BRENTWOOD EAST FAMILY MEDICINE Patient Registration Form (ecw)

BRENTWOOD EAST FAMILY MEDICINE Patient Registration Form (ecw) PATIENT INFORMATION Dr. Miss Mr. Mrs. Ms. Sir Patient s Name (Last) (First) (MI) Previous Name Address Line 1 City, State ZIP Pharmacy Pharmacy Phone Home Phone Cell No. E-Mail Address: Social Security Number - - Date of Birth MM /DD /YYYY Sex F Female M - Male Transgender Race American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Black or African American White Declined Ethnicity Hispanic or Latino Not Hispanic or Latino Declined Language English Spanish Indian Japanese Chinese Korean French German Russian Other Marital Status Married Single Divorced Widowed Legally Separated Partner Employer Name Work Phone Ext. Emergency Contact Name Phone Number Emergency Contact Relationship to Patient Do you have a living will? Yes No 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 Date of Birth MM /DD /YYYY Social Security Number - - Telephone Sex F Female M - Male Address Line 1 City, State ZIP Employer Employer Phone Number 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 Date Termination Date Date 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 Date Termination Date Date of Birth MM /DD /YYYY 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 Date HCA, Inc. 2011

Family Practice Associates of Lenox Village Patient HIPAA Acknowledgement and Consent Form Patient Name: Date of Birth: Patient Consent: I,, hereby consent to the following: Administration and performance of all treatments, medications, needed anesthetic, procedures, tests and cultures that may be deemed necessary or advisable based on the judgment of the attending physician or their assigned designees. Minor Consent: is between the ages of 16-18 and has parental permission to be seen at Brentwood East Family Medicine without parental presence. YES NO please circle your answer ** Please note Patients under the age of 16 will not be seen without a parent or legal guardian present. Notice of Privacy Practices Acknowledgement (patient initials) I acknowledge that I have received Brentwood East Family Medicine 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 Brentwood East Family Medicine s Notice of Privacy Practices. Release of Information (patient initials) I permit the 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 HCAaffiliated admitting facilities to coordinate patient care 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 workers 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 Hepatitis, Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). Over

Disclosures to Friends and/or Family Members I give permission for your Protected Health Information to be disclosed for purposes of communicating results, findings and care decisions to the family members or others listed below. Name Relationship to patient Contact Number Consent to Email or Text Usage for Appointment Reminders and Other Healthcare Communications: Patients in our practice may be contacted via email 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 email or text address at which I may be contacted, I consent to receiving appointment reminders and other healthcare communications/information at that email 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. I understand that this consent will apply to all future appointment reminders/feedback/health information. The cell phone number that I authorize to receive text messages for appointment reminders, feedback, and general health reminders/information is. 000 (Patient initials) I consent to receive email reminders and communications from the practice. I understand that this consent will apply to all future appointment reminders/feedback/health information. 0000. The email that I authorize to receive email 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). Consent for Photographing for Health Care Operations (patient initials) I consent to photographs for security purposes and/or the hospital s health care operations purposes (e.g., quality improvement activities). I understand that the facility retains the ownership rights to the images. I will be allowed to request access to or copies of the images when technologically feasible unless otherwise prohibited by law. I understand that these images and/or recordings will be securely stored and protected. Images in which I am identified will not be released and/or used outside of the practice without a specific written authorization from me or my legal representative unless otherwise required by law. Declination/Revocation I hereby revoke my consent for photography and/or communications via email or text message. I hereby decline/revoke my consent to Photography I hereby decline/revoke my consent to receive text message communications from the practice I hereby decline/revoke my consent to receive email communications from the practice I assign benefits payable for services payable to Brentwood East Family Medicine: (patient initials) Patient and/or guarantor are responsible for charges incurred. It is a courtesy for our office to file with your insurance; however, you are responsible for your co-pay and or percentage which the insurance is not responsible for on the day of your visit. If we are unable to obtain payment within a reasonable amount of time from the patient/guarantor we will place your account with a collection agency which will leave you liable for any additional charges incurred. Patient/Patient Representative Signature: Date:

