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1 Patients Name: (Last, First, MI): DOB: SSN: Circle One: Male Mailing Address: Apt. #: City: State: Zip Code: Female Home Phone: Preferred? Cell Phone: Preferred? Work Phone: Preferred? Race: Ethnicity: Hispanic or Latino Primary Language: Non-Hispanic or Latino Occupation: Employer: Marital Status: Married Single Domestic Partner Parent/Guardian (if patient is a minor): Relationship to Patient: Guarantor Phone: Guarantor SSN: Address: Apt #: City: State: Zip Code: Emergency Contact: Relationship: Home Phone: Primary Insurance: Primary Ins. Group #: Primary Insurance ID #: Subscriber Name(If different from Subscriber DOB: Relationship to Patient: patient) Secondary Insurance: Secondary Ins. Group #: Secondary Insurance ID #: Cell/Other: Subscriber SSN: Subscriber Name(If different from Subscriber DOB: Relationship to Patient: Subscriber SSN: patient) Preferred Local Pharmacy: Street: City: Preferred Mail Order Pharmacy: ID: Consent to Treat: The information that I have given to Peninsula Primary Care is complete and true to the best of my knowledge. I authorize the doctors and staff of Peninsula Primary Care to administer treatment and procedures deemed necessary and that I find agreeable. I understand that Peninsula Primary Care implies no guarantees of a cure, and that I have the right to choose my treatment options at any time. Assignment of Benefits: I authorize the release of any medical information necessary to process my insurance billing. I authorize payment of medical benefits to Peninsula Primary Care. Financial Policy: Peninsula Primary Care will bill any commercial or governmental insurance on my behalf; however it is my responsibility to know the details of my particular benefit plan. I understand that PPC is required to report (or code ) procedures and diagnoses based on the services I receive; consequently, the coding cannot be changed later to cause the insurance company to pay for a non-covered service as this is considered fraudulent practice. I, the undersigned, agree to pay Peninsula Primary Care as appropriate, in accordance with regular rates and terms. I also agree that I am overall responsible for the entire balance due on the account, including non-covered services, copayments, co-insurance, deductibles, etc. It is the policy of Peninsula Primary Care to collect co-payments at the time services are rendered. Private pay patients must pay the total balance due at the time of service. I agree to a $25.00 fee for checks returned for non-sufficient funds. Signature Print Guardian Name (If not patient) Relationship Page 1 of 7

2 Acknowledgement of Receipt of Notice of Privacy Practices Patient Name: DOB: : Privacy Official, 100 Wilson Rd, Ste 100, Monterey, CA Phone: (831) I hereby acknowledge that I received a copy of this medical practice s Notice of Privacy Practices. I further acknowledge that a copy of the current notice is posted in the reception area and that I will be offered a copy of any amended Notice of Privacy Practices at each appointment. Signed: : Print Name: _ If not signed by the patient, please indicate your relationship to the patient: Parent or guardian of minor patient Guardian or conservator of an incompetent patient Beneficiary or personal representative of deceased patient I identify the following individuals as being involved in my care and/or payment of my care. I authorize my healthcare provider, or representative, to discuss any healthcare and/or financial information with the following individuals. Name Relationship Phone Signed: : Page 2 of 7

3 Please complete form to the best of your ability so we can provide you with excellent medical care. Patient Name: of Birth: / / Allergies: Drug/Medication/Food/Environmental Reaction Severity Medications Dose Frequency Prescribed by Example: Metoprolol Example: 25 Example: 1/2 tablet two times daily Example: Dr. mg Peninsula Past Medical History Allergies Anemia Angina Anxiety Arthritis Asthma Atrial fibrillation Benign Prostatic Enlargement Blood Clots Cancer: CVA-Stroke COPD Coronary artery disease Crohn s Disease/Colitis Depression Diabetes Other Gallbladder Disease Gastric Reflux Hepatitis C High Cholesterol High Blood Pressure Irritable Bowel Disease Liver Disease Migraine Headaches Other Heart Attack Osteoarthritis Osteoporosis Peptic Ulcer Disease Kidney Disease Seizure Disorder Thyroid Disease Back Pain Other Page 3 of 7

