Sa1s3.patientpop.com



PATIENT INFORMATION _________________________

Email Address

Patient Name Social Security Number

Address Cell Phone

_______________ _________________

City Home Phone Work Phone

State Zip Date of Birth Age

Employer Sex: Male ◻ Female ◻

Marital Status: Single ◻ Married ◻ Divorced ◻

Preferred Language if other than English

Race & Ethnicity:

American Indian or Alaska Native ◻ Asian Black or African American ◻

Native Hawaiian or Other Pacific Islander ◻ White ◻ Other Race ◻ Declined to Specify ◻

Hispanic or Latino ◻

Preferred number to leave personal health information?

How would you prefer to be reminded of appointments? Home # ◻ Cell # ◻ Work # ◻

Would you like to receive an email invitation to use our Patient Portal, which allows you to access many tools including viewing your medical records, requesting an appointment, and requesting refills on your prescriptions?

◻ Yes, I would like to receive an invitation ◻ No, I do not use email ◻ No, I do not wish to use Patient Portal

If patient is not the policyholder please complete the following:

PRIMARY INSURANCE: _________________________

Insurance Company

_____/_____/_________

Policy Holder’s Name Date of Birth

Social Security Number Phone Number

Relationship to Patient Is the policyholder a current or past patient at Canyons Medical Center? YES ◻ NO ◻

SECONDARY INSURANCE: _________________________

Insurance Company

______/_____/_________

Policy Holder’s Name Date of Birth

Social Security Number Phone Number

Relationship to Patient Is policyholder a current or past patient at Canyons Medical Center? YES ◻ NO ◻

Health History

Name__________________________________ Date of birth_____________ Age______

Past Medical History (Mark yes if you have the condition, have been treated for, or have ever been diagnosed with it)

|  |YES |NO |  |YES |NO |

|ADHD |  |  |Emphysema/COPD |  |  |

|Anxiety |  |  |Heart Disease |  |  |

|Arthritis |  |  |High blood pressure |  |  |

|Asthma |  |  |High cholesterol |  |  |

|Bipolar |  |  |Migraine |  |  |

|Cancer |  |  |Obesity |  |  |

|Dementia |  |  |Seizures |  |  |

|Depression |  |  |Stroke |  |  |

|Diabetes | | |Substance Abuse | | |

|Other: |

Surgical History

Procedure: _________________________________________________ Date___________

Procedure: _________________________________________________ Date___________

Procedure: _________________________________________________ Date___________

Have you ever been hospitalized for something other than the above? Yes____ No____

Date__________ What for____________________________________________________

Date__________ What for____________________________________________________

Have you ever had an injury other than the above? Yes____ No____

Injury: _______________________ Date__________ Injury: _______________________ Date__________

Health Maintenance (Please provide an approx. date. If never write N/A. If date unknown write UNK)

Last: Tetanus shot_______ Pneumonia shot________ Flu shot/mist _________

Last: Cholesterol test _______ Colonoscopy________ Bone density/DEXA scan _________

Males: Last PSA________

Females: Last mammogram_______ Last PAP test________ Last period______ Total # Pregnancies_______

Social History

Occupation________________________________ Hours per week _______

Married____ Single____ Divorced____ Number of children______

Tobacco use: Never____ Smoker_____ Chewing tobacco_____ Quit_____

Packs a day____ Approx. quit date________

Alcohol use: Never____ Socially_____ Frequently _____ Quit_____

Exercise: Never____ Lightly Active____ Moderately Active_____ Very Active_____

Drug use: Never____ Occasionally____ Regularly_____ Quit_____

Family History (Mark an “X” in the appropriate space)

◻ Adopted, Unknown

  |Mother |Father |Sister |Brother |Daughter |Son |G'mother |G'father |Uncle |Aunt | |ADHD |  |  |  |  |  |  |  |  | | | |Anxiety |  |  |  |  |  |  |  |  | | | |Arthritis |  |  |  |  |  |  |  |  | | | |Asthma |  |  |  |  |  |  |  |  | | | |Bipolar |  |  |  |  |  |  |  |  | | | |Cancer |  |  |  |  |  |  |  |  | | | |COPD | | | | | | | | | | | |Dementia |  |  |  |  |  |  |  |  | | | |Depression |  |  |  |  |  |  |  |  | | | |Diabetes |  |  |  |  |  |  |  |  | | | |Heart Disease |  |  |  |  |  |  |  |  | | | |High blood pressure |  |  |  |  |  |  |  |  | | | |High cholesterol |  |  |  |  |  |  |  |  | | | |Obesity |  |  |  |  |  |  |  |  | | | |Seizures | | | | | | | | | | | |Stroke |  |  |  |  |  |  |  |  | | | |Substance Abuse |  |  |  |  |  |  |  |  | | | |Other |  |  |  |  |  |  |  |  | | | |

