ST. ANTHONY'S PHYSICIAN ORGANIZATION

Transcription

1 Dear Patient: Welcome to St. Anthony's Physician Organization. You, as the patient, are the most important person in our medical practice and we are honored that you have selected us to be your medical provider. Our mission states that we have the privilege and duty to provide the best care to every patient, every day. Our goal is to form a partnership that focuses on excellence for you and your health. Yes, you are involved in this process and are now a part of the team. You can expect that we will share our medical expertise and deliver compassionate, wellcommunicated care. We expect you to take responsibility for your own health and trust you to adhere to the advice we provide. Together, we can help you achieve excellence for you and your health. We have enclosed our new patient documents which we know can be time consuming, but are critical to creating a successful first visit. Below are some key points for the paperwork and your first visit. We would greatly appreciate your help in getting this partnership started on the right foot. 1. Complete the medical record release and mail to your previous doctor as soon as possible. This is a necessary step to allow him/her to provide a copy of your medical records to us. 2. Bring your current insurance card and photo ID card. 3. Bring your co-payment amount with you as it is due at the time of service. 4. Bring your completed new patient paperwork. 5. Bring your immunization record. 6. Arrive 30 minutes before your scheduled appointment. If you have any questions or comments regarding the paperwork, please feel free to contact us, and we would be happy to assist you. Thank you for this opportunity to serve you. Throughout our partnership please do not hesitate to contact us with regards to anything concerning your health or quality of care. It will be our pleasure to help you. We look forward to meeting you. Sincerely, The Physicians and Staff of St. Anthony's Physician Organization.

2 ST. ANTHONY S PHYSICIAN ORGANIZATION Patient Name Reason for Visit Pediatric New Patient Date of Birth Date of Visit Medications Medication Name Strength/Dose Pills per dose Times per day Past Medical History Diabetes Yes No Constipation (requiring doctor visits) Yes No High Blood Pressure Yes No Bed-wetting (after 5 years old) Yes No Asthma/Wheezing Yes No Problems with Urination Yes No Pneumonia Yes No Frequent Urinary Infections Yes No Heart Murmur Yes No (Girls) has she started menstrual Yes No periods? Thyroid Disease Yes No (Girls) any problems with her periods? Yes No Frequent Ear Infections Yes No Eczema/Skin Problems Yes No Seasonal Allergies Yes No Depression/Anxiety (circle which) Yes No Problem with ears or hearing Yes No Behavior Problems Yes No Problem with eyes or vision Yes No Frequent Headaches Yes No Chicken Pox Yes No Seizures Yes No Rheumatic Fever Yes No Anemia or Blood Disorder Yes No Meningitis Yes No Any other medical problem: List Below Yes No Mononucleosis Yes No Frequent Abdominal Pain Yes No Allergies Surgical History/Hospitalizations Drug/Non-Drug Allergy Reaction Previous Surgery/Hospitalization Year Family History Please identify the family member who has had any of these medical problems: Deafness Kidney Disease Nasal Allergies Diabetes (before 50 years old. Asthma Alcohol Abuse Tuberculosis Epilepsy or convulsions Heart Disease Bed-Wetting (after 10 years (before 50 years old) old) High Blood Pressure (before 50 years old) Immune Problems, HIV, or AIDS High Cholesterol Mental Illness Anemia Mental Retardation Bleeding Disorder Drug Abuse Liver Disease Other:

3 ST. ANTHONY S PHYSICIAN ORGANIZATION Household Please list all those living in the child s home. Name Relationship to Child Birth Date Health Problems Are there siblings not listed? If so, please list their names, ages, and where they live: If mother and father are not living together or if child does not live with parents, what is the child s custody status? If one or both parents are not living in the home, how often does he/she see the parent/parents not in the home? Birth Weight Was the baby born at term? Early? Late? If early, how many weeks gestation? Did mother have any illness or problem with her pregnancy? Birth History Was the delivery Vaginal? Cesarean? If cesarean, why? Did your baby have any problems right after birth? During pregnancy, did mother Was initial feeding Breast? Bottle? Smoke Yes No Drink Alcohol Yes No Did your baby go home with mother from the hospital? Use drugs or medications Yes No What When General Do you consider your child to be in good health? Does your child have any serious illness or medical condition? Has your child had any serious injuries or accidents? Has your child had any surgery? Has your child ever been hospitalized? Is your child allergic to any medicine or drugs? Are you concerned about your child s physical development? Are you concerned about your child s mental or emotional development? Are you concerned about your child s attention span? If your child is in school: How is his/her behavior in school? Has he/she failed or repeated a grade in school? How is he/she doing in academic subjects? Is he/she in special or resource classes? Development

