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HAPPI Health813 Franklin Street Huntsville, AL 35801 2597 Sparkman Drive Huntsville, AL 35801Franklin Phone: (256) 519-3650 Sparkman Phone: (256) 585-6212 Fax: (256) 585-6713New Patient Form-ADULT/Transition of CareDate: ___________________________Patient's Name____________________________________________________________________________________________________________ First MiddleLastNickname ________________________________________________________________________________________________________________________Date of BirthSocial Security Number Gender Cell Phone (Does it receive text mgs? YES / NO)________________________________________________________________________________________________________________________Street Address (include apt #, if any)CityStateZip ________________________________________________________________________________________________________________________Alternate Phone Work Phone EmployerOccupationSpouse’s Name___________________________________________________________________________________________________________FirstMiddleLastNickname________________________________________________________________________________________________________________________Address (if different) CityStateZipPrimary Phone (Include Area Code)________________________________________________________________________________________________________________________Date of BirthSocial SecurityEmployerEmp. PhonePreferred Pharmacy and street location: ____________________________________________________________________________________Emergency Contact________________________________________________________________________________________________________________________ Contact's Name (1)RelationshipPhone (Include Area Code)________________________________________________________________________________________________________________________Contact's Name (2)RelationshipPhone (Include Area Code)Insurance InformationInsurance (1) ____________________________________________________________________________________________________________Contract #Group #Co-pay_______________________________________________________________________________________________________________________GuarantorRelationship to PatientD.O.B.SSNGENDERInsurance (2) ____________________________________________________________________________________________________________Contract #Group #Co-pay_______________________________________________________________________________________________________________________ GuarantorRelationship to PatientD.O.BSSNGENDERWhich method would be best for appointment reminders: Text Cell/Voice Mail Home Phone/Voice Mail Email__________________________________________________ Other____________________________________*We are required to collect Race, Ethnicity, and Preferred Language. If you prefer not to report that information, you may write the option "Refused/Unreported." ___________________________________________________________________________________________________________________________________ RaceEthnicityLanguage How Did You Hear About Us? WRSA-Lite 96.9WZYP-104.3WAFF-TV 48WAAY-TV 31InternetYellow Pages Other: __________________________________________________________Patient Name: ____________________________________________________________MEDICARE PATIENTS: I authorize H.A.P.P.I. to release medical information about me to the Social Security Administration or its intermediaries for Medicare Claims. I assign the benefits payable for services to H.A.P.P.I. and understand that if I have questions or complaints that I should contact the Privacy Official.Patient Initials: ________________RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORMI have been informed that a copy of HAPPI, Inc. Notice of Privacy Practices is posted in the waiting room area.? A copy of this Notice will be furnished to me upon my request.HIPAA is an acronym for the Health Insurance Portability & Accountability Act of 1996, (a Federal Law). Of significant concern to healthcare organizations is the Administrative Simplification section of the Act, which requires health care organizations to comply with specific rules regarding: unique identifiers for health plans, providers, individuals, employers, healthcare transaction & code sets for transmitting data electronically, privacy regulations over disclosure and use of health information. Security regulations over protections of electronic health information: It is our policy to NOT release confidential and/or unauthorized information except appointment confirmation by home telephone, answering machine, work telephone, voice mail, cell phone and/or pager and the patient portal. Whenever returning phone calls and the answering machine picks up, we do not leave a message if the name or telephone number is not on the recorded message to identify the residence. Information will also not be left with an unauthorized person who may answer the telephone. ???????????????????????????????????????????????????????????????????????????????????I