Irp-cdn.multiscreensite.com



PATIENT DEMOGRAPHIC INFORMATION

|PATIENT INFORMATION |

|Today’s Date: |MRN: |Account Number: |

|Patient Name: |Nickname: |

|Mailing Address: |

|Email Address: |

|Home Phone: Cell Phone: Work Phone: |

|Can we leave |

|a message? □ Y □ N □ Y □ N □ Y □ N |

|DOB: |Sex: |Marital Status: |

|EMERGENCY CONTACT INFORMATION |

|Emergency Contact Name: |Phone Number: |

|RESPONSIBLE PARTY |

|Guarantor Name: |DOB: |

|Address: |

|INSURANCE INFORMATION |

|Primary Insurance: |Secondary Insurance: |

|Address: |Address: |

|Phone Number: |Phone Number: |

|Subscriber Name: |Subscriber Name: |

|DOB: |DOB: |

|Subscriber ID: |Subscriber ID: |

|Group Number: |Group Number: |

|EMPLOYER INFORMATION |

|Patient Employer: |Patient Occupation: |

|ADVANCED DIRECTIVE |

|Please provide our office with a copy and check the box if you have any of the following in place: |

|□ POA □ Living Will □DNR □None |

|ETHNICITY/RACE/LANGUAGE |

|Which category best describes your race? Please select all that apply |

|□ African American □ Asian □ Caucasian □ Other__________ □ Decline to answer |

|Are you of Hispanic or Latino descent? □ No □ Yes □ Decline to answer |

|What is your preferred language? |

|□ English □ Spanish □ French □ Other______________ |

|HIPAA: (May Discuss Information With) |

|Primary Contact: |Relationship: |Phone: |

|Secondary Contact: |Relationship: |Phone: |

|PATIENT APPOINTMENT AND NO SHOW POLICY |

|At Medical Hills we value our relationships with our patients and understand your time is valuable. With that in mind, we work to maintain the most efficient |

|schedule and make every attempt to get patients an appointment within a reasonable timeframe. We appreciate your understanding of and adherence to our policy. |

|Medical Hills utilizes scheduled patient appointments and does not accept walk-in visits. We also understand that schedules sometimes change. Our office sends |

|automated voice message reminders for provider appointments. In the event you do not receive this message, you are still responsible for no show fees in regards|

|to missed appointments. If you are unable to keep a scheduled appointment, we ask that you call us at least 24 hours in advance to reschedule. This allows us |

|to reschedule your cancelled appointments in a timely manner and allows other patients with urgent needs to quickly access our providers. If you do not call to |

|cancel or reschedule before your scheduled appointment time, it is documented as a NO SHOW. You will be notified via our automated messaging system of the no |

|show. You will need to call our office to schedule another appointment. |

|The following outlines our policy for NO SHOWS: |

|First Occurrence: Notified via automated message and assessed a $25 NO SHOW FEE. |

|Second Occurrence: Notified via automated message and assessed an additional $25 NO SHOW FEE. No more patient appointments will be scheduled until the NO SHOW |

|FEES are paid in full. We will provide one 30-day medication refill to allow time to reschedule the missed appointment and pay the no show fee. |

|Third Occurrence within a 24 month period: If you no show 3 appointments within a 24 month timeframe, you will be dismissed from the practice and be assessed |

|an additional $25 NO SHOW FEE. |

|NO SHOW fees will be billed directly to you, the patient. This fee is not covered by insurance, and must be paid prior to your next appointment. |

|Because it is important to keep our appointments on time and not make patients wait longer than necessary, patients arriving more than 10 minutes late for a |

|scheduled appointment may be rescheduled for another day. |

|Thank you for your understanding and cooperation as we strive to best serve the needs of all of our patients. |

|My signature below constitutes acknowledgement and acceptance of this policy. |

| |

|_________________________________________ _________________________ |

|Patient or Guarantor Signature Date |

Patient Name: «FirstName» «LastName» Date of Birth: «DOB» MRN: «MRNNo»

CONSENT FOR TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS

|PATIENT PORTAL CONSENT TO ACCESS |

|I grant consent for Medical Hills Internists, LLC to activate my account on the patient portal. The portal offers a secure way for our patients to view |

|limited data, clinical summaries, and communicate with our staff through secure messaging. Access to this secure web portal is an optional service, and |

|Medical Hills Internists may suspend or terminate your access at any time and for any reason. If we do suspend or terminate this service we will notify |

|you as promptly as possible. I agree not to hold Medical Hills Internists or any of its staff liable for network infractions beyond its control. I |

|understand and will comply with the terms of use regarding the patient portal. |

