WELCOME LETTER



WELCOME LETTERDear Patient:Welcome to Julie Staats, D.O., Family Medicine! I would be honored to be your physician, and I’m committed to providing you with the best care that I can. My hope is that we form a partnership to keep you as healthy as possible, no matter what your current state of health.We are a teaching clinic, so we have Osteopathic medical students from Auburn University and local Nurse Practitioner students regularly. They may take part in your care unless you expressly state otherwise.A licensed medical provider will ALWAYS see you with or after the student.?I offer patient centered, evidenced based medical expertise, along with my opinions/recommendations, but also may offer you alternative choices which I hope will encourage you to take responsibility for the healthy lifestyle that is so important to your well-being and quality of life. Few of us have a completely healthy lifestyle, but each day we can take a step closer to a healthier life.Below are proven important steps you can take toward better health:? Don’t smoke cigarettes or use other tobacco products.? Drink alcohol in moderation, if at all, and never drive when you’ve been drinking.? Eat a diet low in fat and high in vegetables and fruits.? Exercise at least three times a week.? Wear your seat belt whenever you’re in a car.? Learn about ways to deal with stress and tension.? Discover what spirituality means to you and practice it.? Maintain ties with your family, neighbors, co-workers or your church community.It would be a great pleasure to work with you on these goals, either through my own expertise, through reading I might give you, or by referral to other health professionals. My team will remind you of upcoming appointments and ask your preference (telephone, text, protected email, follow-up appointment) as to how you would like reminders, or any test results communicated to you.We want everyone to be involved in our health maintenance program. Everyone who joins our practice will start by having a complete history and physical exam, followed by a preventive medicine evaluation with assessment of family/social history and personal risk factors. Afterwards, a plan for periodic surveillance to check for your specific higher risk medical conditions/diseases will be suggested (at least annually). Once your care is established with me, please call our office for acute illness as needed, and my team will do our best to provide same day strep, flu and urinalysis tests, as appropriate to your symptoms. Please call before you see a specialist for a problem, we may be perfectly capable of handling in our office: women’s health issues, skin exams, sports physicals, joint injections, skin biopsies, small lacerations or minor injuries. In extenuating circumstances, arranging a home visit for an elder or those with acute transportation issues is not out of the question after clinic hours.I look forward to working with you as your family doctor/Medical Home. It’s my hope that we can have a relationship where the lines of communication are open, where your medical care is accessible and cost effective; where it is all about you.Sincerely,Julie A. Staats, D.O., FAAFPPh: 850 279 3040Fax: 850-279-3312 Julie staats, d.o., family medicineNEW PATIENT REGISTRATION FORMToday’s Date: PATIENT INFORMATIONPatient’s last name: First: Middle: Marital status: M / S / D / MINOR / Widow(er)Is this your legal name?If not, what is your legal name?Former name:Birth date:Age:Sex:Address: Social Security no.:Home phone no.:Cell phone no.:Occupation:Employer:Employer phone no.:First Language: How do you prefer that we contact you? Home ph / Work ph / Cell / US mail / EmailEmail address: Chose clinic because/referred to clinic by:Other family members seen here: What is your preferred Pharmacy and location? Prescription Plan ID# if applicable: INSURANCE INFORMATION (Please give your insurance card to the receptionist)Person responsible for bill:Birth date:Address (if different):Home phone no.:Is this person a patient here?Is this patient covered by insurance?Occupation:Employer:Employer address:Employer phone no.:CIRCLE NAME OF PRIMARY INSURANCE: FLORIDA BLUE / CIGNA / MEDICARE / TRICARE STANDARD/ TRICARE FOR LIFE/ UNITED/ MULTIPLAN Policy Holder:Policy Holder SSN:Birth date:Group no.:Policy no.:Co-payment:$581025023495000Patient’s relationship to subscriber: SELF / SPOUSE / CHILD / Other: Name of secondary insurance (if applicable):Policy holder: Group no.:Policy no.:561022519113500Patient’s relationship to subscriber: SELF / SPOUSE / CHILD / Other: IN CASE OF EMERGENCYName of local friend or relative (not living at same address):Relationship to patient:Home phone no.:Work phone no.:I authorize Julie Staats, DO, Family Medicine to release medical information to ___________________________________Relationship to patient: _____________________________Phone: ____________________ Address: ________________________________________________________________Date: _____________________The above information is true to the best of my knowledge.I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Microsoft Corporation or insurance company to release any information required to