Allergies: _________________________________________________________________________

Preferred pharmacy name and location: _________________________________________________________

Current Medications (please include over the counter medicines such as vitamins and herbals)

Name Dose Frequency Purpose _____________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

How did you hear about us? (Check all that apply)

Insurance directory ____ Internet ____ Dr. Referral ____ Friend ____ Relative ____

Other: ________________________________________________________________________

Michael E. Cobble, M.D.

9355 South 1300 East

Sandy, Utah 84094

Ph# 801.666.6650

Fax# 801.572.3106

Medical Records Request

Patient Information (please print):

Name: ________________________________________ Date of Birth: _________________________

Social Security Number: __________________________ Phone Number: _______________________

Address: _____________________________________________________________________________

Current location of your records that you want copied:

Who has you records now? _______________________________________________________________

Address: _____________________________________________________________________________

Phone Number: _________________________ Fax: _______________________________________

Information you want copied and released:

____ All records -or- Dates of treatment from ______________ to ______________ -or-

____ Only the following records or types of health information (including any dates):

______________________________________________________________________________

______________________________________________________________________________

Sensitive Information (I understand that if my medical record contains information in reference to drug and/or alcohol abuse, psychiatric issues, sexually transmitted diseases, social services, hepatitis testing/treatment, HIV testing/treatment, and/or other sensitive information, I agree to its release).

Location to send your records to:

Name: Canyons Medical Center

9355 South 1300 East

Sandy, UT 84094

Ph# 801.666.6650

Fax# 801.572. 3106

This Authorization expires 120 days from the date of written request. I may inspect or obtain a copy of the health information that I am being asked to allow the use or disclosure of, and I have a right to receive a copy of this authorization. I may revoke this authorization at any time, but must do so in writing. My revocation will take effect upon receipt, except to the extent that others have acted in reliance upon this authorization.

I hereby authorize the release of my records as indicated above (valid for 120 days):

____________________________________________________ __________________

(Patient -or- Guardian signature and relation to patient) (Date)

Michael E. Cobble, M.D. 9355 South 1300 East

Sandy, Utah 84094

801.666.6650

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AGREEMENT

PAYMENT POLICY: Payment in full at the time of service is required unless previous arrangements have been made. We accept: Cash, credit/debit cards, VISA, MasterCard, American Express or Discover.

We are providers for the following insurance companies and will bill them for services. Co-pays are due at the time of service:

Aetna, Altius, Bankers Life, Blue Card, Blue Cross Blue Shield, BCBS Federal, Cigna, Great West, Humana, Mail Handlers, Medicare, PEHP Summit Care, Smith’s Administration, Tricare and United Healthcare.

We will bill your insurance company if you have the complete billing information. Please keep in mind that all insurance companies have different scales of payment for a physician or clinic. You may have a deductible or co-payment amount that you are required to pay. You will be responsible for any charges not paid by your insurance company. Medical insurance is an arrangement between the insurance company and the patient. Any questions regarding coverage should be directed to your insurance company.

If you are from out of state or country, we will be unable to bill your insurance company and you will be responsible for those charges. Should a collection agency become necessary, there will be an additional 40% collection fee added to the bill. If it becomes necessary to refer the account to a collection agency, I agree to pay for any and all attorney fees and court costs incurred.

AUTHORIZATION AND CONSENT FOR TREATMENT

I hereby consent to and authorize the administration of treatment that in the judgment of the attending physician is considered necessary of advisable. I also certify that no guarantee or assurance has been made to the results that may be obtained by such treatment. I hereby agree to pay Michael Cobble, M.D. for all charges and services rendered to or in behalf of the patient. I hereby authorize Michael Cobble, M.D. to release medical information in connection with these services for health insurance purposes or to the patient’s personal physician. I authorize release of any information needed to act on this request. I request that payment of authorized benefits be made in my behalf, the same be paid to Michael Cobble, M.D.

