PDF PATIENT REGISTRATION FORM - Allergy Partners

PATIENT REGISTRATION FORM

First ______________________________ MI________ Last__________________________________ Pt.ID #________________

Prefers to be called_______________ Date of Birth ____/_____/______ Age ____ Marital Status: ____________________________ Married/ Single/Divorced/Widowed/Other

Address Primary _______________________________ City _______________________________ State_____ Zip _____________

Alternate Address ______________________________ City ________________________________ State_____ Zip ____________

Phone #1 _________________________ Home/Cell/ Work

Phone #2 ________________________ Home/Cell/ Work

Phone #3 _____________________ Home/Cell/ Work

Email address __________________________ Preferred method of contact: Letter Phone call Email Other______________

Sex____ SS # ___________________Referring Physician _______________________Primary Care Physician__________________ MF

Preferred Language ___________ Race: _________Ethnicity: _______________________________________________________ Non-Hispanic or Latino/ Hispanic or Latino/ other or Undetermined

Referred by: Physician Self Family/Friend Internet Yellow pages Radio TV Other ____________________________

Occupation_________________________Employer___________________________Is this visit related to a work injury? Y N

Current Pharmacy Name and Location ____________________________________________________________________________

Emergency Contact Name _______________________ Phone # ______________________ Relationship to patient______________

Responsible Party/Guardian/Guarantor

Address Same as Patient

Name__________________________ Address______________________ ______ City________________ State ___ __Zip________

Home# ________________________ Cell # ________________________________ Business # _________________________

SS#___________________________ Patient's Relationship to Guarantor________________________ DOB ____/____/____ ____

Sex _______ Occupation_________________________________ Employer _____________________________________________

Primary Insurance Information

Address Same as Patient

Name of Ins.Co. _______________ ID # _______________________________Group #______________Group Name____________

Policy Holder Name ______________________________DOB ____/____/______Relationship to Patient _____________ _________

Address_______________________ ___ City________________ State_____ Zip________ Phone #___________________________

SS# ______________________ Sex______ Occupation_____________________ Employer _________________________________

Secondary Insurance Information

Address Same as Patient

Name of Ins.Co. _______________ ID # _______________________________Group #______________Group Name____________

Policy Holder Name ______________________________ DOB ____/____/_______Relationship to Patient_____________________

Address____________________________City________________ State. ______Zip_______Phone# __________________________

SS# _______________________Sex_____Occupation____________________Employer____________________________________

Financial Authorization

We participate and accept assignment of payment with most major insurance plans in the area. Even though we may submit insurance claims for you, your insurance coverage is a contract between you and your insurer and you are still responsible for payments and services regardless of the amount your insurance pays. If your insurance company requires an authorization or referral, it is the patient's responsibility to obtain this for the initial visit and for continuation of care.

I hereby authorize the office of Allergy Partners, P.A .to release any information necessary to process any insurance claim for services rendered. I hereby authorize payment from my insurance company or governmental payor to pay directly to Allergy Partners, P.A. for services rendered. Regardless of my insurance benefits, if any, I understand that I am financially responsible for the fees for services rendered.

Print Name/Signature ___________________________________________________________________Date_______________

Print Name / Signature

Patient/Parent/Guardian

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ACKNOWLEDGEMENT ACKNOWLEDGEMENT OF HIPAA PRIVACY NOTICE AND DESIGNATION OF DISCLOSURE

Patient Name:___________________________________

Date of Birth:____________________

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.

______________________________________________________________________________________ Date_______________

Print Name

/

Signature Patient/Parent/Guardian

Communication/Messages: I understand that it may be necessary from time to time for Allergy Partners to leave messages when

we are unable to reach you. I wish to be contacted as follows: (please designate preferred number to call)

YES NO Home telephone ______________________ Leave message with confirmation of appointment, or call back only.

Leave message with results, detailed information.

Work telephone ______________________ Leave message with confirmation of appointment, or call back only.

Leave message with results, detailed information.

Cell telephone ______________________ Leave message with confirmation of appointment, or call back only.

Leave message with results, detailed information.

Send appointment reminders via text message.

Family Members/Parents/Friends: I authorize Allergy Partners to share my Patient Health Information with the following:

Print Name________________________________________

Relationship________________________

Print Name________________________________________

Relationship________________________

*Patients aged 18 years and older: Please note that we cannot discuss your healthcare, insurance or payment with your parents/others unless you fill out the appropriate information above.

