PATIENT INFORMATION INSURANCE INFORMATION

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1 (mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last Name: of Birth(mm/dd/yyyy): SSN: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: address: Employer: Emergency Contact Name: Relationship to Patient: Emergency Contact Phone: IF THE PATIENT IS UNDER 18 YEARS OF AGE OR COVERED UNDER A PARENT S OR GUARDIAN S INSURANCE PLAN, PLEASE COMPLETE THE FOLLOWING INFORMATION: Parent/Guardian s First Name: Parent/Guardian s Employer: Primary Insurance: Last Name: Employer s Phone: INSURANCE INFORMATION Phone: Insured Cardholder s Name: Insured DOB: Insured SSN: Subscriber #: Policy #: Other Insurance? Yes No Secondary Insurance: Phone: Insured Cardholder s Name: Insured DOB: Insured SSN: Subscriber #: Policy #:

2 PATIENT NAME: TODAY S VISIT Reason for today s visit: (if due to an accident, please give description of when, where and how it happened) CURRENT SYMPTOMS OR PROBLEMS At this time, do you have any symptoms or problems in the following areas: Yes No 1. General fatigue, weight loss, appetite problems, sleep problems> 2. Head, eyes, ears, nose, throat? 3. Lungs or breathing: shortness of breath, cough, chest pain with breathing, etc.? 4. Digestive system: stomach, intestines, liver, gall bladder, rectum, etc.? 5. Heart and blood vessels: chest pain, leg ulcers, varicose veins, swelling, etc.? 6. Muscles and bones: injuries, muscle pains, tendinitis, weakness, stiffness, etc.? 7. Brain and nervous system: weakness, numbness, anxiety, depression, headaches, etc.? 8. Skin: rashes, itching, wounds, etc.? 9. Reproductive systems and genitals: pain, discharge, abnormal bleeding, sexual problems, etc.? 10. Urinary system: kidney problems, infections, difficulty urinating, etc.? 11. Any other bothersome symptoms? If you answered yes to any of the above questions, provide details:

3 HEALTH HISTORY NAME: ALLERGIES Drug: Food: Use check ( ) mark for Yes answers FAMILY HISTORY Other: Father Mother Father s Mother s Siblings Children Parents Parents Prescription: No Yes please list Cancer Diabetes Glaucoma Heart Disease High blood pressure Kidney disease Mental illness Stroke Over-the-counter: No Yes please list Thyroid disease Drug or alcohol addiction Epilepsy/convulsions PAST MEDICAL HISTORY Please circle if you have had any problems in the past with the following: High blood pressure Pneumonia Hemorrhoids Low back problems Diabetes Persistent Cough Gall Bladder disease Skin diseases Cancer Tuberculosis Weight loss Blood disorder Heart disease Abdominal discomfort Colitis Venereal disease Chest pain/chest tightness Hay fever Hepatitis or Jaundice Anxiety Shortness of breath Indigestion Thyroid disease Depression Swollen ankles Drug abuse Anemia Asthma Palpitations Headache Alcohol abuse Bronchitis Kidney disease Blood in stool Kidney stones Ulcers Frequent urination Arthritis Changes in bowel habits Rheumatic fever Gout Difficult urination Other(s): Operations: No Yes please list Hospitalizations other than for surgery: No Yes please list Transfusions: please list Immunization history- have you had: Pneumovax: No Yes When? Flu: No Yes When? Hepatitis A: No Yes When? Tetanus: No Yes When? Hepatitis B: No Yes When? Other: No Yes What &When? When was your last: Complete physical : Result: TB test : Result: Cholesterol check : Result: Eye exam : Result: Hearing test : Result: Prostate exam : Result: Stool check for blood : Result:

4 AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS Patient Name DOB / / / / Names and Phone Numbers for Health Care Providers (HCPs) from whom you are currently receiving care or are obtaining prescriptions: NAME Contact # Contact # Contact # Contact # Contact # Contact # I give permission for Physicians Urgent Care to release my medical information to the following person(s) NAME RELATIONSHIP Patient Signature: _ :

