FATHER Present Health MOTHER Present Health Spouse Present Health

Transcription

1 PATIENT INFORMATION : SS/HIC/Patient ID#: Patient Name: Last Name First Name Middle Initial Address: City: State: Zip Home Phone: Cell Phone: Sex: Age: Birthday: Race: American Indian Asia Pacific Islander African American White Hispanic Other Refused Ethnicity: Hispanic/Latino Non-Hispanic/Latino Language: English Indian Spanish Russian Other Occupation: Patient Employer/School: Employer/School Address: Employer/School Phone: Spouse s Name: Spouse s of Birth: Spouse s SS#: Spouse s Employer: IN CASE OF EMERGENCY, CONTACT: Name: Home Phone: Cell Phone: Work Phone: Who may we thank for referring you? INSURANCE Who is responsible for this account? : Birth : SS#: Insurance Co: Group #: Is patient covered by additional insurance? Yes No Subscriber s Name: Birth : : Insurance Co: Group #: SS#: INSURANCE ASSIGNMENT AND RELEASE I certify that I have insurance coverage with and assign directly to COASTAL CAROLINA NEUROPSYCHIATRIC CENTER all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named office may use my health care information and may disclose such information to the above-named insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year for the date signed below. MEDICARE AUTHORIZATION I request that payment of authorized Medicare benefits and, if applicable, Medigap benefits, be made either to me or on my behalf to COASTAL CAROLINA NEUROPSYCHIATRIC CENTER for any services furnished to me by that provider. To the extent permitted by law, I authorize any holder of medical and other information about me to release to the Centers for Medicare and Medicaid Services, my Medigap insurer, and their agents any information needed to determine these benefits or benefits for related services. Signature of Beneficiary, Guardian, or Personal Representative Please print name of Beneficiary, Guardian, or Personal Representative Relationship to Beneficiary FAMILY HISTORY of last physical examination: What is the reason for your visit: Alive Deceased FATHER Present Health MOTHER Present Health Spouse Present Health BROTHERS NO. ALIVE Present Health NO. DECEASED AND CASUE OF DEATH SISTERS NO. ALIVE Present Health NO. DECEASED AND CASUE OF DEATH CHILDREN NO. ALIVE Ages and Present Health NO. DECEASED AND CASUE OF DEATH Check ( ) any illnesses which have occurred in any of your BLOOD RELATIVES: Nervous illness Allergy Diabetes Heart disease Cancer Bleeding tendencies Kidney disease Tuberculosis Stroke Other:

2 MEDICAL HISTORY: All information is strictly confidential Check ( ) symptoms you currently have or have had in past year GERERAL GASTROINTESTINAL EYE, EAR, NOSE, THROAT MEN only Chills Appetite poor Bleeding Gums Erection difficulties Depression/Nervousness Bloating Blurred Vision Lump in testicles Dizziness/Fainting Bowel changes Crossed Eyes Penis discharge Fever Constipation Difficulty swallowing Sore on penis Forgetfulness Diarrhea Double Vision WOMEN only Headache Excessive thirst Earache/Ear discharge Abnormal Pap Smear Loss of sleep Gas Hay fever Bleeding between periods Loss of weight Hemorrhoids Hoarseness Breast lump Numbness Indigestion Loss of hearing Extreme menstrual cramps Sweats Nausea Nosebleeds Hot flashes MUSCLE/JOINT/BONE Rectal bleeding Persistent cough Nipple discharge Pain, weakness, numbness in: Stomach pain Ringing in ears Painful intercourse Arms Hips Vomiting Sinus problems Vaginal discharge Back Legs Vomiting blood Vision-Flashes/Halos Other Feet Neck CARDIOVASCULAR SKIN of last menstrual period: Hands Shoulders Chest pain Bruise easily GENITO-URINARY High/Low blood pressure Hives of last Pap Smear: Blood in urine Irregular/Rapid Heart beat Itching/Rash Frequent urination Poor circulation Changes in moles Have you had a mammogram? Lack of bladder control Varicose veins Scars Painful urination Swelling of ankles Sore that won t heal Are you pregnant? Number of children Check ( ) conditions you have or have had in the past AIDS Chicken Pox HIV Positive Polio Appendicitis Diabetes Kidney Disease Prostate Problem Arthritis Emphysema Liver Disease Rheumatic Fever Asthma Epilepsy Measles Scarlet Fever Bleeding disorders Glaucoma Migraine Headaches Stroke Breast Lump Heart Disease Multiple Sclerosis Thyroid Problems Cancer Hepatitis Mumps Tuberculosis Cataracts Herpes Pacemaker Ulcers Chemical Dependency High Cholesterol Pneumonia Venereal Disease MEDICATIONS/ALLERGIES List medications you are currently taking: Pharmacy Name: Phone: List allergies to medications or substances: Check ( ) which you use and how: Caffeine Street Drugs Tobacco Other HEALTH HABITS Check ( ) if your work exposes you to: Stress Heavy Lifting Hazardous Substances Other Your occupation: SIGNATURES To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. Signature of Patient, Parent, Guardian, or Personal Representative Please print name of Patient, Parent, Guardian, or Personal Representative Reviewed by