BRENTWOOD EAST FAMILY MEDICINE AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI) Section A: Will the Protected Health Information (PHI) be created or used for research and include treatment of the patient? If yes, complete the Authorization for Research Form. If no, proceed to Section B. Section B: Required for all Authorizations for Release of PHI or Right to Access Patient Name: Birth Date: Social Security No. (optional): Patient s Address: Requestor s Name/Phone Number (if patient is not the requestor): PHI Recipient Name: Address/City/State/Zip Phone Number: Fax Number: PHI Sender Name: Address/City/State/Zip Phone Number: ( ) Fax Number: ( ) This authorization will expire on the following: (Fill in the Date or the Event, but not both.) Date: Event: Purpose of Disclosure: Is this request for psychotherapy notes? Yes, then this is the only item you may request on this authorization. No, then you may check as many items below as you need. Description: Date(s) Description: Date(s) Description: Date(s) All PHI in record History and Physical Consult Report Operative Report Progress Notes Physician Orders Laboratory Imaging/Radiology Nursing Notes Medication Record Demographics Rehabilitation Services Special Test/Therapy Itemized Bill/Claims Other: I acknowledge, and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results or AIDS information. (Initial). If not, applicable, check here I understand that: 1. I may refuse to sign this authorization and my treatment will not be conditioned upon signature of this authorization (except for non-health related services such as pre-employment testing, life insurance exams, or drug screenings). 2. I may revoke this authorization at any time in writing, but if I do, it will not have any affect on any actions taken prior to receiving the revocation. Further details may be found in the Notice of Privacy Practices. 3. If the requester or receiver is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be re-disclosed. 4. I understand that I may see and obtain a copy the information described on this form, for a reasonable copy fee, if I ask for it. 5. I will receive a copy of this form after I sign it. Section C: Signatures I have read the above and authorize the disclosure of the protected health information as stated. Signature of Patient/Guardian/Patient Representative: Date: Print Name of Patient s Representative: Relationship to Patient:

Name: Today s Date: HEALTH HISTORY Birth date: Date of last physical examination: SYMPTOMS - Check ( ) symptoms you currently have or have had in the past year. GENERAL Chills Dizziness Fainting Fever Loss of weight Numbness Sweats EYE, EAR, NOSE, THROAT Bleeding Gums Blurred vision Crossed eyes Diffi culty swallowing Double vision Earache Ear discharge Hay fever Hoarseness Loss of hearing Nosebleeds Persistent cough Ringing in ears Sinus problems CARDIOVASCULAR Chest pain High blood pressure Irregular heart beat Low blood pressure Poor circulation Rapid heart beat Swelling in ankles RESPIRATORY Cough Shortness of Breath Decrease in exercise capacity GASTROINTESTINAL Abdominal pain Appetite poor Bloating Bowel changes Constipation or diarrhea Gas Heartburn or indigestion Hemorrhoids Nausea or vomitting GENITO-URINARY Blood in urine Frequent urinating Lack of bladder control Painful Urination MUSCLE/JOINT/BONE Arms Hips Back Legs Feet Neck Hands Shoulders SKIN Bruise easily Hives Itching Change in moles Rash Scars Sore that won t heal NEUROLOGICAL Dizziness or lightheadedness Weakness Fainting Seizures PSYCHIATRIC Depression Headache Loss of sleep Nervousness Stress Trouble concentrating ENDOCRINE Diabetes Hypertension Thyroid disease HEMATOLOGICAL Anemia Bleeding disorder ALLERGIES Asthma Hayfever or allergic rhinitis WOMEN only Abnormal pap smear Bleeding between periods Breast lump Extreme menstrual pain Hot fl ashes Nipple discharge Painful intercourse Vaginal discharge Date of last menstrual period Date of last pap smear Have you had a mammogram Are you pregnant? Number of children CARDIOVASCULAR Erection diffi culties Lump in testicles Penis discharge Date of last prostate exam CONDITIONS - Check ( ) conditions you have or have had in the past year. AIDS Alcoholism Anemia Anorexia Appendicitis Arthritis Asthma Bronchitis Bulimia Cancer Cataracts Chemical dependency Chicken pox Emphysema Epilepsy Glaucoma Goiter Gonorrhea Gout Heart disease Hepatitis Hernia Herpes HIV positive Kidney disease Liver disease Measles Migraines Miscarriages Mononucleosis Mumps Pacemaker Pneumonia Polio Prostate problem Psychiatric care Rheumatic fever Scarlet fever Stroke Tonsilitis Tuberculosis Typhoid fever Ulcers Venereal disease Please complete the back of this form also DMS 123702759 (R 05/10)

PAST MEDICAL HISTORY: List surgeries you have had and the year. 1. 2. 3. 4. MEDICATIONS: List medications you are currently taking. 1. 8. 2. 9. 3. 10. 4. 11. 5. 12. 6. 13. 7. 14. Pharmacy Name: ALLERGIES: To medications or substances. Phone: Fill in health information about your family Age State of Health Age at Death Cause of Death Father Mother Brothers Sisters Pregnancy History: Year of Birth Sex of Birth Delivery Type Complications if any SOCIAL HISTORY: FAMILY HISTORY: Check ( ) the substance you use and describe List any illnesses that run in your family. how much you use. Caffeine 1. 5. Tobacco 2. 6. Alcohol 3. 7. Other 4. 8. I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. Signature Date Physician Signature Date Reviewed