Colorado Gastroenterology Trusted Consultation, Compassionate Care

Transcription

1 Patient Demographics Thomas E.Trouillot, MD Name: Sex: M F Address: City:.State: Zip: Social Security Number: Date of Birth: Home Phone: ( ) Cell Phone: ( ) Primary Contact Phone #: ( ) Preferred method of Contact: 0 Primary Phone 0 0 Other Referring Physician: Primary Care Physician: Preferred Pharmacy Name/Address Employer: Retired? Y N Employer's Address: Business Phone: ( ) Occupation: Marital Status: Spouse/Partner/Significant Other's Name: Emergency Contact: Relation of Contact: Home Phone: ( ) Cell/Business Phone: ( ) MEDICAL INSURANCE INFORMATION Primary Insurance Company: Phone Number Policy/ID Number: Group Number: Policy Holder: Your relationship to the Policy Holder: Secondary Insurance Company: Phone Number Policy/ID Number: Group Number: Policy Holder: Your relationship to the Policy Holder: POLICY HOLDER INFORMATION Name: Date of Birth: M/F Signature Date

2 Patient Information and Treatment Plan Patient Name: Today's Date: Primary Care PhysicianlReferring Physician: What is the reason for your visit today? How long have you been experiencing the problem(s)? New tests or labs done since your last office visit: This is what your physician concluded from today's visit: Your recommended treatment plan is: Labs to be drawn: Procedure: Date/Time: Imaging Study: Date/Time: Facility: Instructions: Your next appointment in this office is: Patient Signature: Physician Signature: Midtown Medical Center I N Ogden Stt + Suite Denver, Colorado ph: fax:

3 Patient Medication List Print Name: Date of Birth: Acct# Please list all prescription medication, over-the-counter medication, herbal medications and vitamins/minerals. (Complete to the best of your ability) Prescription/Over the Dosage (MG, Frequency Route (By Why are you taking CounterlHerballVitamins MCG,GM,IU, mouth, LV., this medication ML Rectally, Eyes, Nose, Ears, Topically Allergies: (List all medications and type of reaction) Patient Signature: Date:

4 KevinSieja,MD Print Name: Date of Birth: Patient Acct# (office use) REVIEW OF SYSTEMS: Check all that apply to the patient's health history I GENERAL: Chronic fatigue Bruise easily/bleed too long Fever Thyroid disease Anemia Less interest in doing things Weight loss (amount-, time--.j Cancer (type: ~) Weight gain (amount-, time--.j Diabetes (diagnosed when? ~) I EYES, EARS, NOSE & THROAT: Ringing in ears Ear infections Dizzy Spells I LUNGS: Pneumonia Asthma I HEART: Chest pain High blood pressure Sinus trouble Hoarseness Eye infections Bronchitis Cough Palpitations Ankle swelling Poor vision Glaucoma Cataracts Shortness of breath Irregular heart beat Blood clots I SKIN: Rashes Allergic reactions/hives Growths I URINARY: Urinary infections Kidney stones I BONES AND JOINTS: Arthritis/rheumatism Back pain I NEUROLOGIC/PSYCHIATRIC: Stroke Tremorlhands shaking Numbness or tingling Headaches (frequent) I GASTROINTESTINAL: Diarrhea Heartburn Black stools Nausea Blood in stool Painful urination Urination at night Weak bones Swollen joints Depression Nervousness Problems with sleeping Memory loss Constipation Stomach pain Poor appetite Vomiting Bloating Blood in urine Decrease in urine force or flow Seizures Panic attacks Migraines Anxiety Liver disease Gas Trouble swallowing Any additional information you feel is important:

5 Patient Health Questionnaire Patient Acct# (office use) Today's Date // Patient Name: Date of Birth: / / Person completing the form, if not patient: Relationship: Referring Doctor: Primary Care Doctor: Reason for today's visit: How long have you been experiencing the problem(s)? New tests or labs since your last visit: Past and Current Medical Conditions: Hospitalizations/Surgeries: Patient Only: Allergies: (List all medications or other allergy sources and type of reaction): Social History: Marital Status: Single Married Widowed Smoking Packs/day Number of years smoking If you quit, when? Alcohol use Drinks/day If you quit, when? Cocaine, marijuana, etc. use Recent Travel: When Where HEALTH OF FAMILY: (If no longer living, please note age and cause of death) Father Mother Sister/Brother Children FAMILY HISTORY: (Indicate any known illnesses of family members and relationship to the patient) Gallstones Relation Colon Polyps Relation Colon Cancer Relation Pancreatitis Liver Disease Other cancer Other illness Relation ~ Relation Relation Relation