I have read the above Authorization and Agreement and fully understand.

Signature of patient or parent/guardian: Date: _________________

Relationship to patient: _

Emergency contact not living at the same address:

Name: Address:

Phone: Relationship to patient:

Witness: Date:

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HIPAA - Personal Representative Authorization

Patient Name__________________________________ Date of Birth______________________

Purpose

This form allows you (the "Patient") to give Canyons Medical Center, PC and their health care provider’s permission (authorization) to disclose your protected health information (PHI) to a person that will act as your Personal Representative. The information covered by this authorization is protected health information, including diagnoses, procedures, billing data, and treatment plans.

Each patient who wishes to name a Personal Representative must complete an authorization form. For example, if you expect your spouse to call us on your behalf, you need to fill out this form. If you do not wish to name a Personal Representative, please indicate below. You are not required to name a Personal Representative, but if you do not, we will not release your protected health information to anyone else who may call or write on your behalf. Your Personal Representative may be anyone of your choosing, such as a spouse, parent, child, friend, and you must provide the information below for each person before we can treat that person as your Personal Representative. If you need additional forms, we will be happy to copy this form for you.

Please Note: This authorization does not give your Personal Representative authority, either implied or direct, over any treatment or direct care decisions.

Authorized Use and/or Disclosure

I authorize you to disclose my protected health information to the person(s) named below for the purpose of assisting with or facilitating my health care and payment of any health benefits. I acknowledge that my authorization is voluntary.

I understand that I have the right to limit the information you release under this authorization. Any such limitations must be described in Restrictions in this section.

Personal Representative 1 (Please Print Clearly)

Full Name_________________________________ Phone Number__________________________________________

Relationship to You__________________________ Restrictions____________________________________________

Personal Representative 2 (Please Print Clearly)

Full Name_________________________________ Phone Number__________________________________________

Relationship to You__________________________ Restrictions____________________________________________

Personal Representative 3 (Please Print Clearly)

Full Name_________________________________ Phone Number__________________________________________

Relationship to You__________________________ Restrictions____________________________________________

This authorization to release information to my Personal Representative will automatically expire in three (3) years after the date of my last visit to Canyons Medical Center, PC. I understand that I have the right to revoke or end this authorization at any time and may do so by giving written notice of my decision to the Privacy Official at the office of Canyons Medical Center, PC. I understand that my revocation of this authorization will not affect any action that has been taken or information that has already been released, based upon this authorization, before receiving my request to revoke authorization.

I have had full opportunity to read and consider the content of this form. I understand that by signing this form, I am confirming my authorization that Canyons Medical Center, PC and their healthcare providers may disclose my protected health information to the person(s) named on this form, for the purpose described above.

Acknowledgement of Receipt of Notice of Privacy Practices

I have been presented with a copy of the Notice of Privacy Practices, detailing how my health information may be used and disclosed as permitted under federal and state law, and outlining my rights regarding my health information.

Signature________________________________________ Date__________________________________________

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ACKNOWLEDGEMENT OF RECEIPT OF

NOTICE OF PRIVACY PRACTICES

Canyons Medical Center has presented to me a copy of the Patient Privacy Policy, detailing how my health records/information may be used and disclosed as per federal and state law. This also includes an outline of my rights regarding my health information.

Patient signature Date

Relationship to patient (if under 18 years)

Witness Date

Canyons Medical + Wellness

Michael E. Cobble, M.D.

Notice of Privacy Practices

Understanding your health records

Each time you visit this office a record is made by your Physician, Physician Assistant, Nurses and office staff members. Your record will include symptoms, examination, test results, diagnosis, treatment plans and a plan for your future care or treatment. This information, often referred to as your health or medical record, serves as:

• A basis for planning your care and treatment.

• A means of communication among health care professionals who contribute to you care.

• A legal document showing the care you have received.

• A means that a third party payer can show that services billed were actual charges.

• A tool in educating health professionals.

• A source of data for medical research.

• A source of information for public healthcare officials charged with improving the healthcare of the nation.

• A source data for facility planning and marketing.

• A tool with which we can continually assess and work to improve the care we provide.

