Personal Contact and Insurance Information

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1 Kenneth A. Holt, M.D Executive Drive Tele: Building E, Suite 222 Fax: Raleigh, NC Personal Contact and Insurance Information Please fill out this form as completely as possible to help us update your medical history. Thank You. Demographic Information Patient Name: Date of Birth Home Address: Apartment Telephone (home): Work: Patient s Social Security Number: Driver License: State Number Preferred method of contact: Phone: Home Cell Work Paper mail Is it permissible to leave personal information on messages? Yes No Primary Care Physician: Referred by: Marital Status: Married Single Separated/Divorced Widowed Sex: Employment Status: Employed Retired Student Other Employer Occupation: Address: Suite Primary Insurance Information Name of Primary Insurance Company: Insured s Name: Relationship to Patient: Self Spouse Parent Insurance Company s Address: Subscriber Number: Group Number: pg 1 please continue to next page Last Updated 6/9/2014

2 Patient Demographic Information Secondary Insurance Information Name of Secondary Insurance Company: Insured s Name: Relationship to Patient: Self Spouse Parent Insurance Company s Address: Subscriber Number: Group Number: Spouse/Partner Name: Date of Birth Relationship to you: Sex: Address: Apartment Telephone (home): Work: Guarantor/Responsible Party Same as: Self Spouse/Partner Name: Relationship to you: Sex: Address: Apartment Telephone (home): Work: Emergency Contact Same as: Spouse/Partner Name: Relationship to you: Sex: Address: Apartment Telephone (home): Work: pg 2 please continue to next page...

3 Patient Demographic Information Special Notices Release of Information to Insurance Companies I authorize the release of any medical or other information necessary to process claims on my behalf. I agree to be fully responsible for all lawful debts incurred by myself for services received Metro Internal Medicine P.A. whether covered by insurance or not. No-Show/Cancellation Fees In order to insure timely and efficient care for all of our patients there will be a $25 fee for missed appointments or appointments cancelled within less than 24 hours. Exceptions to this policy may be made in the case of an emergency or at the physician s discretion. Patient s Signature: Date: Authority to sign, if not patient pg 3

4 Kenneth A. Holt, M.D Executive Drive Tele: Building E, Suite 222 Fax: Raleigh, NC Personal Medical History NAME: DOB: Please fill out this form as completely as possible to help us update your medical history. This form is confidential; however, if you prefer you can discuss these matters (or other personal matters) directly with the nurse or Dr. Holt. Thank You. Medical Problems Problems Date diagnosed Managing physician Surgical and Hospitalization History Reason for hospital visit or surgery Facility Attending Physician Date Allergen (what causes the reaction) Allergies Type of reaction pg 1 please continue to next page... Last Updated: 6/10/2014

5 Personal Medical History Medications, Supplements and OTC drugs For Internal use only: If noted elsewhere in the chart, where are they? Medication, dose, frequency, route Date Started If you need more space please use the back of this page. Immunizations Immunization Provider Date Flu Pneumonia Shingles Tetanus Other Physicians and Care Providers Name & Specialty/Provider Type Type of care Date discontinued Name Local: Mail Order: Preferred Pharmacy (local and mail order, if applicable) Phone number pg 2 please continue to next page...

6 Personal Medical History Do you have an Advanced Directive, Living Will or Healthcare Power of Attorney? If you answered yes, please consider providing us with a copy for your chart. If you do not have an advanced directive, living will or healthcare power of attorney and want one a very user friendly one is available from Simply click on the Download Your State Specific Advance Directive link and find your home state. The North Carolina form is here: Signature: Date: Authority to sign, if not patient pg 3

7 Kenneth A. Holt, M.D Executive Drive Tele: Building E, Suite 222 Fax: Raleigh, NC Family Medical & Social History NAME: DOB: Please fill out this form as completely as possible to help us update your medical history. This form is confidential; however, if you prefer you can discuss these matters (or other personal matters) directly with the nurse or Dr. Holt. Thank You. Family Medical History Deceased Birth year or age Diabetes Hypertension Heart disease Stroke Mental Illness Colon or rectal cancer Breast cancer Other cancer Kidney disease Obesity Genetic disorder Alcoholism Liver disease Depression or manic depressive disorder Other diseases Number of relatives Self Father Mother Sisters Brothers Sons Daughters Pat. Grandfather Pat. Grandmother Mat. Grandfather Mat. Grandmother Paternal Uncle Paternal Aunt Maternal Uncle Maternal Aunt Please check boxes to note any disease or condition you or a relative has. pg 1 please continue to next page... Last Updated: 6/12/2014