| |

|Please initial if you consent to the Patient Portal:_________ |

|MEDICATION HISTORY CONSENT |

|I give permission to Medical Hills Internists, LLC to access my pharmacy benefits data electronically through Sure Scripts. This consent will enable |

|Medical Hills Internists to send my prescription electronically, determine if a patient's health plan allows electronic prescribing to Mail Order |

|pharmacies, e-prescribe to the pharmacy if possible, and download a historic list of all medications prescribed for a patient by any provider. I also |

|allow Medical Hills Internists permission to obtain formulary information, and information about other prescriptions prescribed by other providers using |

|Sure Scripts. |

| |

|Please initial if you consent to Rx History:_________ |

|I-CARE CONSENT |

|I give my consent for Medical Hills Internists, LLC to release my immunization(s) and identifying information to the Illinois Comprehensive |

|Automated Immunization Registry Exchange (I-CARE). I understand the purpose of the I-CARE is to assist in my medical care and to record the immunizations|

|that I have received. My immunization information may potentially be used by the Department of Health for quality improvement purposes, epidemiologic |

|research, and disease control purposes. Any Information used for these purposes will have my personal identifying information removed. The immunization |

|information in the I-CARE may be released to the following: myself, my health insurance organization, the state and local health departments, the school |

|that I am registered to attend, and authorized medical providers that deliver my medical care. I understand that there will be no effect on my treatment,|

|payment, or enrollment for benefits if I choose to participate. This consent may be withdrawn at any time by using the form provided. |

| |

|Please initial if you consent to I-CARE :________ |

|eHX CONSENT |

|I give my consent for Medical Hills Internist, LLC to partake in the eHX summary program. This program electronically shares important parts of patient |

|medical information with authorized healthcare professionals, their agents, and others whose job it is to secure, monitor, and evaluate the operation of |

|the information system and quality of care. The eHX summary will allows the provider to access health information more quickly and accurately with |

|billing and financial management, administrative management, clinical care, reports to public health agencies, reports to protect security of your |

|medical information, reports to evaluate the use of the eHX summary, and reports to track and evaluate the quality of your healthcare services. |

| |

|Please initial if you consent to eHx:_________ |

If at any point you wish to withdraw permission, please notify our office to complete a new form.

|CONSENT TO TREAT (required for all patients) |

|I am seeking medical care and treatment at Medical Hills Internists, LLC. I consent to the rendering of such medical care and treatment deemed necessary |

|by my provider, other members of the clinical staff, and by Medical Hills Internists, LLC and its employees. |

|NOTICE OF PRIVACY PRACTICE |

|By signing this document, I acknowledge that a copy of the Medical Hills Internists, LLC Notice of Privacy Practice has been made available to me. I |

|understand that I can request a copy of the notice at any time. The privacy notice can also be located on the Medical Hills Internists LLC website at |

|. |

| |

|This notice is effective September 23, 2013. |

|FINANCIAL POLICY AND CONSENT FOR PAYMENT |

|Medical Hills Internists, LLC will submit fees for services to insurance. Payment of service is due according to the date listed on your statement. |

|Returned checks, unpaid balances older than 60 days, and failure to pay account balances timely as promised may subject your account to external |

|collection fees and possible termination from the practice. Your insurance is a contract between you, your employer and the insurance company. Please make|

|sure we are in network with your insurance plan before having services to avoid any unexpected expenses or denied services. It is your responsibility to |

|understand your insurance policy, and all coverage and benefits, including pre-certification, in/out of network benefits, and referral and authorization |

|requirements. Medical Hills does not bill for motor vehicle accident claims or become involved in third party litigation. |

| |

|I hereby authorize payment of medical benefits billed to my insurance by Medical Hills Internists, LLC. I have listed all health insurance plans from |

|which I may receive benefits. I accept responsibility for payment for any service(s) provided to me that is not covered by my insurance. I agree to pay |

|all copayments, coinsurance and deductibles at the time services are rendered. I also accept responsibility for fees that exceed the payment made by my |

|insurance, if Medical Hills Internists does not participate with my insurance. I authorize Medical Hills Internists to use and/or disclose my health |

|information, which specifically identifies me or which can reasonably be used to identify me, to carry out my treatment, payment and healthcare |

|operations. I understand that while this consent is voluntary, if I refuse to sign this consent, the Medical Hills Physicians can refuse to treat me. I |

|understand this authorization can only be revoked in writing. |

|PATIENT AGREEMENT |

|On the sections previously initialed, I grant permission for Medical Hills Internists to activate my account on the patient portal and share secured |

|information via ICARE, RX History, and eHX registries. I have read this Consent for Treatment, Payment and Health Care Operations form or have had it read |

|to me, and all information has been explained to my satisfaction. |

| |

|By signing this document, I confirm that I accept the terms of this document and confirm that any questions have been addressed. I further certify that I |