4 Name: of Birth: / / Please complete form to the best of your ability so we can provide you with excellent medical care. Past Surgical History Surgery Heart Surgery Appendix Removed Arthroscopy Knee Back Surgery Carpal Tunnel Release Cataract Gall Bladder Bowel Surgery Bladder Surgery Coronary Artery Bypass Graft Year Surgery Gastric Bypass Hernia Repair Hip Replacement Knee Replacement LASIK Eye Surgery Liver Biopsy Joint or Bone Surgery Pacemaker Small Bowel Resection Thyroid Surgery Tonsils Removed Year Gender Specific Surgery Hysterectomy Breast Surgery Tubal Ligation Breast Biopsy Cesarean Section D and C Mastectomy Uterine Surgery Breast Reduction Prostate Surgery Vasectomy Year Specialists/Other Healthcare Providers Doctor s Name Specialty City Family History Relation Medical Condition Relation Medical Condition Mother Maternal Grandmother Father Maternal Grandfather Brother Paternal Grandmother Sister Paternal Grandfather Daughter Aunts Son Uncles Marital Status/Family/Employment Current status: Children: Married None Single Yes Divorced # Boys: Widowed # Girls: Life partner Military Experience: Yes No For Women Only: *Number of pregnancies: * of last menstruation: Occupation: Highest Level of Education: Page 4 of 7

5 Name: of Birth: / / Please complete form to the best of your ability so we can provide you with excellent medical care. Tobacco Use Use: Current Former Never Type: Cigarettes Cigar Years used: Pack(s) per day: Passive smoke exposure: Yes No Ever tried to quit: Yes No Longest Tobacco free: Alcohol No Yes If yes, type: Amount: Per: Day Week Socially Other Caffeine/Drugs/Exercise Caffeine: Yes No Drinks per day: _ Type: _ Drugs: Yes No Type: Frequency: Exercise: Yes No Type: Frequency: Routine Health Maintenance: What was the date of your last: Bone Density Cardiac Test Colonoscopy Fasting Lab Last Physical Mammogram Pap Smear Immunizations/Vaccines Name Tetanus/Tdap Hep A/B Hib HPV Flu MMR Meningococcal Name Pneumonia Polio Varicella Zoster Other: Other: Other: Do you have any of the following? (Check all that apply) You may request information if desired. Living Will Health Proxy POLST (Physician Order for Life Sustaining Treatment) I would like more information about an Advance Directive Yes No, not at this time Please let us know how you heard about us or who referred you to our clinic: Website Family/Friend Advertisement Physician Referral: Name: Other I certify that the above information is correct to the best of my knowledge. I will not hold my physician or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. Signature Print Guardian Name (If not patient) Relationship Page 5 of 7

