Patient Registration Form

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1 PATIENT INFORMATION Patient Registration Form (Please Print) Dr. Miss Mr. Mrs. Ms. Sir Jr. Sr. Patient s Name (Last) (First) (MI) Previous Name Mailing Address City, State, ZIP (+4) Physical Address City, State, ZIP (+4) Phone Numbers W o r k Day Evening Home Day Evening Cellular Pager Primary Care Provider (PCP) Referring Physician Date of Birth (MM/DD/YYYY) Sex Male Female Transgender Marital Status Married Single Divorced Widowed Legally Separated Partner Social Security Number - - Address Employment Status 1- Full-Time 2- Part-Time 3-Not Employed 4- Self-Employed 5-Retired 6-Active Military Student Status 1- Full-Time Student 2- Part-Time Student N- Not a Student Race Ethnicity Language EMERGENCY CONTACT INFORMATION Emergency Contact Name Emergency Contact Relationship to Patient Phone Number Guardian (information used for emergencies only) Address City; State; Zip (+4): RESPONSIBLE PARTY INFORMATION (information used for patient balance statements) Responsible Party Another Patient Guarantor Self Check here if information is same as patient Responsible Party Name (Last) (First) (MI) Guarantor Account # Date of Birth (MM/DD/YYYY) Male Female Social Security Number - - Phone #(s) Address Mailing Address Physical Address City, State, ZIP (+4) City, State, ZIP (+4) Employer Employer Phone Number Patient Relationship to Responsible Party

2 PRIMARY INSURANCE INFORMATION (provide your insurance card(s) to the front desk at check-in) Insurance Company/Phone Number ( ) Name of Insured Patient Relationship to Insured Subscriber ID (Policy Number) Group ID Copay Amount Effective Date Termination Date Insured Date of Birth / / Insured s Social Security Number - SECONDARY INSURANCE INFORMATION (provide your insurance card(s) to the front desk at check-in) ( ) Insurance Company/Phone Number Name of Insured Patient Relationship to Insured Subscriber ID (Policy Number) Group ID Copay Amount Effective Date Termination Date Insured Date of Birth / / Insured s Social Security Number PRIMARY PHARMACY INFORMATION (provide your primary pharmacy to the front desk at check-in) Pharmacy Name/Phone Number ( ) Address City; State; Zip (+4) I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge. Patient (or Responsible Party) Signature Date

3 Date: PATIENT HISTORY FORM NOTE: This is a confidential record and will be kept in your doctor s office. Information contained here will not be released to anyone without your authorization to do so. Full Name: Date of Birth: Age: Referred by: Primary Care Physician: Chief Complaint (reason for your visit today): How long have you had this problem? PAST MEDICAL HISTORY (problems you have now) AIDS Alcoholism Anemia Arthritis/Gout Bleeding Disorders Blood Clot Cancer Diabetes Heart Disease Hepatitis High Blood Pressure Kidney Trouble/Stones Liver Trouble Lung Disease Mental Illness Phlebitis Seizures Stomach ulcers Stroke Thyroid Trouble Tuberculosis Illnesses No Yes Previous Surgeries: When? List ALL medications you are taking at the present time: Do you have any problems with anesthesia? No Yes Do you take any of the following? Aspirin No Yes How much/how often? Coumadin (warfarin) No Yes How much/how often? Plavix (clopidogrel) No Yes How much/how often? Lovenox (enoxaparin) No Yes How much/how often? blood thinners: Allergies to medications: ARE YOU ALLERGIC TO X-RAY DYE? No Social History Marital Status: Single Married Separated Divorced Widow(er) Most Recent Occupation: Yes Use of Alcohol: Never Rarely Moderate Daily Use of Tobacco: Do you currently smoke? No Yes If yes, how long/how much? Do you use smokeless tobacco? No Yes If yes, how long/how much? _ FAMILY HISTORY No Yes Alcoholism Arthritis/Gout Bleeding Disorders Cancer Diabetes Heart Disease Hepatitis High Blood Pressure Kidney Trouble/Stones Mental Illness Seizures Stroke Tuberculosis Use of Illicit (Illegal) Drugs: Current No Yes If yes, what type and how often? Past No Yes If yes, what type and how often?

4 REVIEW OF SYSTEMS Do you now have or have had any problems related to the following systems? Check Yes or No. Please explain any that you answer Yes in the space provided. Constitutional Symptoms Eyes Fever YES NO Blurred vision YES NO Chills YES NO Double vision YES NO Headache YES NO Pain YES NO Allergic/Immunologic Musculoskeletal Hay fever YES NO Joint pain YES NO Drug Allergies YES NO Neck pain YES NO Back pain YES NO Neurological Tremors YES NO Ears/Nose/Throat/Mouth Ear infections YES NO Dizzy spells YES NO Sore throats YES NO Numbness and tingling YES NO Sinus problems YES NO Endocrine Too hot/cold YES NO Respiratory Wheezing YES NO Excessive thirst YES NO Frequent cough YES NO Tired/sluggish YES NO Shortness of breath YES NO Gastrointestinal Psychological Nausea/vomiting YES NO Memory loss and confusion YES NO Indigestion/heartburn YES NO Nervousness YES NO Hiatal hernia YES NO Depression YES NO

5 Hematologic/Lymphatic Integumentary Swollen glands YES NO Skin rash YES NO Blood clotting problems YES NO Boils YES NO Are you taking blood thinners Persistent itch YES NO At the present time? YES NO Cardiovascular Chest pain YES NO Varicose veins High blood pressure YES YES NO NO

6 UNIVERSAL MEDICATION LIST (UML) Name: Phone Number: Birthdate: Allergic To/Describe Reaction: Address: Allergic To/Describe Reaction List all prescription and over-the-counter (non-prescription) medications such as vitamins, aspirin, Tylenol, and herbals (ex: Ginseng, Gingko Biloba, and St. John s Wort). Include prescription medications taken as needed (ex. Viagra, nitroglycerin) NAME OF MEDICATION Dose How Often? Date and time last taken

7 (AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION PHI) Patient Name: Birth Date: SSN: Address: MR#: I authorize: (Name and Address of Person or Facility which has Health Information) To Use and/or disclose the following Protected Health Information (PHI) to: (Name and Address of Person or Facility to receive Health Information) This PHI is being Used and/or Disclosed for the following Purpose: For the Treatment Dates of: Type of Access Requested: Copies of the Record Inspection of the Record Physician PCI Access Specific Information to be Used/Disclosed: Discharge Summary History & Physical Exam Operative Reports Pathology Reports Consultations Emergency Room Record Laboratory Reports Radiology/Imaging Reports Progress Notes Physician Orders Cardiac Cath Reports Cardiac Studies Demographic Record Patient Care Notes Medication Record : I acknowledge, and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results or AIDS information. (Initial) I understand: 1. This authorization is voluntary. Treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization except if the authorization is for 1) conducting research-related treatment. 2) To obtain information in connection with eligibility for enrollment in a health plan. 3) To determine an entity s obligation to pay a claim, or 4) to create health information to provide to a third party. 2. The person who receives the records to which this authorization pertains may not re-disclose them to anyone else without my specific written consent, except that such person may make a disclosure if it is permitted by federal or state law. 3. I am entitled to receive a copy of this authorization. I have read the above and authorize the disclosure of the protected health information as stated. Unless otherwise revoked, this authorization expires (insert applicable date or event). If no date is indicated, this authorization will expire 90 days after the date of signing this form. Signature of Patient or Patient s Legal Representative Date Print Name of Patient s Representative Relationship to Patient Witness Date

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