hereby authorize HAPPI, Inc. to leave medical information pertaining to my care by home telephone, answering machine, work telephone, voice mail, cell phone and/or pager and the patient portal and will assume responsibility to notify them whenever this information changes.May we fax medical records for your referrals?YES NOPlease list names of people with whom we may discuss your medical care or who may bring your child to an appointment:Spouse Name: ___________________________________________Parent Name: ___________________________________________ Other: ____________________________________________If we cannot release your medical information to anyone but you, please initial here: ________________PATIENT CONTROLLED SUBSTANCE AGREEMENT FORMDisclaimer:?HAPPI Health?is not a pain management clinic.? The physician/provider will refer you to a pain specialist for the issue of chronic pain.? Any narcotics that are dispensed are at the discretion of the?provider.We at?HAPPI Health?are making a commitment to work with you in your efforts to get better.? This agreement is a tool to protect both you and the physician/provider by establishing guidelines,?within?the law, for proper and controlled substance use.I understand and voluntarily agree that:Pain management will not be managed at HAPPI Health.I will keep (and be on time for) all my scheduled appointments with the doctor and other members of the team.I will participate in all other types of treatment that I am asked to participate in.I will keep the medicine safe, secure and out of the reach of children.? If the medicine is lost, stolen, gets wet or destroyed, left on an airplane, etc. I understand it will not be replaced until my next appointment, and may not be replaced at all.I will take my medication as instructed and not change the way I take it without first talking to the doctor or other member of the treatment team.I will not call between appointments, at night or on the weekends looking for refills; early refills will not be given.? I understand that prescriptions will be filled only during scheduled office visits with the treatment team.I will make sure I have an appointment for refills.? If I am having trouble making an appointment, I will tell a member of the treatment team immediately.I will treat the staff at the office respectfully at all times.? I understand that if I am disrespectful to staff or disrupt the care of other patients my treatment will be stopped and I will be dismissed as a patient.I will not sell this medicine or share it with others. I understand if I do, my treatment will be stopped and I will be dismissed as a patient.I will sign a release form to let the doctor speak to all other doctors/providers that I see.I will tell the doctor all other medicines that I take and let him/her know right away if I have a prescription for a new medicine.I understand that I will be required to submit urine or serum toxicology testing at the request of the treatment team.? The presence of unauthorized substance or lack of prescribed medications may result in discharge from the facility.I will not use illegal drugs or consume excessive amounts of alcohol in conjunction with controlled substances.? I understand that if I do, my treatment may be stopped and I may be dismissed as a patient.I understand that I may lose my right to treatment in this office if I break any part of this agreement.I understand that all medications that are controlled substances (ADHD medications and Gabapentin) are considered part of this policy.I understand that if I have a controlled medication on my medication list, the provider will be checking the Prescription Drug Monitoring Program (PDMP) in order to assure patient safety.I understand that if I am injured and seek treatment at HAPPI Urgent Care, I will be prescribed no more than a three (3) day supply of controlled pain medication and will need to follow up with my primary care physician for further treatment.REQUEST FOR MEDICAL CARE: I voluntarily consent to examination, lab evaluation, treatment and the rendering of care, including treatments and performance of diagnostic procedures. I grant my consent for treatment for myself, my spouse, or my minor children/dependent as listed on this form.I authorize the release of any medical information necessary to process this claim. I permit a copy of this authorization to be used in place of the original. I have received a copy of the practice's Privacy Notice and agree to follow these policies.Patient or Guardian Signature: _________________________________________________________________ Date ______________________***All signatures will be kept on file for one calendar year; anytime your information changes, please notify the front desk. Medical paperwork will be updated on an annual basis.Date:_____________Patient Name:_________________________________________DOB:______________________Please check all conditions which you have had:GENERALHEENTLYMPHATIC/?Kidney Stones?Serious Infections?Glaucoma HEMATOLOGIC?Kidney Failure?