4 ST. ANTHONY S PHYSICIAN ORGANIZATION Review of Systems Presently, are you experiencing any of the following symptoms? Weight Gain/Loss +/- lbs Yes No Nausea Yes No Failure to Gain Weight Yes No Vomiting Yes No Tired/Fatigue Yes No Diarrhea Yes No Fevers Yes No Constipation Yes No Dental Problems Yes No Bloody Stools Yes No Eye Problems Yes No Burning with Urination Sore Throat Yes No Blood in Urine Yes No Runny Nose Yes No Discharge from Penis/Vagina Yes No Sinus Problems Yes No Swollen/Painful Joints Yes No Hearing Problems Yes No Prior Broken Bone Yes No Frequent Ear Infections Yes No Scoliosis Yes No Heart Murmur Yes No Behavior Changes Yes No Irregular Heart Beat Yes No Depression Yes No Cough Yes No Problems with Sleep Yes No Wheezing Yes No Easy Bruising Yes No Difficulty Breathing Yes No Skin Rash: Where Yes No Stomach Aches Yes No Headaches Yes No Heartburn/Reflux Yes No Seizures Yes No

5 From: Authorization for Use or Disclosure of Protected Health Information To: Provider Name: Address: Patient Name: St. Anthony's Physician Organization Self Doctor/Hospital/Other: (address) Date of Birth: (phone) I hereby request and authorize you to release the following records (please check all that apply): All medical records concerning my care and treatment rendered by you, except those relating to:. Dates of Service: to. Important: I understand that unless I specifically request that such information not be disclosed, authorized disclosure may contain Protected Health Information containing diagnosis, treatment and other information regarding psychiatric and mental health, substance abuse (chemical dependency), HIV and/or AIDS. The Protected Health Information indicated above is to be used and/or disclosed for the following purpose(s): Continuity of Care Reimbursement Self Other: To be read by patient prior to signing: I understand that I may refuse to sign this authorization. I understand that my treatment by St. Anthony's Physician Organization or payment for that treatment will not be affected if I do not sign this form. I understand that I may request to inspect and copy the Protected Health Information that is to be used and/or disclosed pursuant to this authorization. I understand that I should receive a copy of this authorization form after I sign it. I understand that if I authorize release of my Protected Health Information to a person or organization that is not subject to federal law governing privacy and that person or organization re-discloses my Protected Health Information, my Protected Health Information may no longer be protected by federal privacy laws. I understand I may revoke this authorization at any time by notifying St. Anthony's Physician Organization in writing, at the above address, but that any such revocation will not have any effect on any actions that St. Anthony's Physician Organization took before receiving the revocation. This authorization expires one year from the date signed if I have not provided an expiration date or event. A photo static copy of this authorization shall be considered as effective and valid as the original. Signature of Patient or Patient s Representative Date *If signed by patient s representative, indicate relationship to the patient Telephone number where patient may be contacted PLEASE READ Fee Information: St. Anthony's Physician Organization contracts with Datafile Technologies to copy and provide all medical records requested from our office. Patients requesting records to be transferred to a third party (ex: life insurance, law firm, etc.) will be charged the following fees as set forth by the state of MO: $22.82 handling fee, $0.53 per page. Patients requesting a personal copy of their records will be charged a flat fee of $25.00 by Datafile Technologies. In the case of continuity of care, we may transfer a minimal portion of your records directly to a physician as a courtesy.

