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PATIENT INFORMATIONName: __________________________________________________Date of Birth: ____________________ Sex: __________Address: __________________________________________________City: ____________________ State: __________ Zip: _______________Social Security #: ____________________ Marital Status: _______________Phone: ____________________ Alternative: ____________________Employer: ___________________________________________________ Phone/Address: ____________________________________________Emergency Contact: __________________________________________ Phone: ___________________ Relationship: ____________________Primary Care Physician: ________________________________________ Phone/Address: ____________________________________________Pharmacy: __________________________________________________ Phone: ____________________ Fax: ____________________The following individuals/organizations have the right to view my personal health information as described by HIPAA.Please list name and relationship of individual:NAME RELATIONSHIP_____________________________________________________________________________________________________________________________________________________________________________________________________________________________Patient/Guarantor (if patient is a minor) Signature DatePATIENT CONSENT FORMI understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorized you to use and disclose my protected health information to carry out:Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)Obtaining payment from third party payers (e.g. insurance company)The day-to-day healthcare operations of your practiceI have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.PATIENT AUTHORIZATION FORM: This authorization sets forth your right to use or disclose my protected health information as specified below for the purposes and parties as designated below.DESCRIPTION OF SPECIFIC INFORMATION AUTHORIZED: Any information needed to process insurance claim forms.DESCRIPTION OF THE SPECIFIC PURPOSES FOR USE AND DISCLOSURE: Billing purposesPARTIES REQUESTING INFORMATION AND AUTHORIZED TO USE AND DISCLOSE THE INFORMATION: Authorized representative of my insurance carrierPARTIES TO WHOM INFORMATION MAY BE DISCLOSED: Authorized representative of my insurance carrierI reserve the right to:Revoke this authorization in writing by submitting it to the attention of your Privacy OfficerInspect or copy the protected health information to be used or disclosedRefuse to sign this authorization knowing that you will condition treatment or payment on my providing this authorization (except for research related treatment)I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by HIPAA.Under certain circumstances we may receive compensation from a third party requesting your medical records.Print Patient Name: ____________________________________________________Signature: ____________________________________________________________Georgia Mountain Endocrinology Corporation120 Oakside Court, Suite HCanton, Georgia 30114Phone: (678) 880-8770 * Fax: (770) 213-4418FINANCIAL POLICYIf covered by health insurance, please present a current insurance identification card. Please notify our office if your coverage should change. It is the responsibility of the patient to obtain a referral if needed. All co-payments will be collected at the time of service before your visit with the provider. Deductibles, co-insurance, and any unpaid balance will also be collected at the time of service. As a courtesy to you, we will file your claims for you. For your convenience we accept cash, checks, VISA, Mastercard, and Discover. If your insurance company does not pay your claim, you will be responsible for the balance. If you are a private pay patient, payment in full is expected at the time of service unless prior arrangements have been made. Statements will be sent every thirty (30) days. Unpaid accounts will be sent to an outside collections agency at ninety (90) days. You will also be responsible for a collection fee of 25% of the past due amount. There is a $25.00 fee for returned checks in addition to any charges the bank might make. This charge plus the amount of the check must be sent in the form of cash, money order, or cashiers check. Once a check has been returned , we will be unable to accept checks in the future. Please be prepared to pay with cash or credit card.Charges for copying medical records are based on the charges set forth by the Georgia Office of Planning and Budget pursuant to O.C.G.A. 31-33-3. In order to comply with HIPAA regulations, a signed, written request for medical records must be received along with the payment before records can be released.If you are unable to keep your appointment or need to change it, please call our office at 678-880-8770 at least 24 hours prior to the scheduled appointment to avoid being charged for a “no show.” There is a $50.00 fee for “no shows.” Please remember it is the patient’s responsibility to keep up with scheduled appointments, but as a courtesy we do our best to provide reminder calls two days prior to the scheduled appointment. I have read and understand the above financial policy:Signature: ________________________________________________________ Date: _____________________ MEDICATION LISTNAME: ______________________________________ DOB: ___________________PHARMACY: _________________________________ PHONE: ________________In order for our providers to help you keep current on all your medications, we ask that you please list ALL PRESCRIPTIONS AND OVER THE COUNTER MEDICATIONS (OTC) you are currently taking.Thanks.MEDICATIONDOSEDIRECTIONS FOR TAKINGPRESCRIBED BYOTCALLERGIES:MEDICAL HISTORY QUESTIONNAIRE Date: _______________Patient Name: ______________________________ Date of Birth: _______________Referred By: __________________ Primary Care Physician: ___________________Please state the reason(s) for your visit today:__________________________________________________________________________________________________________________________________________________________________________________________________________________Please list in order of occurrence all previous hospitalizations, serious illnesses, serious injuries, serious accidents, and surgeries. (Please list pregnancies on menstrual history form):Diagnosis Date Location____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Describe the following about your health habitsA. Packs of cigarettes smoked per day/number of years smoked: _________________B. Amount of snuff/chewing tobacco used per day: ____________________________C. Amount of caffeinated soft drinks/coffee/tea per day: ________________________D. Amount and type of alcohol per week: ____________________________________E. Amount and type of recreational drugs used now and in the past (includes marijuana, cocaine, etc): _______________________________________________F. Amount and type of exercise per week: ___________________________________G. Number of hours of sleep on an average night: _____________________________H. Minimum and maximum body weight over the past 10 years (excluding pregnancy): ________________________________________________I. List all blood transfusions and hazardous exposures to chemicals, gasses, radiation, etc: ________________________________________________________________Social HistoryPlace of birth: ________________________ Marital Status: ____________________Number of children and ages: _____________________________________________Highest level of education and completed degrees: ____________________________Occupation: ___________________________________________________________Traveled outside the US in the past 5 years: __________________________________Recent stress or major life change: _________________________________________Family HistoryCONDITIONCheck if yesWhich relative(s)AlcoholismAnemiaBleeding DisorderBreast CancerColon CancerDiabetesHeart DiseaseHigh Blood PressureHigh CholesterolKidney Disease/StonesMental IllnessObesityOsteoporosisStrokeThyroid DiseaseOther:Other:List the following information on your immediate family:Family MemberExisting ProblemCause Of Death If DeceasedAge At DeathFatherMotherBrother(s)Sister(s)Son(s)Daughter(s)IMMUNIZATIONS IN PAST 10 YEARS (APPROXIMATE DATE)ImmunizationReceived immunizationApproximate dateMeasles/MMRTetanus/DPT/DTHepatitis (any)FluPneumoniaOtherCHECK ANY OF THE FOLLOWING SYMPTOMS WHICH HAVE BEEN RECURRING OR CHRONIC. USE THE BLANKS TO CLARIFY DETAILS OF THE SYMPTONS.Abnormal SweatingChest PainAbnormal TasteCold IntoleranceAcneColor BlindnessAllergies/HayfeverConstipationAnxietyCoughArthritisCoughing BloodAsthmaDepressionBack PainDiabetesBlack StoolDiarrheaBloatingDifficulty HearingBlood In StoolDifficulty Sleeping Blood In UrineDifficulty SpeakingBlue Fingers/ToesDouble VisionBlurred VisionEar PainBone FracturesEating DisorderBreast ImplantsEmphysemaBreast EnlargementEnlarged Lymph NodesBreast MilkExcessive BelchingBronchitisExcessive GasBrown UrineExcessive Hair GrowthBruise EasilyExcessive HungerBumps In TesticlesExcessive ThirstChange In AppetiteExcessive UrinationChange In Hair/NailsFatigueChange In Hand SizeFeeling FaintChange In HandwritingFeverChange In SensationsFood IntoleranceChange In Shoe SizeFrequent InfectionsChng In Skin Color/TextureGallbladder DiseaseChange In StoolGerman MeaslesChange In Urinary StreamGoiterChange In VisionGray StoolHair LossHallucinationPenile DischargeHandicappedPeripheral ChangeHeadachesPhlebitisHead/Neck IrradiationPhobiasHeart DiseasePhysical AbuseHeart MurmurPleurisyHeartburnPneumoniaHeat IntolerancePrevious Chest X-RayHepatitisProblems Starting StreamHigh Blood PressureProblems With TeethHigh CalciumProstate CancerHIV PositiveProstatitisHivesPsychiatric TreatmentsImpotenceRashesInflammatory BowelSeizuresItchingSexual AbuseJaundiceShortness Of BreathJoint Pain/StiffnessSleep ApneaJoint SwellingSore Throat/TongueKidney StonesSpastic ColonLack Of Sex DriveStomach PainLactose IntoleranceStrokeLarge ProstateSugar In UrineLeg PainSuicide Attempts/ThoughtsLow CalciumSwellingMeaslesThyroid DiseaseMitral Valve ProlapseTremorMotion SicknessTrouble Losing WeightMuscle CrampsTrouble SwallowingMuscular PainTuberculosisMumpsUlcersNasal CongestionUnable To Have ErectionNauseaUnable To Have OrgasmNegative TB Skin TestUrinary LeakageNight BlindnessUrinary UrgencyNoises In EarsUTI’sNose BleedsUrination At NightNumbness/TinglingVertigoOsteoporosisVomitingPain In TesticlesVomiting BloodPain With UrinationWeaknessPalpitationsWheezingPancreatitisWt Gain >10 lbsParalysisWt Lose > 10 lbs ................
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