An understanding of what is in your record and how your health information is used to help you to:

• Ensure its accuracy.

• Better understand who, what, when, where, and why others may access your health information.

• Make more informed choices when authorizing disclosures to others.

Your Information Rights

Although your health record is the physical property of Canyons Medical Center, the information belongs to you and you have the right to:

• Request the information to be restricted in certain cases. (as provided by 45 CFR 164.522)

• receive a copy of information practices

• Inspect and copy your health record (45 CFR 164.522).

• Amend your health record (45 CFR 164.522).

• Obtain an accounting of disclosures of your health information (45 CFR 164.522).

• Request communications of your information by alternative means or at alternative locations.

• Revoke your authorization to use and disclose health information except to the extent that action has already been taken.

Our Responsibilities

Our office is required to:

• Maintain the privacy of your records.

• Inform the patient of legal notices and privacy acts regarding the information we collect about you.

• Notify you if we are unable to agree with a restricted request.

• Accommodate reasonable requests you have to communicate health information by alternate means or at alternate locations.

Reporting a Problem

If you have any questions regarding this notice or would like additional information, you may inquire at the front desk or contact us by phone at 801.666.6650.

If you believe your rights have been violated, you can file a complaint with our office and with The Office for Civil Rights, US Department of Health and Human Services (OCR). There will be no retaliation for filing a complaint with either our office or the ORC. The address for the OCR is as follows:

Office of Civil Rights

US Department of Health and Human Services

200 Independence Ave SW

Room 509 F, HHH Building

Washington D.C. 20201

Examples of Disclosures for Treatment, Payment, and Health Operations

Your health information will be used for treatment.

The information we obtain in this office will be recorded in your chart (electronically and/or physically) and used to determine the best course of treatment for you. Your healthcare provider will document his expectations in your record and will then follow through with any and all team members the actions they took. All other team members will also document their actions that will allow the healthcare provider to maintain consistent care for you. We will provide any other healthcare provider (when applicable) copies of your records / reports that will assist them with your care.

We will use your healthcare information for payment.

A bill may be sent to a third party payer (such as an insurance company). The information on the bill or sent with it may include information that will identify you as well as procedures, diagnosis, and supplies used.

We will use your health information for regular health operations.

Members of the medical staff or quality improvement staff can use your information to assess the care and outcomes in your case and others to continually improve the healthcare services we will provide to you.

Business Associates: There are some services that we provide through contacts with associates that we may need to supply your information to, such as transcriptionists, other physicians, emergency rooms, radiology, and labs. Because of the services we have asked these people to do we are obligated to give your health information tin order for them to do their job. To protect this information we require these associates to safeguard your information they use.

Research: We may disclose information to researchers when an institutional review board that has reviewed the research proposal and established protocols to ensure privacy of your information has approved your research.

Funeral Directors: We may disclose health information to funeral directors to carry out their duties consistent with the law.

Organ Procurement Organizations: Consistent with the law, we may disclose health information to organ procurement organizations or others engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Food and Drug Administration: We may disclose to the FDA information that is related to adverse events with respect to food, supplements, products and product defects or post marketing surveillance information to enable product recalls, repairs, or replacements.

Workers Compensation: We may disclose your information to the extent authorized by and necessary to comply with laws relating workers compensation or similar programs established by law.

Public Health: As required by law, we may disclose your health information to public health and legal officials charged with preventing or controlling disease, injury, or disability.

Appointment Reminders: We may contact you or a family member at the phone number you gave us as a reminder of an appointment.

Marketing: We may contact you to give information about alternate treatment and or other benefits that may be of help to you.

Directory: This office will not give out and information of your location, general condition while in our facility unless you sign the appropriate documentation stating so.

Notification: We may use or disclose information to assist in notifying a family member or representative (or person responsible for your care) of your location and general condition.

Communication with Family: Healthcare providers, using their best judgment, may disclose to a family member or other relative, or close personal friend health information that is relevant to that person taking care of you or making payment related to your care.

Law Enforcement: We may disclose health information for law enforcement purposes as required by law or when a subpoena is presented. Federal Law makes provisions for your health information to be released to an appropriate oversight agency, public health authority, or attorney approved by the workforce member or business associate that believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards endangering more patients, workers, or the public.

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Today’s date_____________

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