Geisinger Health System Remote Second Opinion Instructions
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- Jessie Reynolds
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1 Geisinger Health System Remote Second Opinion Instructions If you or a loved one wants to receive a Remote Second Opinion, please follow these instructions. There are five (5) forms in this packet. Each form serves a specific purpose and is necessary to complete in order to receive your second opinion. Please print this instruction sheet and all forms in this packet, and then follow these steps for completing each designated form. 1. Consultation Request Form Before seeking a Remote Second Opinion from Geisinger Health System, you should discuss with your physician why you are interested in receiving this service. After reviewing our terms and conditions, complete the Consultation Request Form and have your physician sign it. We are unable to provide you with your Remote Second Opinion without your physician s written acknowledgement and permission. 2. Remote Second Opinion Checklist Review the Remote Second Opinion Checklist with your physician. This will help you determine which medical records or diagnostic reports are appropriate to send to Geisinger. After you have identified the appropriate documents, obtain a copy of those records. Please note that your physician s office and/or hospital may charge a fee for providing you with a copy of your records. Geisinger is not responsible for any fees charged by other providers or entities in assembling your medical records for a remote second opinion. 3. New Patient History Questionnaire Compete the New Patient History Questionnaire and include it with your applicable medical records. 4. Patient Disclaimer Form Carefully review, date and sign the Patient Disclaimer Form. 5. Payment Authorization Form Complete the Payment Authorization Form, and then print, sign and include it with your medical records. This form must be completed in order for you to receive your Remote Second Opinion. If payment authorization is not provided, Geisinger does not assume responsibility for fees charged by other health care providers in assembling your medical records for a Remote Second Opinion. Questions If you have any questions, please contact us at We are happy to help you. For Submission to Geisinger: Verify that each form is complete, and then package the following documents for shipping: Consultation Request Form New Patient Medical History Questionnaire Patient Disclaimer Form Payment Authorization Form
2 All applicable medical records, and/or pathology reports Send the package to: Geisinger Health System Attn: Tess Mordan, RN Destination Nurse Navigator 100 N. Academy Avenue M.C Danville, PA We recommend all correspondence be sent via a courier (FedEx, UPS, DHL, registered US Postal Mail, etc.) that tracks the delivery of packages and requires a signature when the package arrives at Geisinger. As the patient, you assume all liability related to the decision to use a particular courier or mail service. Within 10 business days of receipt of all information (forms and medical records), a Geisinger physician will mail written reports to you and your physician who authorized your Remote Second Opinion. Upon request, the Geisinger physician who completed your Remote Second Opinion will be available for a phone call with you and your physician, to discuss your Remote Second opinion and answer any questions.
3 Geisinger Health System Remote Second Opinion Consultation Request Form Name of Patient: I request Geisinger Health System to provide a remote second opinion for the above- named patient. My patient and I have discussed this request and understand the risks and limitations of this service. I agree to provide my patient with copies of their medical records and any other relevant diagnostic reports or studies. I also understand I will receive a copy of the assessment and recommendation and will review it with the above- named patient as I deem appropriate. I also acknowledge that I am a licensed physician in the state in which my practice is located AND in which the patient resides. PHYSICIAN SIGNATURE DATE: / / (Please Print) Treating/Referring Physician Name: Name of Practice: Street Address: Suite: City: State: Zip: Office Phone: ( ) - Office Fax: ( ) /13 DPMC
4 Geisinger Health System Dermatology Remote Second Opinion Checklist The following list of items is needed to provide you with the best assessment and recommendation: Required Forms Patient Disclaimer (authorized signature required) Consultation Request Form (signed by your local physician) Payment Authorization Form (authorized signature required) New Patient History Questionnaire (authorized signature required) If any of the following tests have been performed, copies of the test (hard copy or disc) and their official readings or reports are needed in order to process your request: High quality picture of the mole or area you are requesting consultation Tissue processing results (if available) Tumor histology (if applicable/ available) Most recent blood tests Any radiologic studies such as x-rays, MRI s or CT scans
5 Geisinger Health System Department of Dermatology New Patient History Questionnaire DEAR PATIENT: Welcome to the Department of Dermatology at Geisinger Health System. We ask that you fill out this form as part of the second opinion process. Please complete this questionnaire to the best of your ability. This questionnaire will allow the doctor to get to know more about you, your medical condition, your family and your habits. This questionnaire is confidential and will be kept as part of your medical record. If you have any questions about issues of confidentiality, please feel free to contact our Nurse Navigator for clarification at 1-(855) First Name: M.I.: _ Last Name: PERSONAL INFORMATION (REQUIRED) Date of Birth: / / Social Security Number: - _ - Mother s Maiden Name: Father s Name: CONTACT INFORMATION (REQUIRED) Home Phone: ( ) - Cell Phone: ( ) - Work Phone: ( ) - Other Phone: ( ) - Is it okay to contact you at work: Yes No Street Address: Apt: City: State: Zip: MEDICAL QUESTIONS (REQUIRED) What diagnosis/ disease/ disorder are in question?
