San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet

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1 San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet By completing this questionnaire you provide us with important, basic information for our records. Please print your answers so that our Business Office can establish an accurate record with the information you furnish. Patient s Name: Patient s Date of Birth: / / Patient s Home Address: Primary Contact Phone: ( ) home work cell (Appointment reminders are received at this number) Secondary Contact Phone: ( ) home work cell address: Guarantor Information (Person who carries insurance ) Last Name: First Name: Relationship to patient: Date of Birth: Home Address: City, State, Zip: Employer: Daytime phone: ( ) home work cell Evening phone: ( ) home work cell Revised 8/12/11 P:Registration Ind Forms MKH IM New patient update sheet

2 San Ramon Valley Primary Care Medical Group, Inc. Internal Medicine Department Patient Name: Date of Birth: PATIENT PRIVACY Your privacy is important to us. San Ramon Valley Primary Care Medical Group, Inc. complies with current state and federal privacy standards. Your/your child s health information will not be released by us without your express written permission except under required State and Federal statutes. Please note that parents of children over the age of 18 have no legal right to access their adult child s medical record without written permission from the patient. I have been given a copy of San Ramon Valley Primary Care s Notice of Privacy Practices. I have been given a copy of San Ramon Valley Primary Care s Notice of Privacy Practices. Signature: Date: Emergency Contact: Name Telephone Number ************************************************************************************************** Cancelling Appointments We charge $50.00 for physical examination appointments not cancelled with 48 hours notice. We charge $25.00 for ill visits not cancelled with 24 hours notice. Financial responsibility for services rendered by San Ramon Primary Care Medical Group I acknowledge that I am responsible for payment of a $15.00 fee which will be added to my copayment for failure to pay at the time of service. I acknowledge that acceptance of my insurance information is not a guarantee of payment by my health plan until the claim has been processed and paid. I further understand that if my claim is not accepted for payment I am personally responsible for payment of medical services rendered to myself or a member of my family. I acknowledge that all health plan deductibles and charges for non-covered benefits are due and payable within 30 days of presentation of a billing statement from the Practice. I acknowledge that medical billing statements for services rendered by San Ramon Valley Primary Care will be sent to the person who carries the insurance for the patient/family member. I acknowledge that I have read the above payment policies of San Ramon Valley Primary Care Medical Group, Inc. and agree to abide by them. Assignment of insurance benefits I assign all medical, surgical benefits, and or major medical benefits to which I am entitled from private insurance and/or any other health plans, to San Ramon Valley Primary Care Medical Group Inc. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I further authorize the release of any medical or other information necessary to process this claim. Signature: Date: NOTICE TO CONSUMERS Medical doctors are licensed and regulated by the Medical Board of California (800)

3 San Ramon Valley Primary Care Medical Group, Inc. Release of Medical Information Your privacy is important to us. San Ramon Valley Primary Care Medical Group, Inc complies with current state and federal privacy standards. Your health information will not be released by our office without your express written permission except under state and federal legal statutes. If you would like to authorize our office to release your personal medical information to another individual i.e. husband, wife, parent, adult child, sibling, please sign the authorization below. You may revoke this authorization at any time by notifying our office in writing. I hereby authorize San Ramon Valley Primary Care Medical Group to release my medical information to the following individual: Name: Relationship: Name: Relationship: Name: Relationship: I understand that I may revoke this authorization any time by notifying San Ramon Valley Primary Care in writing of my intention. Signature: today s Date: Print Name: D.O.B. Regarding Telephone Messages Patient privacy considerations prevent us from leaving medically-related messages on your voic /answer system unless you choose to authorize us to do so. Authorizing the recording of medically-related messages on your voic /answer system is your choice, not your obligation. If you choose to authorize us to leave medically-related messages on your voic or answer message system, please read and sign the following: I hereby authorize San Ramon Valley Primary Care Medical Group, Inc., to leave a message on the answering device at: Phone: (Circle One) Home Cell Office

4 Signature: Today s Date: Last Name Date of Birth / / Age Signature Legal First Name Today s Date / / Abnormal Pap AIDS/HIV Alcoholism Anemia Anorexia/Bulimia Appendicitis Arthritis Asthma Bleeding Disorder Blood Transfusion Breast Lump Cancer Cataracts Chicken Pox Colitis Congenital Disorder Depression Diabetes Diverticulitis PAST MEDICAL HISTORY Place a checkmark ( ) next to the conditions you have now or have had in the past. Drug Dependency Emphysema Fibromyalgia Gallbladder Disease Glaucoma Gout Hay Fever / Allergies Head Injury Heart Disease Hepatitis Hernia High Blood Pressure High Cholesterol Hormone Therapy Kidney Disease Measles Migraine Mononucleosis Multiple Sclerosis Mumps Pacemaker Pneumonia Polio Prostate Problems Psoriasis Psychiatric Care Rheumatic Fever Scarlet Fever Seizures Stroke Suicide Attempt Tonsillitis Tuberculosis Typhoid Fever Ulcer(s) Vaginal Infection Venereal Disease Other Illness: Women Only: Age started menses: # Days bleeding: # Days in cycle: # Pregnancies: # Live births: # Miscarriages: # Abortions: Contraceptive method: PAST HOSPITALIZATIONS / SURGERIES Please list all the times you have been hospitalized, or operated on. Year Hospitalization for Illness / Injuries Surgeries HEALTH MAINTENANCE INFORMATION Last Physical Exam: Last Pap Smear: Last Mammogram: Last Chest X-Ray: PROVIDER USE ONLY Last Blood Tests: Usual Weight:

5 Patient Name: DOB: FAMILY HISTORY Relationship Father Mother Brothers Sisters Spouse Children Age if living Age at death Please fill in health information about your family. State of Health OR Cause of Death Have any blood relatives had any of the following? If so, indicate relationship to you. ILLNESS Alcoholism Arthritis Asthma/Emphysema Blood Disease Cancer Colitis Diabetes Drug Dependency Heart Disease High Blood Pressure Mental Problems Migraine Stroke Suicide Tuberculosis Other: FAMILY MEMBER SOCIAL PROFILE Where were you born? Level of education? Current employment? Recent change in job? Marital status? Living with (spouse / significant other / roommate / family) How often do you exercise? What exercise do you do? Have you ever had a problem with drugs/alcohol? How much coffee/tea do you drink per day? Have you ever smoked? How many cigarettes per day? For how many years? What year did you quit smoking? Do you drink alcohol? How many drinks per day? Are you exposed to fumes/solvents? Are you exposed to loud machinery? Do you regularly wear a seatbelt? Is your sex life satisfactory?

6 Patient Name: DOB: CURRENT ALLERGIES, SENSITIVITIES, INTOLERANCES List anything you are allergic/sensitive to (medication, foods, chemicals, etc.) and how each affects you. Allergic to Effect CURRENT MEDICATIONS List all medications you are now taking, including those you buy without a prescription. List name, dose, and how often per day. Have you traveled outside the U.S. in the past two years? YES NO Where? When? When was your last Tetanus Pneumococcus Rubella Hepatitis B? Measles TB Skin Test (pos / neg) Influenza Mumps Please list any other physicians/providers who are treating you:

7 PLEASE BRING THE FOLLOWING ITEMS TO YOUR APPOINTMENT: INSURANCE CARD If you do not have your insurance card, payment will be required at the time of your visit. PHOTO ID - Required for patients over the age of 18. IMMUNIZATION RECORD If available. PRESCRIPTION BOTTLES VITAMIN BOTTLES This information will enable the physicians and staff of San Ramon Valley Primary Care Medical Group to better serve you. Thank you for your assistance.

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