6 Payment Policy We accept cash, check, Visa, Master Card, Discover, American Express and most insurance plans. If you have insurance, the following apply: 1. It is your responsibility to provide us with the correct information regarding your insurance company, and to follow the rules of your insurance company. You must comply with such rules as a valid referral and precertification of testing and surgery in order for your claims to be paid. We will assist you, but if claims are denied because of your failure for the above, you will be responsible for paying the denied services. 2. For auto related accidents, you are responsible for the bill. We will bill your personal insurance first, but you should expect to get an additional statement if your health insurance denies your claim. 3. You are responsible for paying any deductibles, co-payments or non-covered services. 4. If you are involved in a lawsuit that affects the payment for our services, we hold you responsible for payment of our regular fees. 5. We file group insurance claims and by law, must file Medicare claims. Children that are brought to our office less than 18 years of age must have authorization from their parent or legal guardian before being treated by one of our providers. A service fee of $30.00 will be charged to the patient for each returned check and only cash, cashier s check, or credit card will be accepted to satisfy payment of this returned check service charge fee. A minimum 24-hour notice is requested on cancellations. If a patient does not show up for an appointment or calls to cancel within 23 hours of their scheduled appointment time, it is considered a No Show. A fee of $25.00 may be charged to your account for the missed appointment (special circumstances are taken into consideration). If appointments are consistently missed, you may be requested to seek care through another physician. In the event your account is turned over to a collection agency, you are responsible for any and all related attorney and/or collection fees and may be asked to seek care through another physician. FINANCIAL RESPONSIBILITY: In accordance with the above terms and in consideration of the services rendered to the patient designated herein at my request for this occasion of service, I guarantee and agree to pay St. Anthony's Physician Organization charges for those services rendered, including any deductibles, coinsurance or amounts not paid by my insurance plan, Medicare, Medicaid, health service plan or health maintenance organization. Members of health maintenance organizations (and preferred provider organizations) are generally required to comply with certain policies and procedures requiring the use of participating providers and compliance with plan requirements for primary referral, pre-certification, and utilization review. These are conditions to payment of benefits by the health maintenance organization (and preferred provider organizations). By signing the financial responsibility statement, the patient and guarantors acknowledge and agree they are responsible for payment of billed charges rendered in any case in which payment may be denied by the health maintenance organization (or preferred provider organization) because of a failure to comply with such coverage requirements or for any other reason. I have read all the above terms and assume full responsibility for paying any medical service charges and finance charges according to these terms. Signature of Patient or Representative of Patient Relation Date Printed Name of Patient or Representative of Patient

7 General Information Emergencies: For a life threatening situation, call 911 or proceed to the nearest emergency room. If you need to reach a physician after business hours for an urgent issue, you may contact your physician s exchange to speak with the physician on call. (Please note: your own doctor may not be on call.) Prescriptions: To facilitate medication refills, we ask that you have your pharmacy fax us your refill requests. We make every effort to complete these as soon as possible, but to ensure that you do not run out of medication, please call your pharmacy to request your refill a few days before you will need it. Appointments: Please call in advance for routine office visits and make follow up appointments as you leave. We make every effort to stay on schedule but if we are seriously delayed, we will attempt to notify patients. As a courtesy to our patients and staff, please call our office as soon as possible if you will be late. You may be asked to reschedule if you are more than 15 minutes late. If three consecutive appointments are missed without appropriate notification, you may be asked to seek care through another physician. Physician Completion of Letters, Forms & FMLA paperwork: Please allow up to 10 business days for completion of forms. There may be a fee due for letters, forms and FMLA services and money will need to be collected before paperwork is sent or given out. Fees for forms and letters may be up to $ Insurance: While we accept many insurance plans, please contact the customer service number on the back of your insurance card to check with your insurance provider and make sure our doctors do accept your plan. Please review insurance information with our staff prior to services being rendered. You will need to present your insurance card(s) at every visit, especially your first visit after the New Year and when you receive new cards in the mail or change plans. Test Results: We make every effort to contact you within a reasonable time regarding your test results. If you have not heard from us within two weeks from the time of service, please contact our office. Please notify our office of any change in name, address, phone number, pharmacy or insurance information so that we will always know how to contact you. Lab Preference: Due to time constraints, we are unable to call every insurance plan to obtain the preferred lab. Our preferred lab is St. Anthony s and unless we are notified otherwise, we will send your labs to St. Anthony s. Please let us know if you wish to have your labs sent elsewhere. Thank you for choosing our practice!

8 Patient Name: D.O.B.: Permission to Contact and Release of Information In order to improve communications between the office and our patients, an automatic service will be calling to confirm your appointment. Please check the following options below to receive your confirmation call: Please contact me at: Home Cell Work Please leave a message at: Voice Message Text Message I prefer to be contacted in the: Morning Afternoon Evening 8 am 12 pm 12 pm 4 pm 4 pm 8 pm There may be times when we need to speak to you personally regarding your appointment or to discuss your confidential health information. Please provide how and where you would like to be contacted. Please check the boxes below to indicate your preference. Please contact me at: Home Cell Work I authorize you to leave normal tests results only on my voic . I request that you leave a message on my voic but only to indicate you have called and I will return your call. Authorization granted will remain in effect during the course of your care in this office unless revoked by you in writing. You may at any time release my confidential health information to: (If no names are listed, we will not release any information.) Name Relationship to Patient Phone Type Phone Number Name Relationship to Patient Phone Type Phone Number Name Relationship to Patient Phone Type Phone Number Signature of Patient/Guardian/Parent Printed Name Date

9 Primary Care Provider: Patient Information Referred By: NAME: (Last) (First) (MI) PREVIOUS NAME: ADDRESS: (City/State) (Zip) HOME PHONE: ( ) CELL PHONE: ( ) WORK PHONE: ( ) DATE OF BIRTH: / / SEX: M F MARITAL STATUS: S M D W Separated SOC. SEC. NO. / / (Ext) NAME OF GUARANTOR: GUARANTOR S DATE OF BIRTH: / / GUARANTOR S ADDRESS: (City/State) (Zip) TELEPHONE NUMBER: ( ) SOC. SEC. NO. / / RELATIONSHIP TO PATIENT: EMERGENCY CONTACT: TELEPHONE NO: ( ) RELATIONSHIP: Insurance Information PRIMARY INSURANCE: EFFECTIVE DATE: / / NAME OF INSURED: RELATIONSHIP TO PATIENT: INSURED S DATE OF BIRTH: / / INSURED S ID NO. GROUP NO. INSURED S ADDRESS: TELEPHONE NO. ( ) (If Different From Patient s) INSURED PARTY EMPLOYED BY: EMPLOYER S ADDRESS: TELEPHONE NO. ( ) SECONDARY INSURANCE: EFFECTIVE DATE: / / NAME OF INSURED: RELATIONSHIP TO PATIENT: INSURED S DATE OF BIRTH: / / INSURED S ID NO. GROUP NO. INSURED S ADDRESS: TELEPHONE NO. ( ) (If Different From Patient s) INSURED PARTY EMPLOYED BY: EMPLOYER S ADDRESS: TELEPHONE NO. ( ) Additional Information ADVANCED DIRECTIVES: Y N POWER OF ATTORNEY: Y N PATIENT PORTAL: Y N LOCAL PHARMACY: PHONE: MAIL ORDER PHARMACY: ADDRESS: PATIENT DEMOGRAGHICS: The St. Anthony s Physician Organization is participating in Meaningful Use, a new nationwide initiative to improve the health of our nation. To better identify possible disparities in access and quality of healthcare based on race and ethnicity on a nation wide level, we are required to ask the following demographic questions: RACE ETHNICITY PREFERRED LANGUAGE AMERICAN INDIAN/ALASKA NATIVE HISPANIC/LATINO BOSNIAN ASIAN NOT HISPANIC/LATINO ENGLISH AFRICAN AMERICAN I PREFER NOT TO REPORT SIGN LANGUAGE CAUCASIAN SPANISH NATIVE HAWAIIAN or OTHER PACIFIC ISLAND OTHER OTHER I PREFER NOT TO REPORT I PREFER NOT TO REPORT SIGNATURE OF RESPONSIBLE PARTY: DATE: / /

