepts various insurances and managed health care programs (HMOs). For patients that are members of one
of these plans, our business office will submit a claim for services rendered. The patient must complete all necessary
forms required by the insurance company.
•
If a patient has insurance that we do not accept, our office will file the claim; however, payment in full is expected at the
time of service.
•
It is the patient's responsibility to pay any deductible, co-payment or any portion of the charges as specified by the
insurance plan at the time of visit. Any medical services not covered by an individual's insurance plan are the patient's
responsibility and payment is due at the time of visit.
•
It is the patient's responsibility to ensure that any required referral for treatment is provided to the receptionist prior to the
visit. Your visit may need to be rescheduled, or the insurance coverage may be denied if the referral is not provided in
advance.
•
If you are unable to pay for urgent medical care, you may be eligible for a payment plan. However, charges for tests such
as lab work, ultrasound, etc., must be paid for at the time of service, even though they are separate services not
offered in our office. The bill you receive today may not be your fmal bill for any lab or radiology services billed
by our office. It is your responsibility to inform us prior to the visit if this situation applies to you.
•
We accept Medicare assignment and our Practice will bill directly for services. Patients are responsible for payment of
deductible or co-insurance after Medicare has processed the claim for the services rendered.
•
If a patient is being seen for an employer-authorized work-related injury, our Practice will bill workers' compensation
directly. If the employer's verification of injury cannot be obtained, the patient will be responsible for payment and
private patient billing information will be required.
•
If the patient is a minor (18 years and younger), the parent or guardian will be responsible for payment at the time of
service.
•
Any patient account balance that is placed on a payment plan or is referred to a collection agency will be assessed a
minimum 5 percent fee on the outstanding patient portion.
•
We ask that appointments be cancelled at least 24 hours in advance. If this does not occur and you cancel less than 24
hours in advance it will be considered a "no show". If we do not receive advance notice of the cancellation, a $25.00
charge will be billed to the patient directly and not the patient's insurance.
•
If a patient accrues more than 3 No Show's in a calendar year, provider may initiate dismissal from the practice.
I have read and understand the practice's financial policy, and I agree to be bound by its terms. I also understand and agree that
such terms may be amended by the practice from time to time.
Signature of Patient or Responsible Party, if minor
Please print the name of the patient
Revised.SK 07/11
Date