process my claims.Patient/Guardian signatureDateTHIS PAGE INTENTIONALLY LEFT BLANKPEDIATRIC HEALTH HISTORY QUESTIONNAIREAll questions contained in this questionnaire are strictly confidential and will become part of your medical record. Please complete questions appropriate to age of the child.Name (Last, First, M.I.): M FDOB:School status: None Daycare Pre-K Elementary Middle High School Home schooled Previous or referring doctor:Date of last physical exam:PERSONAL HEALTH HISTORYChildhood illnesses experienced: Measles Mumps German Measles/Rubella Chickenpox Rheumatic Fever PolioImmunizations dates: Tetanus271780635 Shingles/Zoster Pneumonia Hep B HPV Chickenpox Influenza Hib MMRList or circle any Medical problems previously diagnosed. Allergies, Asthma, Ear problems, Eczema, high blood pressure, heart murmur, high cholesterol, Diabetes, Migraines, Rheumatoid arthritis, Seizures, Urinary tract infections or urinary Reflux, recurrent tonsillitis. List or circle any Mental Health problems previously diagnosed. ADD, ADHD, Anxiety, Autism, Bipolar, Depression, Dyslexia, other Learning Disability, Obsessive Compulsive Disorder, Oppositional Defiant Disorder, Schizophrenia, Tourette’sList or circle any Cancers previously diagnosed: Brain tumor, Bone tumor, Leukemia, Lymphoma, Neuroblastoma, Sarcoma, Testicular, Ovarian, Melanoma.My Child was born at: home or birth Center or HospitalPregnancy or birth complications? Yes No If so, explain: (gestation diabetes, pre-eclampsia, premature, breathing problems, feeding problems, jaundice, fever workup)My top Concerns for my child:1.2.3.My Child was breast fed or bottle fed or bothPlease list any Hospitalizations and/or Surgeries:YearReasonHospitalHas your child had a blood transfusion?YesNoHas your child had a major trauma, fall from height or any broken bones?YesNoHas your child ever lost consciousness? If yes, plz explain:YesNoIs your child seeing any specialists? If yes, plz list:YesNoIs your child right handed or left handed?RtLtWhen was your child’s Last Dental Exam?When was your child’s Last Eye Exam?Were you or your child born outside the USA?YesNoHas your child stayed with friends or family from: Africa, Asia, Latin America, or Eastern Europe?YesNoList child’s prescribed drugs and over-the-counter drugs, such as vitamins and inhalersName the DrugStrengthFrequency TakenAllergies to Medications, Foods or InsectsName the Drug or substanceReactionHEALTH HABITS AND PERSONAL SAFETYAll questions contained in this questionnaire will be kept strictly confidential.Activity Sedentary (No exercise) Mild exercise (climb stairs, walk 3 blocks) jungle gym Occasional vigorous exercise (less than 4x/week for 30 min.) plays outside, plays a sport, rides bike Regular vigorous exercise (4x/week for 30 minutes) plays outside, plays a sport, rides bikeScreen timeHow many hours per day does your child spend using a phone, tablet, TV, or computer (combined)?DietDo you have any concerns about your child’s diet?YesNoDoes your child seem to have any food intolerance? If so, to what?YesNoDoes your child take a daily multi-vitamin? Yes NoRank sugar intake Hi Med LowRank fat intake Hi Med LowRank processed/fast foods intake Hi Med LowSleepHow many hours per night does your child sleep?TobaccoDrugsDoes anyone in the home use tobacco products?YesNo Cigarettes – pks./day # of years Chew - #/day Pipe - #/day Cigars - #/dayDoes your child use recreational or street drugs?YesNoSexIs your child sexually active? YesNoHas your child completed the HPV vaccine to prevent high risk wart virus?YesNoSexual orientation? Hetero or Lesbian, Gay, Bisexual, TransgenderIllness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would you like your provider to speak to your child about Sexually transmitted Infections and the risks of HIV?YesNoPersonal SafetyDoes your child live with both parents?YesNoIs there a shared custody situation?YesNoDoes your child drive?YesNoDoes your child use an approved booster seat, car seat or a safety belt every time you drive in a car?YesNoDoes your child know how to swim?Has your child ever had a heat Injury?YesNoDo you have firearms in your home?YesNoDoes your child know how to resolve conflict without anger?YesNoPhysical and/or mental abuse have also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse by a bully or romantic interest. Would you like your provider to discuss this with your child?YesNoDoes your child have chores?YesNoDoes your child wear a bicycle helmet and sports safety gear?YesNoDoes your child use sunscreen?YesNo-142240-317500FAMILY HEALTH HISTORYPlease note any health conditions like high blood pressure, heart attack, high cholesterol, Diabetes, Migraines, Glaucoma, Osteoporosis, Rheumatoid arthritis, Mental health disorders (depression, Anxiety, Bipolar, Schizophrenia, OCD, ADD, completed suicides). Please note any Cancers: Breast, Colon, Uterine, Ovarian, Skin-Melanoma, Prostate, Thyroid, Lung, Liver, PancreasAgeSignificant Health ProblemsAgeSignificant Health ProblemsFatherSiblings M FMother M F M FGrandmotherMaternal M FGrandfatherMaternal M FGrandmotherPaternal M FGrandfatherPaternalEthnic Heritage: (Circle all that apply) Native North American or Eskimo / British Isles / Northern European / Asian / Pacific Isles / Middle Eastern / Mediterranean / African American / South American / Spanish / Filipino MENTAL HEALTH (14yrs and older)Is stress a major problem for you?YesNoDo you panic when stressed? YesNoIn the past month have you felt depressed, down or hopeless?YesNoDo you have problems with eating or your appetite? Not hungry, comfort eat, binge and purge, make yourself vomit (Circle)YesNoIn the past month have you been bothered by little interest or pleasure in doing things you normally like? Yes NoDo you cry frequently?YesNoHave you ever seriously thought your family would be better off without you or have you thought about hurting yourself? YesNoHave you ever made plans to end your life or attempted suicide?YesNoHave you purposely cut yourself? YesNoDo you have trouble falling or staying asleep?YesNoGIRLS ONLY Age period started: ______ Date of last Period: ____________ I have a Period every _____ days. My Periods last _____ days.My type of birth control: (Circle) Abstinence, Pill, Condoms, Patch, DepoNumber of pregnancies _____ Number of live births _____Heavy periods, menstrual irregularity, spotting, pain, or other vaginal discharge? (Circle)YesNoDo you have uncontrollable PMS crying spells, irritability, pain, bloating, or other symptoms at or around time of period?YesNoAre you pregnant, breastfeeding or trying to get pregnant?YesNoAny urinary tract, bladder, or kidney infections within the last year?YesNoDo you have any discomfort or bleeding with intercourse?YesNoDo you have any current vaginal itching, burning, excess discharge or odor?YesNoHave you ever had any of the following: Herpes, HPV/ genital warts, Chlamydia, Gonorrhea, Syphilis, TrichomonasYesNoDo you have any family history of Breast, Uterine or Ovarian cancer? (Circle)YesNoDate of last Pelvic exam if applicable? _________________ BOYS ONLYDo you have both testicles down in your scrotal sac?YesNoDo you feel pain / burning with urination or noted any blood in your urine?YesNoDo you have any new discharge from your penis?YesNoHave you had any: Hernias, Kidney stones, or bladder infections?YesNoDo you perform self testicle exams? testicle pain, swelling, lump (Circle)YesNoDo you have any testicular pain?YesNoOTHER PROBLEMSCheck and circle if your child has had recent symptoms in the following areas and explain below or to the doctor.Headaches, Seizures, tics, Loss of consciousnessFevers, night sweats, heat or cold intoleranceFace, Leg, feet swellingVision loss or changeChest Pain/ pressure, Palpitations, exercise intoleranceEarly puberty changesNeck Pain, swollen glandsBack, joint or bone pain, swelling, stiff joints, broken bonesWeight increase or decrease w/o explanation Hearing change, ear pain, or discharge from earsAbdominal pain, constipation, blood in stool, black smelly stool, vomitingIrreg periods, severe period crampsNasal burning, congestion, sneezing, Allergies, nose bleedsBladder infection, pain, urinary frequency, cloudy or smelly urine, bed wettingHungry and/or thirsty all the timeSore Throat, mouth breathing, “kissing” tonsils, hoarseness, snoringAbrupt change in behavior or decrease in appetite, not wanting to go to school or see friends, sad, irritable or resentfulOther pain/discomfort:Cough, Short of Breath, WheezeRashes, Easy bruising, hivesNOTICE OF PRIVACY PRACTICES---PATIENT ACKNOWLEDGMENTPatient’s Name: ________________________________ Date of Birth: ______________I have received this practice’s Notice of Privacy Practices written in plain language. The Notice provides, in detail, the uses and disclosures of my protected health information that may be made of this Practice, my individual rights, and the Practice’s legal duties with respect to my protected health information. The Notice includes: . A statement that this Practice is required by law to maintain the privacy of protected health information.. A statement that this Practice is required to abide by the terms of the Notice currently in effect. . Types of uses and disclosures that this Practice is permitted to make for each of the following purposes: Treatment, payment and health care operations. . A description of the other purposes for which this Practice is permitted or required to use or disclose protected health information without my written consent or authorization. A description of uses and disclosures that are prohibited or materially limited by law. . A description of other uses and disclosures that will be made only with my written authorization and that I may revoke such authorization.. My individual rights with respect to protected health information and a brief description of how I exercise these rights in relation to: . The right to complain to this Practice and to the Secretary of HHS if I believe my privacy rights have been violated and that nor retaliatory actions will be used against me in the event of such a complaint. . The right to request restrictions on certain uses and disclosures of my protected health information, and that this Practice is not required to agree to a requested restriction. . The right to receive confidential communications of protected health information. . The right to inspect and copy protected health