6 What specific questions would you like to have addressed during the remote second opinion? What do you hope to gain by engaging the services of a remote second opinion? WHO REFERRED YOU TO OUR OFFICE? Physician Name: Address: Phone: Specialty: Fax: PLEASE LIST ALL OTHER PHYSICIANS WHO SHOULD RECEIVE A COPY OF OUR REPORT: Name: Address: Phone: Fax : Name: Address: Phone: Fax: Name: Address: Phone: Fax:
7 HISTORY OF PRESENT ILLNESS: 1. What is the reason for your visit today? 2. How long have you had the problem? 3. How severe is the problem? 4. What type of symptoms are you experiencing? 5. How often do the symptoms occur? 6. How long do the symptoms last? 7. Does anything make the problem better? 8. Does anything make the problem worse? 9. Have you ever had treatment or surgery for this problem? 10. Please rate your pain on a scale from 0 (no pain) to 10 (worst imaginable). REVIEW OF SYSTEMS: Please circle and provide brief details for the medical conditions below that apply to you now. GENERAL EYE CARDIOVASCULAR Weight loss or gain Blurred vision Chest pain Change in appetite Double vision Chest pressure Altered taste or smell Glaucoma Angina Excessive sleepiness Cataracts Fainting Unable to sleep Fatigue EARS, NOSE, MOUTH, THROAT Balance problems Trouble breathing Sinus disease Mouth sores Trouble swallowing Sore Throat Ringing in ears Dizziness Hearing loss RESPIRATORY Emphysema COPD Tuberculosis Chronic cough Bronchitis Pneumonia Leg swelling High blood pressure Low blood pressure Heart Murmur Heart Failure Shortness of breath
8 GASTROINTESTINAL GENITOURINARY PSYCHIATRIC Ulcer Kidney Stones Depression Hepatitis Urinary urgency Anxiety Vomiting Urinary incontinence Trouble concentrating Constipation Sexual dysfunction Diarrhea Impotence INTEGUMENTARY Bowel incontinence Vaginal bleeding Skin rash Gastritis Painful urination Hiatal hernia Frequent urination Rectal bleeding Blood in urine NEUROLOGICAL MUSCULOSKELETAL ENDOCRINE Headache Low back pain Diabetes Seizure Neck pain Thyroid Disease Loss of consciousness Joint pain Memory loss Joint swelling Weakness Trouble walking Trouble with balance HEMATOLOGICAL Numbness Blood disorder Tingling Leukemia Concussion Sickle Cell Disease Falls Enlarged lymph nodes Vertigo HIV PAST MEDICAL HISTORY: Please list all current medical problems as well as major illness you have had in the past. Provide approximate dates
9 PAST SURGICAL HISTORY: Please list all operations you have had in the past. Provide approximate dates Have you ever had a problem with anesthesia? If yes, please explain. Have you ever had a blood transfusion? If yes, why? MEDICATIONS: Please list all medications you are currently taking, including over the counter medications, with dosage Do you take aspirin or any medicines that contain aspirin, or pain relievers like ibuprofen or Motrin? If yes, please specify. ALLERGIES: Please list any known drug and food allergies: 1. 2.
10 FAMILY HISTORY: Please list all medical problems and current age of the following family members. If they are deceased, please list the cause and approximate age of death. Grandparents: Aunts: Uncles: Father: Mother: Brothers: Sisters: Children: Grandchildren: SOCIAL HISTORY: What is your highest level of education? What is your occupation? Are you disabled? Was the injury due to a work-related accident? Was the injury due to a non-work-related injury? Was the illness/injury caused by an automobile accident? Was another party responsible for this accident? Is there any litigation involved? If yes, please explain. Do you smoke? If yes, how much and for how long? If you quit, when did you quit? Do you drink alcohol? If yes, approximately how many drinks per week?
