Patient Registration Form (ecw)

Transcription

1 PATIENT INFORMATION Patient Registration Form (ecw) (Please Print) Dr. Miss Mr. Mrs. Ms. Sir Patient s Name (Last) (First) (MI) Previous Name Address Line 1 City, State ZIP Home Phone Cell No. Work Phone Ext. Primary Care Provider (PCP) Referring Provider Rendering Provider Name (this practice) Address: of Birth MM /DD /YYYY Sex F Female M - Male Transgender Race American Indian/Alaska Native Asian Native Hawaiian/Pacific Islander Black/African American White Hispanic Other Declined Language English Spanish Indian Japanese Chinese Korean French German Russian Other Ethnicity Hispanic or Latino Not Hispanic or Latino Declined Marital Status Married Single Divorced Widowed Legally Separated Partner Social Security Number - - Employer Name Employment Status 1 - Full-Time 2 - Part-Time 3 - Not Employed 4 - Self-Employed 5 - Retired 6 - Active Military Student Status F - Full-Time Student P - Part-Time Student N Not a Student Emergency Contact Last Name First Name Phone Number Do you have a living will? Yes No Emergency Contact Relationship to Patient Guardian Address Line 1 City, State ZIP Home Phone Work Phone Ext. Referring Provider Name RESPONSIBLE PARTY INFORMATION (information used for patient balance statements) Responsible Party Another Patient Guarantor Self Check here if information is same as patient Responsible Party Name (Last) (First) (MI) Guarantor Account Number of Birth MM /DD /YYYY Telephone E -Mail Address PRIMARY INSURANCE INFORMATION (provide your insurance card to the front desk at check-in) Insurance Company/Phone Number ( ) Name of Insured Patient Relationship to Insured Subscriber ID (Policy Number) Group ID Copay Amount Effective Termination of Birth MM /DD /YYYY SECONDARY INSURANCE INFORMATION (provide your insurance card to the front desk at check-in) Insurance Company/Phone Number ( ) Name of Insured Patient Relationship to Insured Subscriber ID (Policy Number) Group ID Copay Amount Effective Termination of Birth MM /DD /YYYY PHARMACY Pharmacy Name / Phone Number ( ) Address I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge. Patient (or Responsible Party) Signature HCA, Inc. 2012

2 Name: DOB Please list all your current medications: (including over the counter, vitamins/minerals/herbal supplements) Medication Dose Frequency Prescribing Dr. Medical History: (Please check all appropriate columns) No Known Medical Problems Adopted Abuse: Domestic, Emotional, Sexual Alcoholism Asthma: Adult/Childhood/Exercise Birth Defects Blood Clots in Legs or Lungs Blood Transfusion Breast Problems (specify) Cancer Ovarian Breast Colon Other (specify) Depression Diabetes Heart Disease Hepatitis High Blood Pressure High Cholesterol Kidney Problems Liver Disease Lupus Osteoporosis Seizures Stomach/Bowel/Gall Bladder Problems Stroke Thyroid Disorder Other Medical Problems (specify) You Specific family member/age Details/s: 2.0

3 Do you have any medical allergies? Y/N (please specify drug and reaction) Drug: Latex? Y/N Iodine? Y/N Penicillin? Y/N Sulfa? Y/N Other? Other? Reaction: Gynecologic History Have you ever had a mammogram? Y/N Most recent Normal/Abnormal? Do you do monthly self breast exams? When was your last pap test? / / Have you ever had an abnormal pap test? no yes: date/result What was your treatment? LEEP Cone Biopsy Other Have you ever had a sexually transmitted disease? herpes genital warts trichomoniasis chlamydia gonorrhea Have you ever had a bone density scan? / / Result: Have you ever had a colonoscopy? no yes when/result Menstrual and Sexual History How old were you when you first began menstruating? What was the first day of your last period? How many days pass between the first day of each period? How long do your periods last? On your heaviest day how many pads/tampons do you use? How do you rate your menstrual pain? How do you treat your pain? years old / / days pass days long pads and/or tampons mild moderate severe Have you ever had sex? Are you currently in a sexual relationship? Your sexual preference is: Have had any new partners since your last visit? What do you use to prevent pregnancy? men women both (specify) How old were you when you went through menopause? Did you have a hysterectomy? If yes, when? Why was this done? Do you still have your ovaries? Do you still have your cervix? years old years old (specify) 2.0

4 Pregnancy History How many times have you been pregnant? How many times have you given birth? Have you ever been treated for post-partum depression? Did you have any complications with your pregnancies? (specify) Y/N Y/N Please list all of your pregnancy outcomes: : M/F Weight # of weeks Delivery type Epidural? Notes: Surgical History: /Details: /Details: Laparoscopy C-Section Tubes Tied Gallbladder Appendix Breast Surgery Bowel Surgery Cosmetic Other (Specify) Social History: Do you smoke? Y/N packs/day or c/day How long? Do you drink alcohol? Y/N drinks/week Do you use recreational drugs? Marijuana Cocaine/Crack Heroin Other Do you drink caffeine? Y/N drinks/day What is your occupation? (specify) 2.0

5 Are you experiencing any of the following symptoms as an ongoing problem? None Fever Chills Night Sweats Unexplained weight gain Skin Changes Excessive Hair Loss Difficulty Sleeping Fatigue Anxiety Depression Diarrhea Constipation Painful Urination Leaking Urine Urinary Frequency Bloody Stool Swelling Muscle Weakness Genital Sores Unexplained Rash Breast Tenderness Vaginal Discharge Shortness of Breath Chest Pain Change in Appetite Nausea Vomiting Heavy Periods Menstrual Pain Irregular Periods 2.0

6 Lara Lane, MD MD Juliet Leman Ridge Gate Parkway Suite 280 Lone Tree, Co Phone: Fax: Print Patient Name: Insurance Coverage of Ultrasounds I have read and understand the information regarding my financial responsibility for associated ultrasound costs if not covered by my insurance. Patient Signature Consent for Cystic Fibrosis Carrier Blood Test I have read and understand the information regarding cystic fibrosis carrier blood testing, and accept financial responsibility for any associated costs that are not covered by my insurance. Initial One: I CONSENT to the CF Carrier Testing Patient Signature I DECLINE to the CF Carrier Testing Consent for Genetic Screening I have read and understand the information regarding Nuchal Translucency and Blood Testing. I also accept financial responsibility for any associated costs that are not covered by my insurance. Initial One: I CONSENT to the Nuchal Translucency and Blood Testing. Patient Signature I DECLINE to the Nuchal Translucency and Blood Testing Please circle one: YES NO Will you be 35 years or older at your due date? YES NO Have you had alcohol (beer,wine,liquor) during your pregnancy? YES NO Have you used any drugs (cocaine, marijuana, etc) during your pregnancy? If so what: YES NO During your pregnancy have you taken Acutance or epilepsy medication? YES NO During your pregnancy have you taken blood thinners or Lithium? YES NO Have you had radiation therapy or chemotherapy since your last period? YES NO Are you diabetic? YES NO Are you and your partner related in any way (other than marriage)? YES NO Do you or your partner have a history of genital herpes? YES NO Do you or your partner have a history of HIV or Hepatitis B or C? YES NO Have you taken any medications (prescription or OTC) during your pregnancy? If so what: Have you OR your partner, OR anyone in either family ever had: (please answer in all three columns) MYSELF PARTNER EITHER FAMILY A child with Down Syndrome or other chromosome problems? Y N Y N Y N A child with mental retardation? Y N Y N Y N Open Spine (Spina Bifida), skull defect or Anencephaly? Y N Y N Y N Heart defect? Y N Y N Y N Muscle or neuromuscular disease (Muscular Dystrophy)? Y N Y N Y N A stillborn baby? Y N Y N Y N A baby that died shortly after birth or within the first year? Y N Y N Y N Cystic Fibrosis? Y N Y N Y N Hemophilia, Sickle Cell, Thalassemia, or other blood disorder? Y N Y N Y N Any birth defect or genetic disorder? Y N Y N Y N 0

7 Lara Lane, MD Juliet Leman DO Patient Record of Disclosures Ridge Gate Parkway Suite 280 Lone Tree, Co Phone: Fax: In general, the HIPAA privacy rules give individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by an alternate means, such as sending correspondence to the individuals office instead of the individuals home. Patient Name (PLEASE PRINT) DOB I wish to be contacted in the following manner (Check all that apply) Home Phone O.K. to leave message with detailed information Leave message with call-back number only Work Telephone O.K. to leave message with detailed information Leave message with call-back number only Written Communication O.K. to mail to my home address O.K. to mail to my work/office address O.K. to fax to this number Cell Phone O.K. to leave message with detailed information Leave message with call-back number only Other (Spouse, Children, Etc) Patient Signature Print Name Birthdate CMT

8 Lara Lane, MD Juliet Leman DO HIPAA Ridge Gate Parkway Suite 280 Lone Tree, Co Phone: Fax: Patient Name: DOB: (Patient initials) Notice of Privacy Practices. I acknowledge that I have received the practice s Notice of Privacy Practices, which describes the ways in which the practice may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the Privacy Officer designated on the notice if I have a question or complaint. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice s Notice of Privacy Practices. (Patient initials) Release of Information. I hereby permit practice and the physicians or other health professionals involved in the inpatient or outpatient care to release healthcare information for purposes of treatment, payment, or healthcare operations. Healthcare information regarding a prior admission(s) at other HCA affiliated facilities may be made available to subsequent HCA-affiliated admitting facilities to coordinate Patient care or for case management purposes. Healthcare information may be released to any person or entity liable for payment on the Patient s behalf in order to verify coverage or payment questions, or for any other purpose related to benefit payment. Healthcare information may also be released to my employer s designee when the services delivered are related to a claim under worker s compensation. If I am covered by Medicare or Medicaid, I authorize the release of healthcare information to the Social Security Administration or its intermediaries or carriers for payment of a Medicare claim or to the appropriate state agency for payment of a Medicaid claim. This information may include, without limitation, history and physical, emergency records, laboratory reports, operative reports, physician progress notes, nurse s notes, consultations, psychological and/or psychiatric reports, drug and alcohol treatment and discharge summary. Federal and state laws may permit this facility to participate in organizations with other healthcare providers, insurers, and/or other health care industry participants and their subcontractors in order for these individuals and entities to share my health information with one another to accomplish goals that may include but not be limited to: improving the accuracy and increasing the availability of my health records; decreasing the time needed to access my information; aggregating and comparing my information for quality improvement purposes; and such other purposes as may be permitted by law. I understand that this facility may be a member of one or more such organizations. This consent specifically includes information concerning psychological conditions, psychiatric conditions, intellectual disability conditions, genetic information, chemical dependency conditions and/or infectious diseases including, but not limited to, blood borne diseases, such as HIV and AIDS. Disclosures to Friends and/or Family Members DO YOU WANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM YOU ALLOW TO PICK UP YOUR PRESCRIPTION OR THE PROVIDER MAY DISCUSS YOUR MEDICAL CONDITION? IF YES, WHOM? I give permission to the follow people to pick up prescriptions from Lone Tree Woman s Care on my behalf. Also the follow people have access to my Protected Health Information (PHI) to be disclosed for purposes of communicating results, findings, care decisions &/or billing concerns to the family members &/or other individual listed below. I fully understand this consent will remain valid until revoked. Name Relationship Contact Number 1: 2: 3: Patient may revoke or modify this specific authorization and that revocation or modification must be in writing. CMT

9 Lara Lane, MD Juliet Leman DO HIPAA Ridge Gate Parkway Suite 280 Lone Tree, Co Phone: Fax: Consent to or Text Usage for Appointment Reminders and Other Healthcare Communications: Patients in our practice may be contacted via and/or text messaging to remind you of an appointment, to obtain feedback on your experience with our healthcare team, and to provide general health reminders/information. If at any time I provide an or text address at which I may be contacted, I consent to receiving appointment reminders and other healthcare communications/information at that or text address from the Practice. (Patient initials) I consent to receive text messages from the practice at my cell phone and any number forwarded or transferred to that number or s to receive communication as stated above. I understand that this request to receive s and text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing (see revocation section below). The cell phone number that I authorize to receive text messages for appointment reminders, feedback, and general health reminders/information is The that I authorize to receive messages for appointment reminders and general health reminders/feedback/information is. The practice does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan (contact your carrier for pricing plans and details). Revocation I hereby revoke my request for future communications via and/or text. I hereby revoke my request to receive any future appointment reminders, feedback, and general health via text messages. I hereby revoke my request to receive any future appointment reminders, feedback, and general health via . NOTE: This revocation only applies to communications from this Practice. Patient Name: Patient/Patient Representative Signature: : Time: Consent for Photographing or Other Recording for Security and/or Health Care Operations (Patient Initials) I consent to photographs, videotapes, digital or audio recordings, and/or images of me being recorded for security purposes and/or the practice s health care operations purposes (e.g., quality improvement activities). I understand that the facility retains the ownership rights to the images and/or recordings. I will be allowed to request access to or copies of the images and/or recordings when technologically feasible unless otherwise prohibited by law. I understand that these images and/or recordings will be securely stored and protected. Images and/or recordings in which I am identified will not be released and/or used without a specific written authorization from me or my legal representative unless it is for treatment, payment or health care operations purposes or otherwise permitted or required by law. (Patient Initials) I do not consent to photographs, videotapes, digital or audio recordings, and/or images of me being recorded for security purposes and/or the practice s health care operations purposes (e.g., quality improvement activities). Patient Signature Patient Name (Printed): : DOB: CMT

10 Lara Lane MD Juliet Leman DO Patient Responsibilities Ridge Gate Parkway Suite 280 Lone Tree, Co Phone: Fax: Patient Name: DOB: I, the undersigned, in consideration for services being rendered by Women's Care of Colorado, understand and agree to the following: 1. I understand that payment for co-pays, deductibles, coinsurance and account balances are payable at the time of service. 2. I hereby authorize Women's Care of Coloradoto file a claim with my insurance carrier and I authorize payment for medical services to Women's Care of Colorado. 3. I have read and understand the Notice of Privacy Practices. I give my consent to use and disclose my protected health information to carry out treatment, payment activities and health care operations. 4. I authorize release of any and all medical records and information necessary for continuation of care and for processing any claims associated with services I receive in this office. 5. I understand that my insurance benefits and referral requirements are my responsibility. Women's Care of Colordao will assist me in any area possible, but ultimately, I am responsible to understand my benefits and obtain any referrals necessary. 6. I will inform Women's Care of Colorado anytime my personal information or insurance coverage has changed. 7. I will keep my account balance current. In the event I fail to pay my account balance. 8. I understand Women's Care of Colorado reserves the right to not continue care due to excessive late arrivals to appointment or no-show to scheduled appointments. It is important to cancel within twenty-four hours of your scheduled appointment. My signature below indicates I agree to all the terms set above. Patient or *Personal Representative Signature *If this consent is signed by a personal representative on behalf of the patient, complete the following: Personal Representative s Name Relationship to Patient: 6.0