Special requests to identify specific person(s) not authorized to receive my PHI, speak directly with the Practice Manager.

I may revoke my consent in writing by completing a new Acknowledgement of HIPAA Privacy Notice and Designation of Disclosure form except to the extent that the practice has already made disclosure in reliance upon my prior consent.

______________________________________________________________________________________ Date_______________

Print Name

/

Signature Patient/Parent/Guardian

RESEARCH

We perform medical research at Allergy Partners. Our clinical researchers may look at your health records as part of your current care or to prepare or perform research. All patient research conducted by us goes through a special process required by law that review protections for patients involved in research, including privacy. We will not use your health information or disclose it outside of the practice for research reasons without either getting your prior written approval or determining that your privacy is protected.

If you do not object to being contacted about research opportunities by our clinical research team, please select yes: Yes

If you prefer not to be contacted by our clinical research team, you must opt out by selecting no:

No

______________________________________________________________________________________ Date_______________

Print Name

/

Signature Patient/Parent/Guardian

MEDICAL HISTORY FORM

Name:_________________________ Date of Birth:____________

Past Medical History:

( check any of the following which you have now or have been treated for in the past )

ADD

Chronic Sinusitis

GERD/Reflux

Alcoholism

Chronic Pansinusitus

Heart Disease

Anemia

Congestive Heart Failure

Hypertension

Anxiety

COPD

Hypothyroidism

Arthritis

Depression

IBD

Asthma

Diabetes

IBS

Chronic Hives

Eczema

Immune Deficiency

Chronic Rhinitis

Food Allergies

Kidney Disease

Liver Disease Migraines Skin Cancer Other Cancer

Prostate Disorder Sleep Apnea Thyroid Disease

Tuberculosis

Surgery History:

Adenoidectomy Gallbladder (Cholecystectomy) Deviated Septum Hip/Knee Surgery Pacemaker Tonsillectomy

Appendectomy Colon Resection Ear tubes Hysterectomy Sinus Surgery Thyroid Surgery

CABG (heart bypass) C- section Hernia Repair Organ Transplant Tonsillectomy & Adenoidectomy

Other___________________________

Family History: (Immediate family only Mother, Father, Sibling or Children)

Mother No Problems Unknown History Allergies Asthma Anaphylaxis Cystic Fibrosis Eczema Food Allergies Heart Disease Hives Hypertension (high blood pressure) Hyperlipidemia (high cholesterol) Immune Deficiency Infections, recurring Psychiatric Disorder Swelling Venom Allergies

Father

Sibling

Patient's children

Social History (13 years of age and older) marital status: single divorced/separated married widow(er) smoking status: current every day smoker current some day smoker former smoker never smoker unknown if ever smoked cigarettes _____ packs per day cigars _____# per day smokeless/chew _____tins per day smoking duration: n/a 1-5 years 6-10 years 11-20 years over 20 years year started: _________ maximum packs per day: ? 1 1 ? 2 or more passive cigarette exposure: home secondary home other none readiness to quit: very ready somewhat ready not ready relapsed not willing to quit target quit date:______ occupation:______________________________ work location: indoors outdoor caffeine intake (per day) 0 1/2 1 2 3 4 5 6+ alcohol intake never rarely weekly daily socially

hobbies:______________________________________________________________________

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Pediatric patients only

attends school daycare (name of school/daycare) ________________________________

does child have siblings? yes no if yes, how many _____

child was born

premature full term

delivery type

vaginal C-section

complicated labor and delivery

yes no

prolonged hospitalization as newborn yes no

breast fed

yes no

feeding difficulties

yes no

severe infections

yes no

LATE on immunizations

yes no

Abnormal growth and development yes no

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MEDICATION FORM Name:_________________________ Date of Birth:____________

Medication Name

Current Medications and Supplements

(include milligram and number of times per day)

Strength

Times per Day Taking This for What Diagnosis?

Name of Medication

Allergies to Medications Reaction (hives, throat swelling, other reactions)

NO KNOWN DRUG ALLERGIES

When was your last flu shot?_________________________ When was your last pneumonia shot?___________________ Preferred Pharmacy: (Name) ____________________________________________________________________________ (Street Address) _____________________________________________________________________ (City, State, ZIP Code) _______________________________________________________________ (Telephone Number) _________________________________________________________________ (Fax Number) _______________________________________________________________________

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