New Patient Packet. Welcome and thank you for choosing Provident Healthcare. Please complete this packet and bring it with you to your first visit.

Transcription

1 New Patient Packet Welcome and thank you for choosing Provident Healthcare. Please complete this packet and bring it with you to your first visit. For your reference, you may want to write down your appointment time here: Appointment Date and Time: Provider: Please remember to arrive 25 minutes prior to your appointment time if your paperwork is completed. If you have not completed your paperwork, please arrive 45 minutes prior to your appointment time. Enclosed in this packet, you will find: Patient Information Sheet Medical History Form (2 pages) Review of Systems Form (2 pages) Office Policies Release of Healthcare Information When you arrive for your appointment, you will be asked to review our Privacy Practices policy and sign an acknowledgement that you have received it. If you have any questions before your appointment, please call our office at If you prefer, you can ask to speak to the clinic manager. New Patient Packet Page 1 Internal Use: Info Entered Provider Signoff Scan to Patient Information Sheet

2 Today s Date: Patient Information Sheet Date of Appointment: Patient Name: Street Address: Apt. or Unit #: City: State: Zip Code: Social Security Number: Date of Birth: (Your Social Security number is used for identification purposes only; you are not required to provide it.) Which provider are you seeing for your first appointment? How did you hear about us? Physician Friend/ Patient Insurance Company Internet Other Home Phone Number: ( ) Our computer system has the capability to store several phone numbers for patients. If you would like us to keep an alternate number (other than your work number) on file, please list it here: ( ) Type of number (e.g. cell phone, pager): Which is the number that you prefer we use most of the time? Please note that our computer system leaves messages reminding you of appointments at your home number. Would you like to be able to communicate via with your care team or receive results? Yes / No Employer: Work Phone: ( ) x Please give us the name of a relative or friend to contact in case of emergency. Name and Relationship to you: Phone: ( ) Address, if not living with you: City, State and Zip: Insurance Billing: Please be sure to bring your insurance card(s) and prescription cards (if applicable) to your appointment with you. If you are not the policy holder of your insurance policy, please provide the name of the policy holder here: Policy holder s date of birth: Responsible Party (the bills for the patient's healthcare will be sent to this person). Do not complete if it is the patient. Name: Address: City: State: Zip: Home Phone: Work Phone: New Patient Packet Page 2 Internal Use: Info Entered Provider Signoff Scan to Patient Information Sheet

3 Patient Name: Medical History Form Date of Birth: Date of First Appointment: Reason for your visit today: When did problem first begin Work/ Accident Related: Yes/ No If yes, what was the date of the accident/ injury Please list any chronic illness or diseases that have been diagnosed by a doctor: Please list any operations you have had (include date, type of surgery, name and location of hospital): List previous hospitalizations (other than operations): Have you ever received a blood transfusion? yes no Please list any allergies you have (and the reaction): What pharmacy do you use? Phone Number: What medications are you currently taking? (Please include over the counter medications, including vitamins or herbal remedies. If you need more room, please attach a separate page.) Medication Dose (strength) How often Reason for taking Social History and General Questions: What is your job or occupation? Excessive exposure at home or work to: Fumes Dust Solvents Airborne Particles Noise Are you: single (never married) married divorced widowed Do you have any children? yes no How many? Sons Ages: Daughters Ages: Have you ever been a smoker? yes no If you have quit, when? How much per day? For how many years? How much alcohol do you drink? drinks per day week month (please circle one) New Patient Packet Page 3 Internal Use: Info Entered Provider Signoff Scan to Health History

4 Medical History Form, continued Patient Name: Date of Birth: Date of First Appointment: What do you do for exercise? How many days per week do you exercise? When was your last tetanus shot? Pneumonia shot? Males Only: If you are over the age of 45, when was your last prostate exam? Females Only: Number of pregnancies: Number of miscarriages: Number of live births: Number of abortions: Date of last menstrual period: When was your last Pap smear? Was it normal? yes no When was your last mammogram? Was it normal? yes n Family History: Age if living Cause of death (if dead) Age of death Father Mother Brothers Number Living Number Dead Sisters Number Living Number Dead List any other illnesses that run in your family: (hypertension, strokes, diabetes, heart attacks, cancer, thyroid problems): New Patient Packet Page 4 Internal Use: Info Reviewed Provider Signoff Scan to Health History

