CONSENT FOR MEDICAL TREATMENT

Transcription

1 CONSENT FOR MEDICAL TREATMENT Patient Name DOB Date I, the patient or authorized representative, consent to any examination, evaluation and treatment regarding any illness, injury or other health concern affecting me at any time I am present at Gold Canyon Urgent Care & Family Medicine for care. These services may include, but are not limited to, laboratory procedures, drug screen, x-ray examinations, and medical or surgical treatment or procedures. I have read and understand this treatment agreement. I am the patient, the parent of a minor child, or the legally authorized representative of the patient and am authorized to act on behalf of the patient and to sign this agreement. Gold Canyon Urgent Care & Family Medicine has the permission to request and download the medication history from my pharmacy. FINANCIAL POLICY/ADVANCE BENEFICIARY NOTICE OF NON COVERAGE All patients must provide accurate and complete personal and insurance information prior to being seen by the doctor. Payment is required at the time of service and may be in the form of cash, debit, or credit card. Gold Canyon Urgent Care & Family Medicine may disclose all or part of a patient s medical or financial records (including information related to alcohol and drug abuse, mental health diagnosis and treatment, HIV related or other communicable disease related information) to third parties to obtain payment for services provided. We will gladly file a claim with your insurance company. It is your responsibility to comply with any pre-determination or notification requirements of your insurance plan. Many of the services provided may be covered and paid for by your insurance company. Unfortunately, insurance companies do not pay for all services that the provider may deem appropriate. In all cases we require the guarantor, the person who is financially responsible, to be personally liable for all balances. The Guarantor agrees to pay any and all applicable fees should the account be referred to an outside collection agency, including, and not limited to 33% of the account balance at the time it is sent to collections. We believe the fees we charge to be reasonable and customary fees for our region and specialty. If your insurance company uses a different fee schedule, you may be responsible for any balance remaining. Gold Canyon Urgent Care & Family Medicine may charge reasonable fees for services related to your account including, but not limited to, returned check fees, interest on unpaid accounts, and medical record copies. Your personal information will be verified and updated at each visit, to ensure information on file is accurate. We may collect a deposit on the charges you incur today toward your balance (e.g. copay, deductible, self pay) and bill you for any remaining balance. All bills are due upon receipt. Federal laws require that we submit every claim to an insurance company accurately and report the exact services performed and the exact reason for performing them. We are not allowed to change information just so the insurance company can pay a claim. I certify that the information provided is true and accurate. I assign any payable benefits to be paid directly to Gold Canyon Urgent Care & Family Medicine and authorize them to submit a claim on my behalf. I understand that I am financially responsible for any non-covered service. I authorize Gold Canyon Urgent Care & Family Medicine to release any information required to process claims for my care and treatment. I have read and understand the financial policy and agree to abide by it. ACKNOWLEDGEMENT OF PRIVACY ACT POLICY RIGHTS I have been made aware of Gold Canyon Urgent Care & Family Medicine privacy rights policy, consent for treatment and the financial policy. Signature Relationship to Patient Date Relationship to Patient Reason for Visit Witness 1

2 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY Use and Disclosure Treatment Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record for all health professionals who may provide treatment or who may be consulted by staff members. Reminders/Notifications Our staff will use your health information to send you follow-up care, referral or appointment reminders. We may also send you information describing changes occurring at Gold Canyon Urgent Care / Gold Canyon Family Medicine such as address changes, new locations or changes in business hours. Treatment Information Your health information may be used to send you information that you may find interesting on the treatment and management of your medical condition. Payment Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided and the medical condition being treated. Healthcare Operations Your health information may be used as necessary to support the day-to-day activities and management of Gold Canyon Urgent Care / Gold Canyon Family Medicine. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality. Law Enforcement Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government-mandated reporting. Public Health Reporting Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state s public health department. Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization. 2

3 INDIVIDUAL RIGHTS You have certain rights under the federal privacy standards. These include: The right to request restrictions on the use and disclosure of your protected health information, The right to receive confidential communications concerning your medical condition and treatment, The right to receive confidential communications concerning your medical condition and treatment, The right to inspect and copy your protected health information, The right to an accounting of how and to whom your protected health information has been disclosed, The right to receive a printed copy of this notice. Gold Canyon Urgent Care/Gold Canyon Family Medicine Care Duties We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We are also required to abide by the privacy policies and practices that are outlined in this notice. Right to Revise Privacy Practices As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain. Complaints If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to: Gold Canyon Urgent Care 6820 S. Kings Ranch Rd. Suite 130 Gold Canyon, AZ If you believe that your privacy rights have been violated, you should bring the matter to our attention by sending a letter describing the cause or your concern to the address listed above. You will not be penalized or otherwise retaliated against for filing complaint. This is effective on or after October 8,

4 PATIENT REGISTRATION FORM Last Name: First Name: MI: Birth date: SSN: Gender: Male Female Primary Address: City: State/Zip: Home Phone: Cell Phone: Race Ethnicity: Preferred Language: Secondary Address: City: State/Zip: Emergency Contact: Phone: Relationship: Relative Friend Reason for today s visit: Primary Pharmacy: How did you hear about us? Location: Family/Friends AJ News Independent News Copper News Television Internet Drive by/signage Other MINORS ONLY Mother: Last Name: First Name: MI: Birth date: SSN: Phone: Primary Address: City: State/Zip: Father: Last Name: First Name: MI: Birth date: SSN: Phone: Primary Address: City: State/Zip: INSURANCE INFORMATION Primary Insurance: Secondary Insurance: Policy Number: Group Number: Policy Number: Group Number: (If policy holder is NOT patient) Policy Holder: Relationship to Patient: Birth date: SSN: Personal Phone: Work Phone: Primary Address: City: State/Zip: 4

5 HEALTH HISTORY SHEET Date: Patient s Name: Date of Birth: Age: This history form provides us with information to help us meet all your health care needs, please complete this form answering each question. This is a confidential part of your medical record and will be kept in this office. HABITS Do you smoke? Y N How many Packs a day? Have you ever quit smoking? Y N Do you drink alcohol? Y N How often? Drink caffeine? Y N How often? Do you use recreational drugs? Y N What type? How often? PATIENT HISTORY Y N Coronary Artery Disease (CAD) Y N Essential Hypertension Y N Hyperlipidemia Y N Diabetes Type I or II Y N HIV Infection Y N Asthma Please list ALL allergies you may have to medications, food and environment Please list ALL operations, conditions and hospitalization you have had; also include the year they occurred Please list ALL medications you are currently taking (include nonprescription drugs) Last Menstrual Period (LMP) Date: 5

6 **PLEASE SPECIFY REASON FOR TODAY S VISIT** Please list (in order of importance) health concern, symptoms, or problems you are experiencing. FAMILY HISTORY Please select any family member who has or has had any of the following: Cancer: Father Mother Sibling Other Heart Disease: Father Mother Sibling Other High Blood Pressure / Hypertension: Father Mother Sibling Other Early Death: Father Mother Sibling Other Depression: Father Mother Sibling Other Stroke: Father Mother Sibling Other Obesity: Father Mother Sibling Other Migraine Headaches: Father Mother Sibling Other High Cholesterol: Father Mother Sibling Other Drug/Alcohol problems: Father Mother Sibling Other Other: Father Mother Sibling Other Please list family member s health status: Good, Fair, Poor, or Deceased (At Age) Mother Father Siblings Children IMMUNIZATIONS Are all immunization up to date? Y N Tetanus within last 10 years? Y N To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is also my responsibility to inform the doctor s office of any changes in my medical status. I also authorize the staff to perform the necessary health care services I may need. Signature Date 6

7 Reason for Visit: Staff Member: VERIFICATION FORM Patient Name: DOB: SS#: Phone #: Address: INSURANCE INFORMATION Primary Insurance: ID#: Group#: Phone #: Address: Subscriber s Name: DOB: SS#: Secondary Insurance: ID#: Group#: Phone #: Address: Subscriber s Name: DOB: SS#: Tertiary Insurance: ID#: Group#: Phone #: Address: Subscriber s Name: DOB: SS#: 7

8 ADVANCE DIRECTIVE According to Arizona State Law we must inquire about your Advance Directive What is an Advance Directive? An Advance Directive is a written document (like a Living Will, Durable Health Care Power of Attorney etc.) that explains what a person wants or doesn t want in the event they cannot make their wishes known regarding medical treatment. Among these treatments are life-sustaining efforts, CPR, organ/tissue donations, terminal conditions, autopsy etc. Yes No (Please circle) Do you have an Advance Directive? Yes No (Please circle) Have you provided Gold Canyon Urgent Care & Family Medicine a copy of your Advance Directive? Patient Signature: Date: The Arizona State Legislature created the Arizona Advance Health Care Directive Registry in May The Registry is a database for the storage of advance directives. The Arizona Secretary of State oversees its security and operations. Free of charge, you can setup and store your Advance Directives this helps you ensure the health care decisions you have made in advance are followed. If you have questions or want to file your directives go to under the Advance Directives section or call (602)