8 Family Medical & Social History Personal Social History Tobacco: Current Type: Freq: 2 nd hand Never Prior use Quit date: Recreational drug use: Never Occasional Daily Prior use Quit date: History (please describe): Alcohol: Never Occasional Daily History (please describe): Caffeine: Never Occasional Daily Native area/hometown: Hobbies: Sexually active: Travel outside USA: Occupation: Occupational exposure: Diet notes: Exercise type/frequency: Home Environment Private home Assisted living Smoke detector Other (Describe): Patient Signature: Date: Authority to sign, if not patient pg 2

9 Metro Internal Medicine, P.A. Kenneth A. Holt, M.D Executive Dr. Tele: Bldg E, Suite 222 Fax: Raleigh, NC Office Policy on Managed Care Insurers In order to accommodate the needs and requests of our patients we have enrolled in numerous managed care insurance programs. While we are pleased to be able to provide this service to you, it is extremely difficult for us to keep track of all the individual requirements of the plans. Every program has different stipulations regarding which services are permitted, how often services may be rendered, and even more importantly, where those services may be performed. Plans may differ depending upon what type of contract you or your employer has negotiated. Providing quality medical care for our patients is our primary concern. We are more than willing to provide that care within your insurance contract guidelines if you let us know at EACH time of services exactly what those guidelines are. It is the patient's responsibility to settle ALL outstanding balances with Metro Internal Medicine and maintain and follow up with any issues pertaining to medical claims upon each office visit. It is the patient's responsibility to inform us of any special requirements in your contract that we subsequently order services for, such as lab work, consultations and/or hospitalization. We, nor the selected medical facility, will have any other choice but to bill you directly for those charges. Investigating any potential attempts for acquiring reimbursement for your charges with your indemnity is also your responsibility if the claim is denied to the providers of your medical services. Payment for ALL charges is your responsibility. With your cooperation and help, you should be able to receive all of the benefits offered to you by your insurance company and we will be able to concentrate on caring for your medical necessities. I have read and understood the office policy stated above for Metro Internal Medicine and agree to accept responsibility for all balances incurred as described. Sincerely, Metro Internal Medicine, P.A. Patient s Signature: Date: Patient s Name: Authority to sign, if not patient (including your printed name)

10 Kenneth A. Holt, M.D Executive Dr. Tele: Bldg E, Suite 222 Fax: Raleigh, NC AUTHORIZATION TO RELEASE MEDICAL RECORDS All sections must be completed Patient s Name: Birthdate: Address: Social Security #: City, State, Zip: Phone # (home): Maiden/Other Names: (work): I authorize Metro Internal Medicine to release and/or receive information in my patient records as directed below: 1. Name and address of person or organization with whom medical information is to be exchanged: Name: Phone: Address (City, State, Zip): 2. Purpose of disclosure: 3. Dates of service: From To 4. Specific provider s records to be released: 5. Revocation/Expiration. This authorization can be revoked in writing at any time, unless the provider marked above has already acted upon your request. All requests/instructions must be in writing, dated and signed. 6. Fees. There may be a fee associated with the processing of this request. Please check with staff for estimated costs. The providers marked above frequently contract with third party vendors for confidential record copy services, so the bill for records copy may be generated by a third party vendor. 7. Method of release: Mailed Faxed ed Picked up ( Paper CD) If records are to be ed I acknowledge that is inherently unsecured. And, while the providers marked above will make every effort to insure security on their end they have no control over the security of my Important Notice: THE CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS ARE PROTECTED BY NORTH CAROLINA AND FEDERAL LAWS AND REGULATIONS. THE CONFIDENTIALITY LAWS AND REGULATIONS PROHIBIT THE DISCLOSURE OF THESE RECORDS UNLESS ONE OF THE FOLLOWING CONDITIONS IS MET: a. THE PATIENT CONSENTS IN WRITING; b. THE DISCLOSURE IS ALLOWED BY A COURT ORDER; c. THE DISCLOSURE IS MADE TO MEDICAL PERSONNEL IN A MEDICAL EMERGENCY OR TO QUALIFIED PERSONNEL FOR RESEARCH, AUDIT OR PROGRAM EVALUATION. VIOLATION OF THESE LAWS AND REGULATIONS IS A CRIME. SUSPECTED VIOLATION MAY BE REPORTED TO APPROPRIATE AUTHORITIES IN ACCORDANCE WITH THE LAWS AND REGULATIONS. FEDERAL LAWS AND REGULATIONS DO NOT PROTECT ANY INFORMATION ABOUT SUSPECTED CHILD ABUSE OR NEGLECT FROM BEING REPORTED UNDER STATE LAW TO STATE OR APPROPRIATE LOCAL AUTHORITIES. My authorization to disclose the above information is voluntary, and the providers marked above will not condition the provision of treatment on this authorization. I further understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and is no longer protected by the laws and regulations applicable to the providers marked above. Signature Date Authority to sign, if not the patient Copy to patient

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