5 Patient Name: Review of Systems Form Date of Birth: Date of Appointment: Have you been diagnosed with or are currently having (within the last 6 months) any of the following? If the response is No for an entire category, circle No on the top line and skip the remaining part of the section. Constitutional: Do you have the following: Weight Gain Insomnia Weight Loss Fever Fatigue Weakness Chills Night Sweats Lethargy Hematologic: Do you have the following: Easy Bruising Easy Bleeding Blood Clots Swollen lymph nodes Comments: Comments: Neurological/ Head, Eyes, Ears, Throat: Do you have the following: Headaches Eyes: Double Vision Redness Pain Spots/ Floaters Itching Burning Tearing Discharge Visual Loss: None Right Eye Left Eye Bilateral Corrective Glasses Contacts Both History of: Radial Keratotomy Lasik Ears: Hearing Loss Pain Ringing Discharge Fullness/Plugging Nose & Sinus: Nasal Congestion Facial Pain Obstruction Decreased Smell Allergies Freq. Nose Bleeds Discharge Sneezing Freq. Infections Throat: Freq. Sore Throats Swallowing probs Hoarseness Cold Sores Sore Tongue Change in Taste Tooth Pain Snoring Comments: _ Respiratory: Do you have the following: Cardiovascular: Do you have the following: Chest pain with breathing TB Exposure Chest Pain Passing out Shortness of Breath Wheezing Swelling in legs/ ankles Palpitations Cough Freq. Infections Shortness of Breath with Exertion Shortness of Breath at night Comments: Gastrointestinal: Do you have the following: Significant loss of appetite Altered Bowel Habits Weight Loss Abdominal Pain Nausea Abdominal Mass Vomiting Difficulty swallowing (Food Getting Stuck) Vomiting of Blood Acid Reflux Diarrhea Indigestion/ Heartburn Constipation Jaundice Blood in Stool/ Rectal Bleeding Anal Conditions (e.g., hemorrhoids) Abdominal Bloating Comments: If you would like to make additional notes, please do so at the bottom of the next page. New Patient Packet Page 5 Internal Use: Info Reviewed Provider Signoff Scan to Health History

6 Patient Name: Review of Systems Form, continued Date of Birth: Date of First Appointment: Genitourinary/ GYN: Do you have the following: Urinary frequency Change in urine color Urinary hesitancy Urinary urgency Back Pain Painful urination Blood in urine Flank Pain Excessive urine Incontinence Decreased Stream Passage of stone/gravel Groin Mass Foul urine odor Cloudy Urine Frequent Urination at Night Comments: Male Reproductive: Do you have the following: Musculoskeletal: Do you have the following: Scrotum/ Testicular Mass Blood in sperm Bone/Joint Symptoms Genital Herpes Penile Discharge Back Pain Scrotum/Testicular Pain Muscle Aches History of other sexually transmitted diseases: Metabolic/Endocrine: Do you have the following: Voice Change Cold Intolerance Heat Intolerance Hair Loss Coarse Hair Excessive Perspiration Goiter (enlarged thyroid) Chronically Overweight Tremors Chronically Underweight Excessive Thirst Excessive Urination Abnormal Hair Distribution Generalized Weakness Infertility Darkening of Skin History of Abnormal Glucose Tolerance Test Comments: _ Neurological/Psychiatric: Do you have the following: Vertigo Difficulty enunciating words Seizures Incoordination Fainting Gait Disturbance Numbness Visual Disturbance Dizziness Memory Loss Focal Weakness Psychiatric/ Emotional Concerns Comments: _ Dermatologic: Do you have the following: Rash Excessive Sweating Changing or concerning moles Nail Changes Acne Comments: _ Immunological: Do you have the following: Asthma Hay Fever Hives: Contact Dermatitis: Food Allergies: Bee Sting Allergies Environmental Allergies: Animals at Home: Animals in Work Place: Chemicals at Home: Chemicals in Work Place: Comments: _ Any additional comments: _ New Patient Packet Page 6 Internal Use: Info Reviewed Provider Signoff Scan to Health History

