How To Get A Medical Checkup From A Doctor

Transcription

1 WELCOME Metropolitan Pediatrics, L.L.C. WELCOME! It is our pleasure to welcome your family to Metropolitan Pediatrics! We are very excited that you have chosen us, and can t wait to get-toknow you, your care preferences, and health goals so we can care for your family like no one else! HOME SWEET MEDICAL HOME During your visit, we want you to feel welcome, cared for, and respected just like you do in your own home! That s why we make it easy and comfortable for you to get the care you need, in the way that works best for your family. As your Medical Home, we will: Listen to you and answer your questions. Connect you to care, information, and services to keep you healthy. Encourage you to have an active role in your own health. Help and support you in any way we can! In return, we ask that you get involved in your care, team up with us to meet your health goals, and let us know when you have questions or concerns. Immunizations are an essential part of well child care. Metropolitan Pediatrics follows the national immunization guidelines set forth by the American Academy of Pediatrics, the Advisory Committee on Immunization Practices of the Centers for Disease Control, and the American Academy of Family Physicians. APPOINTMENTS On weekdays, we are available by phone between 7:30am and 5:30pm, and see patients starting at 8:30am. We do our best to accommodate same-day appointments. Call early as openings tend to fill quickly. Well Care Please schedule check-ups 1 to 2 months in advance, so you can reserve a time that works best with your schedule. Cancellations We ask that you kindly give us 24- hour notice when canceling or rescheduling appointments. Preparation At the time of your visit, you will be asked to present the following: copay, if applicable enclosed forms, completed health insurance card(s) photo ID current medications, including dosage and strength current immunization records previous medical records, or arrange for your previous physician to send records 24/7 ADVICE & SUPPORT During business hours, we are happy to answer general questions over the phone. Urgent matters will be addressed before the day is over. For less urgent matters, we will return your call within hours. For after-hours advice, we offer a live answering service that can assist you, or connect you with oncall advice for guidance. Reach Advice anytime, day or night, by calling your clinic s daytime phone number. WEEKEND CARE Weekend appointments are available for patients with urgent problems or certain pre-scheduled well exams. Our clinics are typically open through the morning and into the early afternoon, depending on patient demand. If you feel your child has a medical problem that cannot wait until Monday, please call us to reserve an appointment. Phones open at 8:00am for scheduling. *Gresham patients requiring Weekend Care will be seen at our Happy Valley Office. Please contact us before going to an urgent care clinic or the ER! In most cases, we can treat your child in our clinic, saving you time and worry. Locations SE Stark St., Ste. 200 Gresham, OR SE 91 st Ave., Ste. 200 Happy Valley, OR NW 22 nd Ave., Ste. 320 Portland, OR NW Greenbrier Pkwy., Ste. 111 Beaverton, OR Hours Monday Friday: 8:30 AM 5:30 PM* Scheduling starts at 7:30 AM *Some clinics offer extended hours Saturday & Sunday: Scheduling starts at 8:00 AM

2 Metropolitan Pediatrics, LLC Authorization to Release Medical Records Patient Date of Birth: / / Please print full name. Address: Street City State Zip Code Home/Cell Phone: ( ) Work Phone: ( ) Release Purpose: Self Changing provider Consultation Legal Other: I authorize Metropolitan Pediatrics to (check all appropriate boxes, and provide complete name and address information): Give records to: Verbally exchange with: Request records from: Phone: ( ) FAX: ( ) Address: Street City State Zip Code My medical information: MAY or MAY NOT be faxed. MAY or MAY NOT be securely ed. Metropolitan Pediatrics accepts medical records via fax, secure , or mail. By initialing spaces below, I specifically authorize the release of the following medical records if such records exist: Chart notes Laboratory reports ALL medical records Diagnostic imaging Immunization records Past 2 years Other: Records containing the following information require additional consent (items must be initialed to be released): Mental health and ADD/ADHD diagnosis or treatment information Genetic testing Drug/alcohol diagnosis, treatment, or referral information HIV/AIDS testing MY SIGNATURE INDICATES THAT I UNDERSTAND AND AGREE TO THE FOLLOWING: I understand that the information used or disclosed in this authorization may be subject to re-disclosure and may no longer be protected under federal law. However, I also understand that federal or state law may restrict re-disclosure of HIV/AIDS test or result information, mental health information, genetic testing information, and drug/alcohol diagnosis, treatment, or referral information. I understand that the person or entity I am authorizing to use and/or disclose information may receive compensation for doing so. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain health care services or reimbursement for services unless authorization is required to bill my insurance company. The only circumstance when refusal to sign means I will not receive health care services is if the health care services are solely for the purpose of providing health information to someone else, and the authorization is necessary to make that disclosure. I understand that I may revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to: HEALTH INFORMATION SERVICES NW Greenbrier Parkway, Suite 112, Beaverton, OR FAX HIS@metropediatrics.com I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition:. If I fail to specify an expiration date, event, or condition, this authorization will expire 1 year from the date signed. X X / / Signature of Patient/Parent/Legal Guardian Print Name Relationship to Patient Date X X / / Patients 14 years and older SIGNATURE REQUIRED Print Name Date Rev. 05/29/2015 Authorization to Release Medical Records Page 1 of 2