3 CONSENT TO TREATMENT By signing below, I am authorizing Coastal Carolina Neuropsychiatric Center, PA (CCNC) to evaluate and treat the following person:. I accept full responsibility for payment of services rendered. I authorize insurance benefits to be paid directly to CCNC, realizing that I am responsible for paying non-covered services. I consent to the release of pertinent medical information for treatment, payment, and health care operations. Print Patient Name of Birth Signature of patient, parent, legal guardian Witness I acknowledge receipt of the notice of privacy practices of CCNC. Signature of patient, parent, legal guardian Witness

4 Patient Name DOB No Show and Cancellation Policies It is the responsibility of the client to attend all scheduled appointments and arrive in a timely fashion. Should the client not be able to attend an appointment, a 24 hour notice is requested. If a client fails to call to cancel or attend a scheduled appointment, a service fee of $25.00 may be charged, at the provider s discretion. CCNC does understand there are sometimes extenuating circumstances, and those will be taken into consideration. Should a client perpetually no show their appointments, the provider reserves the right to decline any further services. Please see individual providers for more information. I have read and understand the above no show and cancellation policies. Signature Identity Theft Prevention and Detection (and Red Flags Rule Compliance It is the policy of CCNC of CCNC that our Identity theft prevention and detection (and Red Flags Rule compliance program is as follows: All patients (or legal guardian) must present a photo ID with the patient s current address at check in and current insurance card. If the photo ID does not show the patient s current address, then a current utility bill with the current address must be shown. On their first visit, a photo will be taken of the patient. The photo becomes a part of their medical record, and will be protected as such. If the patient (or legal guardian) refuses to allow a picture to be entered into their medical record, they will be required to show their current photo ID and insurance card to the front office staff at the time of check in and to the clinician at every visit. Please note, only the legal guardian of record (listed on the patient s paperwork) will be able to bring the patient to their appointments. I have read and understand the above Identity Theft Prevention policy. Signature

5 If the following information is not completed in full, there may be a delay in fulfilling your request while we obtain the necessary information. Patient of Birth Parent/Guardian Name POSITIVE IDENTIFICATION OF RECIPIENT IS REQUIRED Prescriptions May Be Picked Up On My Behalf By the Following Individuals: Correspondence May Be Picked Up On My Behalf By the Following Individuals: A COPY OF THIS SIGNED AND WITNESSED FORM IS AVAILABLE UPON REQUEST. I hereby request and authorize the above named agency, organization or individual who possesses information relative to the patient named above to release information, as specified, to the individual(s) named on this request. I certify that this authorization is made freely, voluntarily and without coercion. I understand that the information to be released is protected under state and federal laws and cannot be disclosed without my written consent unless otherwise provided for by state and federal law. I understand that any documents or information disclosed pursuant to this authorization, upon receipt by the above named individual(s), may no longer protected by HIPAA Privacy Rule. Proof of authority to act for a patient must be provided. This consent shall not expire without express written revocation. Consent is subject to revocation at any time except to the extent that action has been taken in reliance thereon. Printed Name of Patient Printed Name of Legal Representative Patient Signature Legal Representative Signature Witness Signature NOT VALID WITHOUT WITNESS SIGNATURE 200 Tarpon Trail Jacksonville, NC office fax

6 Initial Release Form Addition to Previous Release(s) Replaces Previous Releases Compound Authorization for Release of Verbal Information Name of Patient of Birth Coastal Carolina Neuropsychiatric Center, PA (CCNC) is authorized to release protected health information about the above named patient to the entities named below. The purpose is to inform the patient or others in keeping with the patient s instructions. Entity to Receive Information. Check each person/entity that you approve to receive information. Voice Mail Give information to employer (provide name) Give information to school (provide name) Patient s Spouse (provide name) Patient s Parent (provide name) Other (provide name / relationship to patient) Support Group / Group Home (provide name) Description of information to be released. Check each that can be given to person/entity on the left in the same section. Appointment information Results of lab tests/x-rays Other Appointment absentee information Family billing information Financial Medical as follows: Family Billing Information Financial Medical as follows: Financial Medical as follows Demographic Information Appointment Information Rights of the Patient I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed as described in this document by sending a written notification to CCNC. I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. This authorization shall be in effect until revoked by the patient. Signature of Patient or Personal Representative Description of Personal Representative s Authority (attach necessary documentation)

7 PATIENT CARE COMMUNICATION FORM Patient Name of Birth As part of CCNC s pledge to offer quality care for our patients, we would like your permission to communicate with your primary care physician (and/or other clinician who referred you to us) about your mental health care. AUTHORIZATION I,, hereby authorize Coastal Carolina Neuropsychiatric Center, PA to Print Patient s Name Please check one: To release any applicable mental health information to my primary care physician (PCP) or other referring clinician, named below. To release any applicable substance abuse information to my PCP or other referring clinician, named below. I may revoke this authorization at any time except to the extent that action has been taken in Primary Care reliance Physician/Clinician upon it. Name If I do not revoke this authorization, it will Telephone expire one No (1) year after I have terminated treatment. Practice Name Practice Address Print Name of Patient Print Name of Guardian Signature Signature DATE OF INITIAL APPOINTMENT

8 PATIENT ORIENTATION FORM As a patient of Coastal Carolina Neuropsychiatric Center, upon admission I have been instructed in or given written materials regarding: Rights and responsibilities of the person served. Grievance and appeal procedures. Ways in which input is given regarding: (a) The quality of care. (b) Achievement of outcomes. (c) Satisfaction of the person served. An explanation of the organization's: (1) Services and activities. (2) Expectations. (3) Hours of operation. (4) Access to after-hour services. (5) Code of ethics. (6) Confidentiality policy. (7) Requirements for follow-up for the mandated person served, regardless of his or her discharge outcome. An explanation of any and all financial obligations, fees, and financial arrangements for services provided by the organization. Familiarization with the premises, including emergency exits and/or shelters, fire suppression equipment, and first aid kits. The program s policies regarding: (1) The use of seclusion or restraint. (2) Smoking. (3) Illicit or licit drugs brought into the program. (4) Weapons brought into the program. (5) Abuse and Neglect Identification of the person responsible for service coordination.

9 A copy of the program rules to the person served that identifies the (1) Any restrictions the program may place on the person served. following: (2) Events, behaviors, or attitudes that may lead to the loss of rights or privileges for the person served. (3) Means by which the person served may regain rights or privileges that have been restricted. Education regarding advance directives, if appropriate. Identification of the purpose and process of the assessment. A description of how the individual plan will be developed and the person s participation in it. Information regarding transition criteria and procedures. When applicable, an explanation of the organization s services and activities include: (1) Expectations for consistent court appearances. (2) Identification of therapeutic interventions, including: (a) Sanctions. (b) Interventions. (c) Incentives. (d) Administrative discharge criteria. Patient Name: Signature of Patient Signature Parent/Guardian :