6 Patient Account # (office use) Release of Information and Assignment of Benefits Financial Understanding Print Name: Date of Birth I hereby authorize the release of any medical information necessary to process my health insurance claims and request payment of benefits to Colorado for payment of services provided by the physician. I permit a copy of this authorization to be used in place of the original. I understand that I am financially responsible for charges not covered or denied by my insurance company. I further agree in the event of my non-payment to pay the cost of collection and/or court costs and reasonable fees, should this be required. Cancellation Policy for Procedures and Office Visits. By signing this you have acknowledged that you have received a copy of the cancellation policy and you understand that there is a fee for late cancellations, reschedules and no shows. Signature Date Midtown Office N Ogden St, Ste Denver, CO PH: Fax:

7 Colorado HIPAA Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Notice of Privacy Practices describes how we may use and disclose your personal protected health information (PHI) to carry out treatment, payment of health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including your demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services. Uses and Disclosures of Protected Health Information Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation ofthe physician's practice, and any other use required by law. Treatment We will use and disclose your protected health information to provide, coordinate, or manage your health care. This includes the coordination or management of your health care with a third party such as a specialist, pharmacy or laboratory that is assisting in your health care. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Payment Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for your hospital admission. Healthcare Operations We may use or disclose, as needed, your protected health information in order to support the business activities of your physician's practice. The activities include, but are not limited to, quality assessment, employee review, training of medical students, and credentialing. Other Disclosures We may use or disclose your protected health information in the following situations without your authorization: as required by law, for public health issues required by law such as communicable diseases reporting, health oversight, abuse or neglect, Food and Drug Administration requirements, legal proceedings, law enforcement requests, requests from coroners, funeral directors and organ donation centers, research, requests from the military, in interests of national security, and workers' compensation requirements. Other disclosures will be made only with your consent and authorization. You may revoke this authorization at any time in writing, except to the extent that your physician's office has taken action in reliance on the use or disclosure indicated in the authorization. Midtown Office Building N Ogden St + Suite Denver, Colorado ph: fax:

8 IDP AA Notice of Privacy Practices Page 2 Your Rights You have the right to inspect and copy your protected health information. You have the right to request a restriction of your protected health information. This means you may ask us to not use or disclose any part of your protected health information for the purpose of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted and you have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of the notice from us, upon request, even if you have agreed to this notice alternatively (i.e. electronically). You have the right to request amendments to your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement. You have the right to receive an accounting of certain disclosures we have made of your protected health information. We reserve the right to change the terms of this notice and will inform you be mail of any changes. then have the right to object or withdraw as provided in this notice. You If you believe your privacy rights have been violated, you may file a written complaint with the Privacy Officer. If you are not satisfied with the way Colorado handles your complaint, you may also file a complaint with the Office of Civil Rights of the U.S. Department of Health and Human Services. This notice was published and becomes effective April 14, We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at Your signature below is only acknowledgement that you have received this Notice of Privacy Practices. Name: Signature: Date: Midtown Office Building N OgdenSt + Suite Denver, Colorado ph: fax:

9 Cancellation Policy Colorado strives to render excellent medical care to all of our patients. In order to be consistent with this philosophy, we have implemented the following appointment cancellation policy: Procedures We request that you give our office three (3) full business days' notice in the event that you need to reschedule or cancel your procedure with the physician. This includes appointments for colonoscopy, upper endoscopy (EGD), flexible sigmoidoscopy and ERCP. If you miss an appointment for a procedure without providing us at least three (3) full business days 'notice, we consider this to be a missed appointment and a $100 fee may be assessed. Office Visits We request that you give our office at least one (1) full business days' notice in the event that you need to reschedule or cancel your office appointment with the physician. If you miss an appointment for an office visit without providing us at least one (1) full business days' notice, we consider this to be a missed appointment and a $50 fee may be assessed. As a courtesy, we do make reminder calls for appointments. If you do not receive your message or we have incorrect information, the cancellation policy will still be in effect. To cancel or reschedule an appointment, please ca1l303-s61-0s0s. Midtown Office Building N Ogden St. Suite 220. Denver, Colorado ph: