PATIENT REGISTRATION FORM Last Name: First Name: Middle Initial: Street Address: City: State: Zip Code: Date of Birth: E-Mail Address: Daytime Phone: Evening Phone: _ Emergency Contact Name & Phone Number: Primary Care Physician s Name: Primary Care Physician s Address: Primary Care Physician s Phone Number: How did you hear about us? Please note that Dr. Daniel Thomas, DO, MS and More T Clinics are not Medicare providers and do not accept third-party payment. Also, by supplying your email address, you are granting us permission to communicate with you by email for such things as lab results, appointment reminders, and answering your medical questions from time to time. Patient Signature Date
MEDICAL HISTORY FORM Name: Today s Date: Date of Birth: Age: Height: Weight: SYMPTOMS: Please check if you are experiencing any of the following: Decreased Energy Decreased Sex Drive Difficulty Concentrating Lack of Mental Clarity Decreased Memory Difficulty Sleeping Irritability or Grumpiness Sadness or Depression Anxiety Decreased Motivation Weight Gain or Excess Fat Loss of Muscle or Strength Joint Pain or Muscle Aches Migraine Headaches High Cholesterol Weak Erections Other: MEDICAL HISTORY: Please check if you have or have had any of the following: Prostate Cancer Prostate Enlargement Breast Cancer Hepatitis or Liver Disease Kidney Disease Congestive Heart Failure Heart Attack Coronary Angioplasty Heart Bypass Surgery Edema (swelling) Phlebitis or Blood Clots Taking Blood Thinners Sleep Apnea Diabetes Anxiety Depression Hair Loss Thyroid Condition HIV Positive Other: Date of Last Prostate Exam: _ Results: DO YOU HAVE ANY CONDITION THAT PREVENTS YOU FROM WALKING? No Yes ILLNESSES OR CONDITIONS FOR WHICH YOU ARE CURRENTLY UNDER A DOCTOR S CARE: PREVIOUS OPERATIONS INCLUDING COSMETIC SURGERY: CURRENT MEDICATIONS AND DOSAGES: Prescription and non-prescription, including aspirin, herbs, and vitamins: Continued On Other Side
MEDICAL HISTORY FORM cont d Name: _ Date of Birth: FAMILY HISTORY: Please list health problems of parents and siblings: ALLERGIES: Medication or other: DAILY ACTIVITY LEVEL: Sedentary Lightly Active Moderately Active Very Active GOALS OF TREATMENT: Please check any of the following that you would like to achieve: Have more energy Sleep well Have better digestion Be able to eat a greater variety of foods Get rid of my allergies Have a stronger immune system (e.g., less colds and flues) No longer use laxatives or stool softeners Be able to exercise again Have better muscle tone Have less pain No longer use pain medication No longer use allergy medication No longer use sleep medication Feel less sleepy in the afternoon Lose weight Increase my sex drive Increase my metabolism to burn more fat Increase my flexibility Reduce my stress Improve my memory Be more mentally focused Have more stable moods Have stronger erections Have fewer headaches Other: HEALTH RATING: With 1 being poor and 10 being excellent, on a scale of 1-10, please circle below how you would rate your overall health: 1 2 3 4 5 6 7 8 9 10 WHEN WAS THE LAST TIME YOU FELT REALLY GOOD? QUESTIONS AND CONCERNS: Please write down the items you would like to discuss with the doctor: SIGNATURE: Patient Date
HIPAA OMNIBUS RULE PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims. The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this Healthcare Facility (More T Clinic Site 1, LLC operating under the service mark More T Clinics). A copy of this signed, dated document (e.g., by email or fax) shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITY IN THE FUTURE. Date: Please print your name Legal Representative (if applicable) Please sign your name Description of Authority for Legal Rep. Your comments regarding Acknowledgements or Consents: HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM THE RECEPTION AREA: First Name Only Proper Sir Name Other PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION: (This includes spouse, children, step parents, grandparents, and any care takers who can have access to this patients records): Name: Relationship: Name: Relationship: -------------------------------------------------------------------------------------------------------------------------------------------- 1. I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED AND CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT, AND BILLING INFORMATION VIA: Cell Phone Confirmation Home Phone Confirmation Work Phone Confirmation Text Message to my Cell Phone Email Confirmation Any of the Above 2. I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED TO MY INSURANCE PROVIDER(S): YES (any) NO (In refusing we will not be allowed to process your insurance claims on your behalf.) YES, but only the following provider(s): 3. I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS, OR NEW HEALTH INFO on behalf of this Healthcare Facility via: Phone Message Text Message Email Any of the Above None of the above (opt out) In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health, and this office may receive third party remuneration from affiliated companies of such products/services. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent. -------------------------------------------------------------------------------------------------------------------------------------------- Office Use Only As Privacy Officer, I attempted to obtain the patients (or representatives) signature on this Acknowledgement but did not because: It was emergency treatment I could not communicate with the patient The patient refused to sign Signature of Privacy Officer The patient was unable to sign because Other (please describe) More T Clinics (ver. 27Nov2013)
155 Cranes Roost Blvd., Suite 2060, Altamonte Springs, FL 32701 More T Clinic Site 1, LLC NOTICES TO NEW PATIENT COMPLAINTS To report a complaint regarding the services you receive, please call the Agency for Health Care Administration toll-free (1-888-419-3456). ABUSIVE, NEGLECTFUL, OR EXPLOITATIVE PRACTICES To report abuse, neglect, or exploitation, please call the Florida Department of Children and Families toll-free (1-800-962-2873). REWARD FOR REPORTING INSURANCE FRAUD Pursuant to 626.9892, Florida Statutes, the Department of Financial Services may pay rewards of up to $25,000 to persons providing information leading to the arrest and conviction of persons committing crimes investigated by the Division of Insurance Fraud arising from violations of 440.105, 624.15, 626.9541, 626.989, or 817.234, Florida Statutes. REPORT MEDICAID FRAUD To report suspected Medicaid fraud, please call AHCA Medicaid Program Integrity toll-free at (1 888 419 3456) or the Attorney General toll-free at (1-866-966-7226). REWARD FOR REPORTING MEDICAID FRAUD Those who report fraud may be entitled to a reward if a criminal case results in a fine, penalty, or forfeiture of property. The amount of the reward may be up to 25% of the amount recovered or a maximum of $500,000 per case. toll-free at 1-866-966-7226 or online at www.ahca.myflorida.com CONTACT NUMBERS Agency for Health Care Administration Medicaid Program Integrity (1-888-419-3456) Office of the Attorney General Medicaid Fraud Control Unit (1-866-966-7226) U.S. Dept. of Health and Human Services (Medicare and Medicaid) (1-800-HHS-TIPS) HIPAA PRIVACY PRACTICES This health care clinic is fully compliant with the Federal Health Insurance Portability & Accountability Act of 2013, HIPAA Omnibus Rule, and the Notice of Privacy Practices for this health care clinic are always available for download on the website <www.moretclinics.com>. FLORIDA PATIENTS BILL OF RIGHTS This health care clinic respects and honors the Florida Patients Bill of Rights (download copy at moretclinics.com). Undersigned patient hereby acknowledges receipt of and understands the notices provided and referenced above and that patient may obtain a copy of this notice and any notices referenced herein from this clinic upon request. Print Patient Name Patient Signature Date Version Dec2013