3 $ MEDICAL RECORDS COPY FEE: As you may know, we are governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to protect patients rights to confidentiality, as well as to track and report each request. Therefore, in order to fulfill your request, we must ask for an upfront fee before copying. This fee will offset costs associated with copying, tracking, and reporting processes surrounding your request. There is a flat copy charge of $20.00 for any personal request for medical record copies. Please make checks payable to Metropolitan Pediatrics. We will process your request when payment is received. MAXIMUM TIME ALLOWED FOR COPYING MEDICAL RECORDS: Thirty (30) days if chart is maintained at the medical office. Sixty (60) days if chart is maintained off-site in medical records storage facility. Payment Received: $ Date: / / Rev. 05/29/2015 Authorization to Release Medical Records Page 2 of 2

4 Metropolitan Pediatrics, LLC Patient Information Gresham Happy Valley Northwest Westside PARENT INFORMATION _ Marital Status: Married Single Divorced Widowed Address: City/State/Zip: Home: ( ) Cell: ( ) How did you hear about us? OTHER PARENT INFORMATION _ SSN: DOB: / / M F Marital Status: Married Single Divorced Widowed Address: City/State/Zip: Home: ( ) Cell: ( ) PATIENT INFORMATION New Patient? Y N OTHER CHILDREN IN FAMILY Patient Here? Y N....Patient Here? Y N Patient Here? Y N.... EMERGENCY CONTACT (other than spouse) Relationship to Patient: Home: ( ) Cell: ( ) Private Pay (no insurance) Insurance (primary) Eff. Date: / / Insurance Co: Employer: Policyholder: DOB: / / Policy #: Group #: Copay: $ CONSENT FOR TREATMENT: I authorize the physicians and clinic personnel of Metropolitan Pediatrics, LLC, to conduct physical examinations and routine services, order and perform tests, and administer treatment deemed necessary by the examining physician. Should treatment be performed, the physician will fully inform me as to the nature of the procedure, the alternatives to treatment, and the risks involved. I will be given the opportunity to ask questions and have my questions answered. Should special procedures be indicated, I understand that the examining physician will discuss this with me and that additional consent(s) may be required. FINANCIAL RESPONSIBILITY: I understand that I am responsible for all charges resulting from treatment provided by Metropolitan Pediatrics, LLC, as well as any agency and/or legal fees incurred should my account be placed in a collection status. I agree to pay the balance due within 30 days of statement billing unless I have made other payment arrangements. ASSIGNMENT OF BENEFITS: I authorize my insurance carrier(s) to remit payment of benefits for any claim to Metropolitan Pediatrics, LLC. I understand that any ineligible or noncovered expenses are my responsibility. I assign Metropolitan Pediatrics, LLC, as an Authorized Representative to: (1) Submit any and all appeals when my insurance company denies me benefits to which I am entitled, (2) Submit any and all requests for benefit information from my insurance company, (3) Initiate formal complaints to any state or federal agency that has jurisdiction over my benefits, and (4) Release all medical information necessary to process my claims. I authorize any plan administrator or insurer to release any and all plan documents, insurance policy, and/or settlement information upon written request from Metropolitan Pediatrics, LLC. This assignment is valid for all administrative and judicial reviews under PPACA, ERISA, Medicare, and applicable federal or state laws. A photocopy of this assignment is to be considered as valid as the original. X X / / Signature of Patient/Parent/Legal Guardian Print Name Relationship to Patient Date Rev. 10/06/2014 BILLING INFORMATION OHP (circle one): FamilyCare OMAP Insurance (secondary) Eff. Date: / / Insurance Co: Employer: Policyholder: DOB: / / Policy #: Group #: Copay: $