7 Provident Healthcare Office Policies Thank you for choosing Provident Healthcare as your healthcare provider. We receive several questions regarding our office policies and have developed this document to answer some of those questions. If you have any further questions, please ask to speak to our clinic manager. Missed Appointments: We will assess a charge of $25 for any missed appointment or an appointment that is cancelled with less than 24 hours notice. We ask for 24 hours notice so that we may open that appointment time for other patients that may wish to be seen. This fee must be paid before another appointment can be made. Health Insurance: We are contracted with most insurance plans as well as Medicare and Medicaid. In order to verify your coverage and keep our records current, we will ask for your insurance card at each visit. If it is your first visit to our office, we will also ask for your picture ID to verify your identity. If you do not have your insurance card, and we cannot verify coverage with the information you give us, we will ask you to pay for your visit in full at the time of service. Please be aware that you are responsible for the charges billed for the services you receive at our office. We bill your insurance as a courtesy to you. If your insurance does not remit payment, we will bill you for those services. If you do not have health insurance, you will be responsible to pay for the visit in full at the time of service, prior to services being rendered. Payment for services: Copayments are due at the time of service. If you have a balance due on your account, for claims that have already been processed by your insurance company, you will be asked for payment at your next visit. If you do not have a visit scheduled, you will receive a statement in the mail. Other payment arrangements can be made with our billing department. Payments are due within thirty (30) days of the statement date. You will receive 2 statements from our office for a balance due. If the account is not paid within that time, it is considered past due and may be sent to our collection agency. If your account goes past due more than twice in a calendar year, you will be required to keep a credit card on file for future payments. Services not covered by your insurance: We make every effort to order tests that meet "medical necessity" guidelines set by Medicare/ Medicaid and insurance plans. However, we cannot possibly know what is covered under every plan. If your insurance does not cover certain services, you will be responsible for those charges. If you prefer, you do have the option of calling your insurance to check coverage prior to receiving services. Medication refills: Our refill policy is posted in every exam room and you are encouraged to review it. In certain cases, we may require an office visit before we will refill a medication. Lab Results: If your provider orders labs or other testing for you, we may ask you to return for an appointment to discuss those results. Also, it is not our policy to send normal lab results to patients. We will send them, upon request via our secure service. If you would like to enroll in that service, please ask any staff member. We do not mail results due to increasing overhead and postage costs. Paperwork Reduction: We do provide a free service where we will keep your credit card on file for your account balances. This gives you peace of mind knowing that your account is paid. We will give you a courtesy call prior to charging the card. If you would like to sign up for this service, please ask for a form. I have read and understand these policies and agree to abide by them. I understand updates to this document are available on the website. Patient Signature : Date: Patient Name: Patient Date of Birth: New Patient Packet Page 7 Internal Use: Info Entered Scan to Patient Billing and Insurance

8 Authorization to Release Healthcare Information Patient's Name: Previous Name(s): Patient's Date of Birth: Social Security Number: I request and authorize: (name of doctor or practice) Phone Number: Fax Number: to release healthcare information of the above patient to: This request and authorization applies to: Provident Healthcare PO Box 60 Englewood, CO Healthcare treatment or information related to the following condition or dates: Last three office notes and labs, and any other pertinent testing results All healthcare information regarding this patient Other Specific Authorization for certain conditions Yes No I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone. Yes No I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above. Definition: Sexually Transmitted Disease (STD) as defined by law, RCW et seq., includes herpes, herpes simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea. Patient Signature: Date: This Authorization expires ninety (90) days after it is signed. Internal Routing: fax and stamp the form and scan into "records release" section of chart 799 E. Hampden Ave, Ste Englewood, CO fax: