Regional Hospital. Division of Cardiothoracic Surgery PATIENT INFORMATION (DATOS DEL PACIENTE) Social Security # (Seguro Social No.

Transcription

1 Regional Hospital Division of Cardiothoracic Surgery PATIENT INFORMATION (DATOS DEL PACIENTE) Patient s Name (mbre y Apellido Del Paciente) Place of Birth (Lugar de Nacimiento) Social Security # (Seguro Social.) Sex (Sexo) Today s Date (Fecha) Occupation Date of Birth (Fecha de Nacimiento) Local Address (Domicilio) Apt # (Apto.) City (Ciudad) State (Estado) Zip Code (Código Postal) Phone (Teléfono) Employer Name (mbre Del Empleador) Address (Dirección) Phone (Teléfono) Position (Puesto) Cell (Celular) Spouse (mbre del Cónyuge) Date of Birth (Fecha de Nacimiento) Spouse Employer (mbre Del Empleador Del Cónyuge) Title (Cargo) Phone (Teléfono) Address (Dirección) City (Ciudad) State (Estado) Zip Code (Código Postal) Name Primary Care Physician - Doctor/Pediatrician Requesting Consultation (mbre Del Médico Primario. Médico/Pediatra Que Solicita Consulta) Address (Dirección) Phone # (Teléfono) What medication is patient allergic to? ( A QUÉ MEDICINA(S) ES ALÉRGICO(A)? Do you have an Advanced Directive?: (Indicó Directrices Por Anticipado?) Sí If no, would you like additional information: (En Caso Negativo, Desea Información Adicional?) Sí Primary Health Insurance Information (Información De Seguro De Salud Primario) Secondary Health Insurance Information (Información De Seguro De Salud Secundario) Insurance Co (Compañía De Seguros) Address (Dirección) City/State/Zip (Ciudad/Estado/Código Postal) Phone (Teléfono) ID# (Póliza.) Group Name Or # (mbre O. De Grupo) Is This An Employer Plan? ( Es Éste Un Seguro Médico De Su Empleador?) Name of Insured (mbre Del Asegurado) Insured Relationship To Patient (Vínculo Del Asegurado Con El Paciente) Insured Date Of Birth Social Security # (Seguro Social.) (Fecha de Nacimiento Del Asegurado) Insurance Co (Compañía De Seguros) Address (Dirección) City/State/Zip (Ciudad/Estado/Código Postal) Phone (Teléfono) ID# (Póliza.) Group Name Or # (mbre O. De Grupo) Is This An Employer Plan? ( Es Éste Un Seguro Médico De Su Empleador?) Name of Insured (mbre Del Asegurado) Insured Relationship To Patient (Vínculo Del Asegurado Con El Paciente) Insured Date Of Birth Social Security # (Seguro Social.) (Fecha de Nacimiento Del Asegurado) Emergency Contact Other Than Someone Living With You (Contacto De Urgencia De Una Persona Que Viva Con Usted) Name (mbre Y Apellido) Phone # (Teléfono) Relationship (Vínculo) Home Address (Dirección) City (Ciudad) State (Estado) Zip (Código Postal) I Authorize The Release Of Any Paymnt & Medical Information Necessary To Process This Claim. The Information Provided On This Form Is True & Accurate To The Best Of My Knowledge. (Autorizo Pagos E Información Médica Necesaria Para Procesar Esta Reclamación. La Información Que Dí En Este Formulario Es Válida Y Correcta A Mi Leal Saber). I Have Received, Read And Understand My Patient Rights & Responsibilities and the Hand &Respiratoty Hygiene Education. (Recibí, Leí Y Entendí El Documento Derechos De Los Pacientes y Educación para la higiente de las manos y vías respiratorias ). I consent to Medical Care. (Yo autorizo a recibir cuidados médicos). Signature of Patient/Guarantor (Firma Del Paciente/Garante)

2 VERY IMPORTANT: YOU MUST COMPLETE THE FORM NAME: DATE: DATE OF BIRTH: REFERRING/CONSULTING PHYSICIAN: PAST MEDICAL HISTORY: (Circle yes or no) Do you have any medical problems? or If yes, please list: Have you ever had an operation? or If yes, please list procedure and date of procedure: Do you have any allergies to medications or foods? or If yes, please list: Are you currently taking any medications, prescription or over the counter, including supplements or herbals? or If yes, please list all including over the counter, herbal and supplements: Are your immunizations up to date (including: Tetnus, Pneumonia, Influenza)? or If no, please explain: FAMILY HISTORY: (Indicate Relationship) / Diabetes / Lung Disease/TB / Cancer / Heart Disease/Stroke / Hypertension / / / / / Kidney/Urinary Disease Neurological Disease Seizure/Epilepsy Migraines Birth Defects SOCIAL HISTORY: Do you live alone? Are you currently working? Do you use tobacco? Do you drink alcohol? Do you use street drugs? / / / / / If, with whom? If, what kind of work do you do? If, how many packs per day/week? Is, how much: Never Seldom Occasional Social Heavy (cirle one) Is, what kind? THE CARDIAC CENTER Division of Pediatric CArdiac Surgery New Adult Patient History Regional Hospital Patient Sticker

3 VERY IMPORTANT: YOU MUST COMPLETE THE FORM MEDICAL HISTORY: Have you ever experienced any of the following (circle appropiate answers for each:) Headaches Chest pain/angina Frequent stomach pain Neck pain High blood pressure Frequent urination Back pain Swelling hands/feet Burning on urination Weakness/Numbness Productive cough Blood in urine Previous head injury Asthma Enlarged prostate Spinal cord injury Wheezing Bowel incontinence Previous Neurosurgery Frequent colds Bladder incontinence Deafness Shortness of breath Arthritis Ringing in ears Diarrhea Joint pain Nasal drip Constipation Broken bones Sore throat Hemorrhoids Muscle pain/weakness Difficulty swallowing Ulcer Rashes Mouth sores Bleeding ulcers Psoriasis se or mouth infections Depression Skin cancer Melanoma Manic/Depression Do you have any cultural concerns that you would like to share with us? BARRIERS WHICH MAY IMPACT CARE / LEARNING: Is there an inability to read or write? Do you have any religious concerns that you would like to share with us? (i.e. blood transfusions) Do you have emotionañ or psychological concerns that you would like to share with us? Do you have a language barrier? Do you have any financial concerns that you would like to share with us? Do you have any physical, visual, hearing, speech or learning impairments: Other concerns that you feel may affect your care? Reviewed Above Information: Physician Signature/ID # Physician AssistantSignature/ID # THE CARDIAC CENTER Division of Pediatric CArdiac Surgery New Adult Patient History Regional Hospital Patient Sticker

4 Acknowledgement of Receipt of MHS Privacy tice The MHS Privacy tice provides information about how Memorial Healthcare System, its employees, agents, and your personal doctors and other health care professionals caring for you in MHS facilities, may use and disclose protected health information about you. I hereby acknowledge receipt of the MHS Privacy tice. Signature of Patient: OR Signature of Patient s Legal Personal Representative: Relationship: Place Patient Label Here (4-03)

5 Agreement and Release Form Consent For Medical Care:I consent to medical testing, care, and treatment by MHS and my physicians. Assignment of Benefits: I hereby irrevocably assign payment to MHS and physicians accepting this assignment, of all hospitalization and medical benefits applicable and otherwise payable to me. Where Medicare and Medicaid benefits are applicable. I certify that the information given by me in applying for payment, under Title XVII or XIX of the Social Security Act is correct, and request that said payment of authorized benefits are made on my behalf. I understand that i am financially responsible to MHS and physicians for charges which the carrier declines to pay. It is further agreed that any credit balance resulting from payment by my insurance or other sources may be applied to any other accounts owed to MHS by the insured or immediate family. Release of Information for Payment Purposes: I hereby authorize and consent to Memorial Healthcare System s release of medical information to obtain payment as described in the MHS Privacy tice. This consent includes, without limitation, present and future HIV test results and mental health records. Obligation for Payment: I hereby agree to pay usual and customary charges for all services provided by Memorial Healthcare System and physicians to the patient, except those covered by insurance (which includes all commercial and goverment third party payors such as HMO s and Medicare). The Hospital will assist in insurance coverage matters, but i understand that it is my reponsibility to comply with all requirements for insurance coverage. I agree to pay all charges that are not paid by insurance, including without limitation, a private room, personal items, osmetic surgery, routine foot care, private duty nursing, custodial care, elective sterilization and transportation home via taxi or ambulance. In the event that i fail to fulfill any of the obligations in this section, I agree to pay any and all collection costs incurred by the Hospital in the enforcement of this section. Release of Liability for Loss of Personal Property: All patients are advised to deposit their valuables in the Hospital s vault or send them home. I fully understand that because of the complex nature of hospital routine, the staff of the Memorial Healthcare System cannot give attention to any item of personal property, regardless of value. I further understand that i am responsible for any item I choose to keep with me including but not limited to, such personal items as eyeglasses, dentures, cash. jewerly, or clothing, and that in the event of the loss of such items, I will not hold the Hospital responsible, but will personally assume any cost and expense incurred because of such loss. I also understand that any items which are left in the Hospital may be disposed of by the Hospital in thirty (30) days. Professional Billing: Charges for physicians who provided your care and interpreted your tests are not included in your hospital bill. You will receive separate bills from physicians such as the emergency room physician, radiologist, pathologist, anesthesiologist, your attending physician and specialty consults. Print Patient Name: Last, First, Initial Date OR Patient s Signature Witness Signature of Patient s Legal Personal Representative Relationship PATIENT/LABEL Agreement and Release Form English/Spanish (05/1506)

6 Pick-up Mail Out e-delivery CD Medical Record #: Account #: 1. Person(s) or class of persons authorized to use / disclose the information: Memorial Regional Hospital/ Memorial Regional Hospital South Joe DiMaggio Children s Hospital Memorial Hospital West Cancer Center Memorial Hospital West Memorial Physician Practice(s) (specify) Memorial Hospital Miramar Memorial Regional Hospital Cancer Center Memorial Hospital Pembroke All Memorial Helathcare System facilities Memorial Home Health Memorial Primary Clinic Memorial Manor Nursing Home Other (specify) 2. By signing this, I authorize the above to disclose preotected health information about the person named below. Patient Name (Print): Authorization for Release of Confidential Medical Records Date of Birth: 3. Please disxlose the exact information to be disclosed, including dates of service: Abstract (Includes * reports shown below) Date (s) of Service OR the specific records marked below: Date (s) of Service *Face Sheet *Pathology Reports *Discharge Summary *Consultation Reports *Emergency Room *EKG Reports *Outpatient Records *Clinical Lab Reports *History & Physical *X-ray Reports *Progress tes All medical records *Operative Records *Other (specify) *Newborn ID Sheet te: X-ray films must be obtained from the Radiology Department 4. This information is to be released to: Name Address I request my records be sent to me at this address: 5. I acknowledge the following statements: a. I understand that i may revoke this Autorization at any time by sending a written request to the privacy officers at any of the facilities. (See back of form). Such revocation will not have any effect on any action taken by Memorial Healthcare System before the revocation. b. This authorization will expire six (6) months from the date of signature, or when revoked or on the following date c. I understand that this information may include information relating to: 1) Acquired Immune Deficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV) Infection, 2) Mental or behavioral health or psychiatric care, 3) Treatment of drug or alcohol abuse. d. I understand that the information disclosed pursuant to this Authorization may be subject to re-disclosure by the party who receives it because it may no longer be protected by the federal privacy laws. e. I understand that records in electronic form can be distributed on a wide scale with relative ease and losses or unintended releases of the requested information may occur under circumstances beyond the control of MHS, its release of information vendor or the person making the request. By requesting records in this format, the Requestor is knowingly and voluntarily assuming this risk and all consequences, losses and damages that might result. f. If Memorial Healthcare System has requested this Authorization, I understand that Memorial Healtchare System will give me a copy of this Authorization form after I sign it. g. I understand that Memorial Healthcare System may not condition treatment, payment, enrollment or eligibility of benefits on the completion of this Authorization. h. This information will be used / disclosed for the following purpose(s): This section also applies when Memorial Healthcare System requests the Authorization for Marketing purposes only. Will MHS receive compensation for this disclosure) If yes, compensation will be paid by for disclosing information to Signature of patient: -OR- Signature of patient s legal personal representative: Printed name of patient s representative: Relationship to patient / authority to act for patient: Phone # PATIENT/LABEL Phone: Authorization for Release of Confidential Medical Records (REV. 03/10)