5 Metropolitan Pediatrics, LLC Patient Intake Form Gresham Happy Valley Northwest Westside Patient Date of Birth: / / MR#: Date of Service: / / American Indian or Alaska Native Asian Black or African American Hispanic Native Hawaiian or other Pacific Islander White (non-hispanic) Other Welcome to Metropolitan Pediatrics! Please take the time to fill out this form as accurately as possible so we can most appropriately address your child s health needs. Thank you! BIRTH HISTORY Pregnancy Did mother...smoke? Yes No...drink alcohol? Yes No...use drugs/medications? Yes No If yes, what kind(s)?...experience illness/complications? Yes No If yes, what kind(s)? BIRTH HISTORY Delivery/Newborn Period Delivery Type: Vaginal C-section Gestational Age: Birth Weight: Date hepatitis B given: / / Problems in newborn period: PATIENT MEDICAL HISTORY ADD/ADHD Hearing loss Scoliosis Allergies Heart murmur Seizures Anxiety Immune deficiency Sickle cell Arthritis Inflammatory bowel disease Strep throat (recurrent) Asthma Jaundice Thyroid disease Cancer/Oncology Meningitis Tuberculosis Diabetes mellitus Otitis media UTI Eating disorder Pneumonia Varicella (chickenpox) Eczema Prematurity Vision problems Headaches Other: PATIENT SURGICAL HISTORY Adenoidectomy C-section Lymph node biopsy Appendectomy Fracture surgery Tonsillectomy Circumcision Heart surgery Ear tubes Cleft lip Hernia repair Umbilical hernia Cleft palate Inguinal hernia Undescended testicle surgery Cosmetic surgery Other: Rev. 06/30/2015 MORE QUESTIONS ON THE BACK SIDE Patient Intake Form Page 1 of 2

6 FAMILY HISTORY Have any family members had the following conditions? Please mark an X by each condition that applies. Vision Loss Thyroid Disease Sudden Death Substance Abuse Seizures Rheumatologic Disease Obesity Kidney Disease High Cholesterol High Blood Pressure Heart Disease Heart Defect Hearing Loss Eczema Early Death Diabetes Developmental Delay Depression Clotting Disorder Bleeding Problem Birth Defects Asthma Arthritis Allergy-Severe ADHD Other No Known Problems Lives with patient? Family Member Name: Date of Birth: Mother: / / Father: / / Sibling: / / Sibling: / / Maternal Gma: Maternal Gpa: Paternal Gma: Paternal Gpa: Other: / / List any other conditions (by family member): Rev. 06/30/2015 Patient Intake Form Page 2 of 2

7 Genetic Privacy Notice Notice of Your Right to Decline Participation in Future Anonymous or Coded Genetic Research Metropolitan Pediatrics, LLC is required by Oregon law to provide this notice to you regarding the use of your health information or biological samples for genetic research (OAR ). State law protects the genetic privacy of individuals and gives you the right to decline to have your health information or biological samples used for research. A biological sample may include a blood sample, urine sample, or other materials collected from your body. You can decide whether to allow your health information or biological samples to be available for genetic research. Your decision will not affect either the care you receive from your health care provider or your health insurance coverage. Research is important because it gives us valuable information on how to improve health, such as ways to prevent or better treat heart disease, diabetes and cancer. Under Oregon law, a special team reviews all genetic research before it begins. The team makes sure that the benefits of the research are greater than any risks to participants. In anonymous research, personal information that could be used to identify you, such as your name, Social Security number or medical record number, cannot be linked to you health information or biological sample. In coded research, personal information that could be used to identify you is kept separate from your health information or biological sample, making it very difficult to link your personal information to your health information or biological sample. Your identity is protected in both types of research. If you DO NOT want to have your health information and biological sample available for anonymous or coded genetic research, YOU MUST tell your health care provider by checking the box below, signing and returning the form as directed by your clinic representative. GENETIC PRIVACY OPT OUT STATEMENT q I have read and understand the above Genetic Privacy Notice and I DO NOT want to have my health information and biological samples available for anonymous or coded genetic research. Today s Date Patient Name (PRINT) Patient Date of Birth Patient or Personal Representative (Signature) If signed by Personal Representative, Describe Authority or Relationship to Patient If you want to allow your health information and biological sample to be available for anonymous or coded genetic research and make this choice, your health information or biological sample may be used for anonymous or coded genetic research without further notice to you. No matter what you decide now, you can always change your mind later by completing this form and returning it to your health care provider. Your new decision is effective on the date your health care provider receives the Genetic Privacy Opt Out form, and will apply only to health information or biological samples collected after your health care provider receives the form. If you have questions about Genetic Testing, please call the Oregon Genetics Program at This form will be retained in your medical chart throughout your relationship with Metropolitan Pediatrics, LLC. Sincerely, Metropolitan Pediatrics, LLC metpgpn#77