6 Peninsula Primary Care, welcomes you to your Patient-Centered Medical Home, which is designed to provide your primary care provider with a complete overview of your healthcare status and of services you may need or will receive from other providers. This patient-centered, team-based model of care focuses on prevention and wellness and will better manage your individual healthcare needs, keep you healthier and produce better outcomes! Your Patient-Centered Medical Home healthcare team is a multidisciplinary team which includes your primary care provider of choice along with other care team members in the disciplines of nursing case management and social services when needed. All of the care team members are committed to take on the responsibility for keeping you healthy and coordinating care across multiple settings in the ever evolving healthcare system. Comprehensive, team based care is one of our goals at Peninsula Primary Care, focusing on each individual patient s physical and mental health care needs which include prevention and wellness, acute, chronic, behavioral and end-of life care. As the patient, you, your family and caregiver also play a significant role in making sure your Patient-Centered Medical Home is as effective as possible. Good communication with your primary care provider is paramount in ensuring that you receive the highest quality of care. Notifying your medical home of any pertinent changes in your health is the key to fostering great communication. Pertinent changes include: giving updates on your current medication list (whether you stopped taking a medication or started a new one), updating us with any changes in your health status, sharing your self-care information, informing us of recent test results, sharing any updates to your medical history, and updating us on any recent emergency department visits, recent hospitalizations, or recent specialty care visits. Peninsula Primary Care recognizes that you, as the patient, are at the center of your care team. We coordinate care across multiple settings in the healthcare system including; hospitals, specialty care, home health, hospice care, and community resources. In following the patient/care team relationship we support all of our patients by educating them and their families/caregivers on managing their own individual care. We encourage each of you to utilize all members of our care team to assist with your healthcare needs. The success of your healthcare relies not only on your care team but, your ability to selfmanage. Your care team is here to provide all the necessary tools and education for you to be a competent and compliant self-manager. To accomplish this, you now have access to self-management support and evidence based care tools. The role you play in your own health care is critical to making sure you have the best quality of care! As your medical home, it is extremely important to us that we accommodate you with accessible services and same day appointment requests for acute healthcare needs, whenever possible. We follow open access and have reserved times in your provider s schedule for same day appointments. In the event you should call for a same day appointment after 3pm, we may not be able to accommodate you but can add you to your provider s schedule for the following business day or, if deemed necessary, refer you to one of our affiliated urgent care clinics. We make every effort to accommodate requests for routine visits within fourteen days with your provider. At Peninsula Primary Care, it is our policy that patients have access to timely clinical advice by telephone during and after office hours, 24/7 along with access to local urgent care providers. Anytime during or after business hours, you may contact our office and receive clinical advice. When calling after business hours, your call will be answered by a live person at our answering service who will put you in touch with the provider on-call. In addition, Peninsula Primary Care has developed a relationship with Monterey Bay Urgent Care and Doctors on Duty Medical Clinics to provide hands on care for our patients after normal business hours. The purpose of the Patient-Centered Medical Home model is to give our patients the best care possible by providing whole-person care while improving quality of care. Our top priority is to provide you with the highest level of quality health care by continually improving quality measures. Continuous quality improvement involves setting goals based on each patient s unique level of care. Safety is an extremely important part of Peninsula Primary Care s daily duties. As your primary care home, we strive to achieve improved performances as a whole. Peninsula Primary Care encourages you to use the tools that the Patient-Centered Medical Home program provides. The Patient-Centered Medical Home model places you, as the patient, at the center of a team-based, provider-led approach to deliver healthcare. Peninsula Primary Care is working to achieve Level 3 Recognition from National Committee for Quality Assurance (NCQA) for its Patient-Centered Medical Home program which is anticipated in 1 st Quarter We welcome this initiative and encourage you to engage in this journey with us. Sincerely, Your Peninsula Primary Care Team Page 6 of 7

7 Instructions for Obtaining After-Hours Clinical Advice and Care Peninsula Primary Care s office hours are Monday through Friday from 8:00am 5:00pm. Should you require clinical advice or care after hours, please contact our answering service by calling our Carmel office at (831) and/or our Marina office at (831) Our answering service will place you in touch with the on-call provider. Should you require care after business hours, please visit any of the following locations: Monterey Bay Urgent Care 245 Washington St Monterey, CA M-F 7:30am 6:00pm S&S 9:00am 5:00pm Monterey Bay Urgent Care nd Ave #120 Marina, CA M-F 8:30am 5:00pm Sat 9:00am 5:00pm Doctors on Duty 501 Lighthouse Ave Monterey, CA M-F 8:00am 8:00pm S&S 8:00am 6:00pm Upon seeking treatment, please provide the provider with your most recent Visit Summary and be sure to follow up with our office so we have the ability to update your medical record. This information includes changes in medication lists, referrals to specialists, and any diagnostic testing as our goal is to maintain a comprehensive complete record of your care at all times. Page 7 of 7