5 Patient Name: : of Birth: Authorization for release of information by Physicians Urgent Care I hereby authorize and direct the above clinical practice, having treated me, to release to government agencies, insurance carriers, or others who are financially liable for my medical care, all information needed to substantiate payment for such medical care and to permit representative thereof to examine and make copies of all records relating to such care and treatment. Assignment to Physicians Urgent Care I hereby assign, transfer, and give to the above named clinical practice sufficient monies and/or benefits which I may be entitled from government agencies, insurance carriers, or others who are financially liable for my medical care to cover the costs of the care and treatment rendered to myself or my dependent in said practice. Agreement to Pay Medical Bills In the event that my insurance company, for any reason, does not pay for the treatment and care rendered in this office, I agree to pay for all of the charges incurred. Consent for Medical Treatment I voluntarily present to Physicians Urgent Care for medical evaluation, diagnosis, and/or treatment. I consent and authorize my provider(s) or his or her designee(s) to provide diagnostic and therapeutic treatment, which may be necessary or advisable in their professional judgment. By signing this consent form, I do not waive my right to refuse recommended tests or treatment(s).

6 H I P A A You have privacy rights under a federal law that protects your health information. These rights are important for you to know. You can exercise these rights, ask questions about them, and file a complaint if you think your rights are being denied or your health information isn t being protected. Providers and health insurers who are required to follow this law must comply with your right to Ask to see and get a copy of your health records You can ask to see and get a copy of your medical record and other health information. You may not be able to get all of your information in a few special cases. For example, if your doctor decides something in your file might endanger you or someone else, the doctor may not have to give this information to you. In most cases, your copies must be given to you within 30 days, but this can be extended for another 30 days if you are given a reason. You may have to pay for the cost of copying and mailing if you request Have corrections added to your health information You can ask to change any wrong information in your file or add information to your file if it is incomplete. For example, if you and your hospital agree that your file has the wrong result for a test, the hospital must change it. Even if the hospital believes the test result is correct, you still have the right to have your disagreement noted in your file. In most cases the file should be changed within 60 days, but the hospital can take an extra 30 days if you are given a reason. Receive a notice that tells you how your health information is used and shared You can learn how your health information is used and shared by your provider or health insurer. They must give you a notice that tells you how they may use and share your health information and how you can exercise your rights. In most cases, you should get this notice on your first visit to a provider or in the mail from your health insurer, and you can ask for a copy at any time. Decide whether to give your permission before your information can be used or shared for certain purposes In general, your health information cannot be given to your employer, used or shared for things like sales calls or advertising, or used or shared for many other purposes unless you give your permission by signing an authorization form. This authorization form must tell you who will get your information and what your information will be used for. Get a report on when and why your health information was shared Under the law, your health information may be used and shared for particular reasons, like making sure doctors give good care, making sure nursing homes are clean and safe, reporting when the flu is in your area, or making required reports to the police, such as reporting gunshot wounds. In many cases, you can ask for and get a list of who your health information has been shared with for these reasons. Ask to be reached somewhere other than home You can make reasonable requests to be contacted at different places or in a different way. For example, you can have the nurse call you at your office instead of your home, or send mail to you in an envelope instead of on a postcard. If sending information to you at home might put you in danger, your health insurer must talk, call, or write to you where you ask and in the way you ask, if the request is reasonable. Ask that your information not be shared You can ask your provider or health insurer not to share your health information with certain people, groups, or companies. For example, if you go to a clinic, you could ask the doctor not to share your medical record with other doctors or nurses in the clinic. However, they do not have to agree to do what you ask. File complaints If you believe your information was used or shared in a way that is not allowed under the privacy law, or if you were not able to exercise your rights, you can file a complaint with your provider or health insurer. The privacy notice you receive from them will tell you who to talk to and how to file a complaint. You can also file a complaint with U.S. Government. **** All medical records are electronic.**** ****Any paper records are scanned and destroyed by interoffice shredding. **** Signature: Print Name: :

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