10 Consent to Treat CONSENT. I hereby consent to the administration of treatment deemed necessary by my physician(s) and other physicians who may attend me, their associates and assistants, healthcare professionals responsible for my care, St. Anthony's Physician Organization and any of its affiliates, house staff, employees and students to provide medical care, tests, procedures (including, but not limited to, intravenous [IV] catheter placement, drugs or drug products, services and supplies considered advisable by my physician. These services may include injections, minor skin surgery, vaccinations, skin tag/mole removal, incision and drainage, etc. I hereby authorize my physician to photograph, film, and/or videotape me and to use such photographs, films, or videotapes for treatment. I further authorize my physician to examine, use, and/or dispose of in any manner tissues, fluids or parts removed from my body. In the event that I am unable to consent, and any of my caregivers are inadvertently exposed to my blood or other bodily fluids, and such exposure is capable of transmitting disease, I consent to the drawing and testing of my blood for antibodies to the human immunodeficiency virus (HIV), hepatitis, and cytomegalovirus (CMV). Assignment of Benefits ASSIGNMENT OF INSURANCE BENEFITS. In consideration of any and all medical services, care, drugs, supplies, equipment and facilities furnished by St. Anthony's Physician Organization and all attending physicians, I hereby authorize direct payment to St. Anthony's Physician Organization and physicians, of all insurance benefits applicable to this office visit (including Medicare and/or Medicaid benefits), which are now or which shall become due and payable to me. MEDICARE/TRICARE/VA INSURANCE BENEFITS. I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct. I authorize the release of medical or other information to the Social Security Administration or its intermediaries or carriers concerning this or a related Medicare claim filed by St. Anthony's Physician Organization. I request that payment of authorized benefits be made on my behalf. I understand that I am responsible for the Part A&B deductible for each year, the remaining co-insurance and any other non-covered personal charges. I (or my representative) certify(ies) that I or he/she has read (or if the patient/representative is unable to read has had the form read to him/her) and understand(s), and accept(s) the above and further certify(ies) that I am the patient, or I am duly authorized on behalf of the patient to execute such an agreement. Release of Information RELEASE OF INFORMATION. I consent to the electronic storage and transmission of patient health information. I acknowledge that there are instances when St. Anthony's Physician Organization must release information concerning my care, including information related to mental health, substance abuse (chemical dependency), HIV and/or AIDS, including copies of my medical records, to certain individuals or entities who are involved in my care, payment for my care, and other activities related to my care. Such disclosures are more fully described in the Notice of Privacy Practices, and include disclosures to: a. Any health professionals involved in my care for the purpose of facilitating the continuity of care. b. Any person or entity responsible for, or any person or entity acting as agent for the party responsible for payment, including third party payors, self-insurers, worker s compensation carriers and governmental agencies payment for the medical services rendered to me at St. Anthony's Physician Organization by employees of St. Anthony's Physician Organization or any person providing services at St. Anthony's Physician Organization or any affiliate. c. Any federal, state or other governmental or quasi-governmental agencies or other such parties as required by law for purposes of reporting, or for purposes of determining eligibility in government sponsored benefit programs. d. Any person or entity participating in quality studies, utilization review or similar studies of the care rendered by St. Anthony's Physician Organization, affiliates and/or their physicians. e. Any continuing care, including but not limited to: residential, or long-term care facility, or home health agency for the purpose of obtaining and providing services for my care. f. I also authorize my physician to obtain information from other providers regarding my care and treatment including obtaining my electronic medication and prescription history from whatever source for the purpose of my continuing care and treatment. I acknowledge that my medical information may include information relative to alcohol abuse, drug abuse, psychological or psychiatric conditions, Human Immunodeficiency Virus (HIV), and/or Acquired Immunodeficiency Syndrome (AIDS). I acknowledge that I have received a copy of St. Anthony s Physician Organization Privacy Policies. I acknowledge that I have read this form and understand its contents fully and have received a copy of the patient rights/responsibilities, I agree to obey the rules and regulations of St. Anthony's Physician Organization and understand that these rules and regulations apply not only to patients of St. Anthony's Physician Organization, but to the patient s visitors as well. Signature of Patient or Legal Representative Relationship Date Signed