|am the patient or his/her authorized representative or legal guardian, and I am signing voluntarily. |

| |

|Print Name: _________________________________________________ Relationship:_____________ Date:_____________ |

|Patient or Legal Guardian or Patient Representative |

| |

|Signature: __________________________________________________ Relationship:_____________ Date:______________ |

|Patient or Legal Guardian or Patient Representative |

Medical Hills New Patient Information Name: DOB:

|Current Medications |

|Prescribed Medications |Size |Dose |Frequency |Prescriber |

|Lipitor(example) |40mg tablet |1 tablet |Once a day |Dr. Med Hills |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

|Medication Allergies / Intolerances |

|Please list medications you are allergic to |Reaction: |

|(or cannot tolerate). | |

|Example: Penicillin |Example: rash, difficulty breathing |

| | |

|Past Medical History |

|Have you been treated for any of the following conditions? Please circle all that apply. |

|Cardiovascular |

| |

|Mental Health History |

|Circle any of the following conditions that you have been treated for in the past: |

|Depression |Drug abuse |ADHD |

|Suicide attempt |Alcoholism |Bipolar disease |

|Anxiety |Eating disorder |Obsessive-compulsive disorder (OCD) |

|Panic attacks |Posttraumatic stress disorder |Psychosis |

|Other: |

|Specialists/Other Medical Care |

|Are You Currently Under The Care/Supervision Of Any Other Physician For Any Aspect Of Your Medical Care? |

|☐ Yes ☐ No |

|If yes, please list the physician and condition they are treating you for: |

|Physician |Condition being treated |

| | |

| | |

| | |

|Sexual History |

|Are you currently sexually active? NO YES Type of contraception: |

|Have you been sexually active in the past? NO YES |

|How many total sexual partners have you had in your lifetime? |

|Have you ever been treated for a sexually transmitted disease? NO YES Type: |

|Examples of STD’s: gonorrhea, chlamydia, genital warts, herpes. |

|Are you satisfied with your sex life? YES NO Concerns: |

|Women’s Health |

|Bone Health |

|Have you ever had a spine or hip fracture? NO YES |Date of last DEXA Scan: |

| |Date of last Vitamin D level: |

|Has your mom or a sister been NO YES treated for |Do you take supplemental YES NO |

|osteoporosis? |Calcium and Vitamin D? |

|Age of first period: |Are your periods regular? |

|If no longer having periods, how |How often do you have a period? |

|old were you when they stopped? | |

|Total number of pregnancies: |Number of stillbirths: |

|Number of live deliveries: |Number of miscarriages: |

|Gestation diabetes? NO YES |Number of abortions: |

|Pregnancy induced hypertension? NO YES | |

|Surgery/Procedure History |

|Have you had any of the following procedures (please circle)? If you can recall, add date. |

|Tonsillectomy |Carpal tunnel surgery |Vasectomy |Stress test |

|Adenoidectomy |Hip surgery |Prostate surgery |Bypass surgery |

|Cholecystectomy |Knee surgery |C Section |Stent placement |

|Appendectomy |Shoulder surgery |Hysterectomy |Pacemaker |

|Bowel surgery |Foot surgery |Tubal ligation |Neurosurgery |

|Weight loss surgery |Plastic surgery |Cystoscopy |Back surgery |

| |Breast Biopsy |Cardiac catheterization |Cataract surgery |

|Hospitalizations |

|Please list recent hospitalizations: |

|Date |Reason |Hospital |

| | | |

| | | |

|Family History |

|Please indicate any blood relative who has/had the following conditions with an X: |

|Health Problem |

|Circle Y or N for if family is living |

|Occupation |Job description: |Company or place of work: |

|Marital Status |Single Divorced Widowed |What is your spouse’s name? |

| |Married Separated Remarried |(if applicable) |

|Children’s Names | |

|Education |What is your highest level of education? |Where and when did you complete your education? |

|Religion | |Local church or place of worship: |

|Caffeine |Cups of coffee per day: |What do you do for enjoyment? |

|Alcohol |1 drink=12-ounce beer/5 oz wine/1 shot liquor |How many drinks do you have per week? |

| |How many drinks do you have per day? |0 |

| |0 |1-2 |

| |1-2 |3-5 |

| |3-5 |6-9 |

| |6-9 |10 or more |

| |10 or more | |

| | | |

| |Have you ever sought treatment for drug or alcohol use? |No Have you ever had a drink first thing in the morning to steady your nerves |