information. . The right to amend protected health information. . The right to receive an accounting of disclosures of protected health information. . The right to obtain a paper copy of the Notice of Privacy Practices from this Practice upon request. This Practice reserves the right to change the terms of its Notice of Privacy Practices and to make new provisions effective for all protected health information that it maintains. I understand that I can obtain this Practice’s current Notice of Privacy Practices on request.SIGNATURE: ________________________________ DATE: ____________________ JULIE STAATS, D.O., FAMILY MEDICINENEW PATIENT AGREEMENTPlease initial alongside each item of information, acknowledging your understanding and agreement to the policies/expectations listed._____Appointment time: As a new patient, I am expected to arrive a MINIMUM of 15 minutes prior to my appointed time with my new patient packet completed. As an established patient, I am expected to arrive 10 minutes prior. _____Co-Payment: I will pay my co-pay by cash, check or credit/debit card before leaving the clinic. _____No insurance: If I have no insurance, full payment is due on the day of the office visit. _____Delayed payment: If no portion of my outstanding bill has been paid for 60 days, I will contact my insurance to assess the reason for the delay. _____Payment 90 days overdue: If my insurance carrier does not reconcile my outstanding bill for 90 days, then I am responsible for the outstanding amount owed. _____Same day cancellation/No show appointment: I am responsible for showing up on time or calling to cancel AT LEAST 24 hours prior to my appointment; otherwise, there will be a $45 dollar fee which is NOT part of a co-pay and is NOT billed to my insurance._____Controlled Substance Medication: Due to continued efforts to decrease the amount of controlled substances circulated by the general public for recreational purposes, both the state of Florida and the DEA have strict controlled substances laws. All patients requiring regular controlled substance prescriptions (for pain, sleep, narcolepsy, anxiety and attention deficit disorders) are required to sign a controlled Substance Informed Consent, have a face to face visit every 3 months, and are subject to periodic urine drug screen testing. _____Dismissal from practice: The provider has a legal right to dismiss any patient from the practice. The provider will allow said patient(s) to be seen for acute issues and medication refills for 30 days while he/she is establishing care with a new provider. _____An Annual Administrative Fee: $45/individual, $75/couple, or $95/family will be charged each September to off-set expenses incurred by government regulations regarding privacy, electronic health record maintenance and encrypted digital fax. The admin fee also allows us to provide many patient centered services which are not recompensed by an associated appointment, including: medication renewals, specific insurance formulary checks and changes, medication pre-authorization, requested handicap/ worker’s comp/ disability/ school/ work/ insurance forms, special test pre-authorizations and insurance claims denied requiring re-submission._____________________________ ______________________________Patient name and date Staff member name and dateJULIE STAATS, D.O., FAMILY MEDICINE________________________________________________2600 North Partin Drive, Ste. 120, Niceville, FL 32578Phone: 850-279-3040 Fax: 850-279-3312AUTHORIZATION TO RELEASE HEALTHCARE INFORMATIONThis form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.Patient NAME: _____________________________ Date of Birth:___________________Previous Name: ___________________________ Social Security #:________________I request and authorize (prior physician/specialist):___________________________________________________________________________to disclose this health information to the following recipient:Name: JULIE STAATS, D.O., FAMILY MEDICINE___________________________________________Address: 2600 NORTH PARTIN DRIVE, SUITE 120__________________________________________City: NICEVILLE___________ State: FL_______ Zip: _32578____________This request and authorization apply to:? - All of my health information? - My health information relating to the following treatment or condition or dates: _____________________________________________________________________________________________________________? - Other: ________________________________________________________________________________________Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et.seq., includes herpes, herpes simplex, human papilloma virus, wart, genital wart, condyloma, chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.? YES ? NO I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure or these test results to anyone.? YES ? NO I authorize the release of my records regarding drug, alcohol, or mental health treatment to the person(s) listed above.Patient Signature: __________________________________ Date Signed: ________________________THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER DATE SIGNED ................
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