11 Please mark and describe any skin abnormalities and provide a brief description of your concerns. Anterior Posterior
12 Geisinger Health System Remote Second Opinion Patient Disclaimer By using the Geisinger Remote Second Opinion, you agree to abide by the Terms and Conditions posted at our website including particularly the terms and conditions described below: CONSULTATIVE SERVICE The service provided through the Geisinger Remote Second Opinion is different from the diagnostic services typically provided by a physician. The Geisinger physicians providing this service will not have the benefit of information that would be obtained by examining you in person and observing your physical condition. Therefore, the physician may not be aware of facts or information that would affect his or her opinion of your diagnosis. Because this is a limitation on the accuracy of his or her opinion, and this is a risk to you, the recommendations of the Geisinger physician will be shared with your local physician. By deciding to engage this service, you acknowledge and agree that you are aware of this limitation and agree to assume the risk of this limitation. By requesting a Remote Second Opinion, you acknowledge and agree that: The diagnosis you will receive is limited and provisional; The Remote Second Opinion is not intended to replace a full medical evaluation or a face- to- face visit with a physician; The Geisinger physician does not have important information that is usually obtained through a physical examination; and, The absence of a physical examination may affect the Geisinger physician s ability to diagnose your condition, disease or injury. By engaging our services, you acknowledge and agree to assume the risk of these limitations. You further understand that no warranty or guarantee has been made to you concerning any particular result or cure of your condition. / / Patient Signature Date /13 DPMC
13 Geisinger Health System Remote Second Opinion: Department of Dermatology Payment Authorization SERVICES REQUESTED Dermatology Remote Second Opinion $450 Pathology Interpretation (add l $180 per interpretation) $ Total $ Method of Payment: VISA _Mastercard Discover _American Express Expiration Date -- Security Code Name (as it appears on your credit card) Address_ Apt CITY STATE ZIP I authorize Geisinger Health System to charge the above amount for services requested through the Remote Second Opinion Program. I acknowledge that I am an authorized user of this credit card and assume the risks and liabilities associated with its use. SIGNATURE DATE: / / FOR OFFICE USE ONLY Medical Record Number (MRN) Geisinger Physician s Name: Specialty Dept: Pathology Dept: Date of Service: / _/
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1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form
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11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509
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Personal Injury Questionnaire
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Dear Patient, Sincerely, Gastroenterology Associates of North Jersey
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Rehabilitation Medicine Clinic. New Patient Questionnaire
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Western Center Eye Care 2720 Western Center Blvd Ste 316 Fort Worth, TX 76131
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FAIRBANKS PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST If you wish, you can save time and simplify the registration process by completing the registration paperwork before you arrive. This checklist will help make sure you
Patient Registration Form
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Associated Ear, Nose & Throat Specialists, LLC. OCCUPATION: Employer: Work Phone: PHYSICIAN REQUESTING CONSULTATION: TOWN: PHONE:
Associated Ear, Nose & Throat Specialists, LLC Todd A. Zachs, M.D. Kevin C. Krebsbach, M.D Thomas Hinchey, Au.D., CCC-A Amanda Hessenauer, Au.D. Name: Birth date: SOCIAL SECURITY SEX: M F (IF MINOR) PARENT'S
Please fill out forms, sign where needed and bring with you to your first visit. If you have any questions please call the office at 212-751-8300.
Welcome to Manhattan Sports Medicine and the office of Dr. Kyle Worell. Before we get started please see all forms below: Personal History (Intake) Informed Consent Payments HIPPA Please fill out forms,
Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D
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Orthopedic Specialists Of SW FL New Patient Information Form
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Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081
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Name Today's Date Sex. Street Address City State Zip Code. Home # Work # Cell # Would you like to receive text confirmations:
Patient Information 219 Old Hook Road Westwood, NJ 07675 Office: (201) 664-0847 Fax: (201) 664 8890 E-Mail: Mail@2020nj.com Thank you for choosing Valley Eye Associates for you eyecare needs. Please complete
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Thank you for choosing the Rubin Institute for your orthopedic care. We are looking forward to seeing you soon!
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Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684 Phone (727) 784-3366 FAX (727) 784-3527
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New Patient Evaluation
What area hurts you the most? (Please choose one) When did this pain start? Neck Other: Back How did this pain start? How often do you experience this pain? Describe what this pain feels like. What makes
Medical History Form
MAIN SATELLITE 49 Veronica Avenue Suite 202 901 West Main Street Suite 203 Somerset, NJ 08873 Freehold, NJ 07728 P: 732 640 5316 P: 732 640 5327 F: 800 689 2361 F: 800 689 2361 128 Rehill Avenue Suite