| |Yes |or get rid of a hangover? |

| |No |Yes |

| | |No |

|Drugs |Which drugs have you taken before (check all that apply)? |

| |___ Methamphetamines (Speed, Crystal) ___ Cocaine |

| |___ Cannabis (Marijuana, Pot) ___ Ecstasy |

| |___ Tranquilizers (Valium) ___ Hallucinogens (LCD, Mushrooms) |

| |___ Inhalants (Paint Thinner, Aerosol, Glue) ___ Narcotics (Heroin) |

| |___ Barbiturates ___ Synthetics |

| |How many times in the last year have you used a street drug? |How often do you use prescription drugs for non-medical reasons |

| |None |Not at all |

| |A few times |Some days |

| |Several times |Several times |

| |Most days |Most days |

|Tobacco |Which of the following tobacco products have you used in the |Do you need support to quit? |

| |last year? |Yes |

| |Smoke cigarettes or cigars |No |

| |Smoke e-cigarettes | |

| |Dip |Have you tried to quit tobacco within the last year? |

| |Chewing tobacco |Yes |

| |Water pipes |No |

| |Hookahs |If yes, how did it go? |

| |Have often do you smoke/use tobacco? | |

| |Not at all | |

| |Some days | |

| |Most days | |

| |Every day | |

|Preventative Care History |

|Colonoscopy |Date of Last: |Results: |

| |☐ Never |☐Abnormal ☐Normal ☐Unknown |

|Mammogram |Date of Last: |Results: |

| |☐ Never |☐Abnormal ☐Normal ☐Unknown |

|Pap Smear |Date of Last: |Results: |

| |☐ Never |☐Abnormal ☐Normal ☐Unknown |

|PSA (Screening for Prostate Cancer) |Date of Last: |Results: |

| |☐ Never |☐Abnormal ☐Normal ☐Unknown |

|Skin Exam by dermatologist |Date of Last: |Results: |

| |☐ Never |☐Abnormal ☐Normal ☐Unknown |

|Flu Shot/Influenza Vaccine |Date of Last: ☐ Never |

|Gardasil (HPV) Vaccine |Date of Last: ☐ Never |

|Pneumonia Vaccine |Date of Last: ☐ Never |

|Tetanus Vaccine |Date of Last: ☐ Never |

|Shingles Vaccine |Date of Last: ☐ Never |

|Hepatitis A Vaccine (2 shot series) |Date of Last: ☐ Never |

|Hepatitis B Vaccine (3 shot series) |Date of Last: ☐ Never |

|Review of Systems |

|Please place an X by any symptoms that you are experiencing today: |

|Constitutional |Respiratory |Gastrointestinal |Musculoskeletal |

|Weight change |Shortness of breath |Nausea |Morning stiffness |

|Fatigue |Difficulty breathing at night |Abdominal pain |Muscle spasms |

|Weakness |Cough |Vomiting |Joint pain |

|Fever |Coughing up blood |Stomach pain relieved by food/milk |Muscle tenderness |

| |Wheezing |Constipation |Joint swelling |

|Ears/Nose/Throat |Swollen legs or feet |Persistent Diarrhea | |

|Pain | |Blood in stools |Allergic/Immunologic |

|Redness |Neurological |Black stools |Frequent sneezing |

|Double or blurred vision |Headaches |Heartburn |Frequent infections |

|Eye dryness |Dizziness |Excessive gas |Skin/Breast |

|Ringing in ears |Sensitivity in hands/feet |Change in appetite |Easy bruising |

|Hearing loss |Memory loss | |Rash/hives |

|Nosebleeds |Night sweats |Genitourinary |New lesions |

|Loss of smell | |Difficulty urinating |Change in mole |

|Sores in mouth |Psychiatric |Pain/burning when urinating |Hair loss |

|Dry mouth |Excessive worries |Frequent urination |Color changes of hands/feet when cold |

|Hoarseness |Anxiety |Blood in urine |Breast lump |

|Difficulty swallowing |Easily loses temper |Discolored urine |Nipple discharge |

| |Depression |Discharge from penis/vagina | |

|Cardiovascular |Agitation |Rash/ulcers |Hematologic/Lymphatic |

|Pain in chest |Difficulty sleeping |Sexual difficulties |Swollen glands |

|Irregular heart beat |Difficulty concentrating |Change in periods |Tender glands |

|Sudden changes in heart beat | | |Anemia |

|High blood pressure |Endocrine | |Bleeds easily |

|Low blood pressure |Excessive thirst | |Blood transfusion |

|Heart murmur |Cold intolerance | |When?___________ |

| |Heat intolerance | | |

|Advanced Directives |

|Which of the following have you completed? |

|( Power of Attorney for Healthcare ( Living Will ( Do-Not-Resuscitate (DNR) Order |

|What questions do you have for your doctor today? What is your MAIN medical concern? |

| |

| |

Patient Signature:_____________________________________________ Date:_________________________________

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download