(e.g. pneumonia)?Allergies "hay fever"?Thyroid Goiter?Prostate Disease?Diabetes Mellitus?Frequent Ear Infections?Over Active Thyroid?Endometriosis?Rheumatic Fever?Frequent Sinus Infections?Under Active Thyroid?Sexually Transmitted Infection?HIV Infection?Transfusions?Cancer (what type?)RESPIRATORY?AnemiaSKIN/BREAST?Hearing Loss?Asthma?Acne?Vision Loss?EmphysemaGI/GU?Eczema?Blood Clots in Lungs?Stomach Ulcers?PsoriasisCVS?Sleep Apnea?Ulcerative Colitis?Fibrocystic Breast Disease?High Blood Pressure?Cohn’s Disease?Congestive Heart FailureMUSCULOSKELETAL/?Bleeding from IntestinesNEUROLOGIC/PSYCHIATRIC?Heart Murmur EXTREMITIES?Diverticulitis?Chronic Vertigo (Meniere's)?Heart Valve Disease?Osteoporosis?Colon Polyps?Peripheral Nerve Disease?Angina?Rheumatoid Arthritis?Irritable Bowel Disease?Migraine Headaches?Heart Attack?Degenerative Joint Disease?Hepatitis?Stroke?High Cholesterol?Fibromyalgia?Cirrhosis of the Liver?Multiple Sclerosis?Abnormal Heart Rhythm?Neck Pain (herniated disc)?Liver Failure?Depression?Blood Clots in Veins?Back Pain (herniated disc)?Pancreatitis?Anxiety?Blocked Arteries in Neck?Gallstones?Blocked Arteries in LegsPlease indicate any surgeries you have had and the year you had them.YearYearYearYear?Angioplasty?Trauma Related Surgery?Stomach Surgery?Tubal Ligation?Carotid Artery Surgery?Back or Neck Surgery?Inguinal Hernia?C-Section?Other Vascular Surgery?Hip Surgery?Colonoscopy?Hysterectomy?Coronary Bypass Surgery?Knee Surgery?Gallbladder?Ovary Removed?Chest/Lung Surgery?Carpal Tunnel Surgery?Appendectomy?Breast Surgery?Tonsillectomy?Sinus Surgery?Prostate Surgery?Thyroid Surgery?Neurosurgery?Ear Surgery?Bladder Surgery?otherPlease indicate when you last had any of the following preventive tests or services.YearYearYearYear?Cardiac Angiogram?Flu Vaccine?Prostate Cancer Blood Test?Mammogram/Breast Exam?Stress Test?Pneumonia Vaccine?Rectal Exam?Pap Smear?Echocardiogram?Tetanus Vaccine?Colon Cancer Stool Test?Date of Last Physical Exam?Chest X-Ray?Hepatitis Vaccine?Flexible SigmoidoscopyOther___________________?EKG?Bone Density Test?Barium EnemaX-ray_______________CT_________________MRI_________________Please list any allergies or intolerance to drugs or other substances.__________________________________________________________________________________________________________________________________________________________________________________________________________________Please list the medications currently taken, including dosage and frequency:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________FAMILY MEDICAL HISTORYPlease check or list any major illness in your family members. (Mother, Father, Brothers, Sisters, or Children)?Tuberculosis?Diabetes Mellitus?Kidney Disease?Breast Cancer?Emphysema?Thyroid Disease?Epilepsy?Ovarian Cancer?Heart Disease?Anemia?Neurological Disorder?Colon Cancer?High Blood Pressure?Hemophilia?Liver Disease?Prostate Cancer?OsteoporosisOther:_________Other:_______________Other:______________PERSONAL INFORMATIONPlease write in or circle the information that applies to you:Are you employed? __________ How many hours/wk.?__________ Occupation:EducationSexualityMarital StatusLiving StatusDiet ExerciseAlt. Medicineprimaryheterosexualsinglealonenonenoneholisticsecondaryhomosexualmarriedw/ spouselow fatwalkingchiropracticcollegebisexualdivorcedw/ parentslow cholaerobicshomeopathypost gradtranssexualwidowedassisted livinglow carbsWeigh tliftingacupuncturedoctorateseparatednursing homevegetariandays/wk.herbalTobaccoAlcoholIllicit DrugsCaffeinenever/ past/ activenever/ past/ activenever/ past/ activenever/ past/ activecigarette/ cigar/ pipeliquor/ wine/ beercocaine/ marijuanacoffee/ tea/ sodanever/ past/ activenumber of drinks________heroin/ amphetaminenumber of drinks per day______snuff/ dip/ chew per day/ week/ monthbarbiturate/ LSD/ PCPStarted_____________AA/ Alcohol RehabIV Drug abuseQuit________________NA/ Drug RehabAmount per day__________How would you rate your overall health? Good Fair PoorDo you see any specialists? If so, please list below.Allergist:___________________________________Hematologist/Oncologist:______________________________Cardiologist:________________________________Neurologist:________________________________________Dermatologist:______________________________Psychologist:_______________________________________ENT:_____________________________________Pulmonologist:______________________________________Endocrinologist:_____________________________Rheumatologist:_____________________________________Gastroenterologist:___________________________Urologist:__________________________________________Other:_____________________________________Have you travelled outside the United States in the last year? _________ If so, where? _______________________________________I certify that the information collected in this paperwork is correct.Signature: ___________________________________________________Date: __________________ ................
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