Huntsville Memorial Hospital | Walker County Medical Center



Adult New Patient PacketAges: 19 years of age and olderPlease fill out this packet in its entirety. Thank you!If you have any questions, please ask! 21304253937000PATIENT INFORMATION FORMPatient Name:(LAST)(FIRST)(MI)Social Security Number:Date of Birth:Gender: Male Female Permanent Address: StreetCityStateZip CodeMailing Address: Street CityStateZip CodePrimary Language: English Spanish Sign Language OtherMarital Status: Single Married Divorced Legally Separated Life Partner WidowedDay Phone: ( ) Cell Phone: ( )E-mail address:Race: Black/African American White/Caucasian American Indian Other:Ethnicity: Latino or Hispanic Non-Hispanic Unknown Ethnicity GUARANTOR INFORMATIONName of Guarantor/Guardian (if different from patient):Address:Gender: Male FemaleDay Phone: ( ) Cell Phone: ( )SSN:Date of Birth:Relation to Patient: INSURANCE INFORMATIONInsurance Coverage: Self Pay Medicaid Medicare OtherName of policy holder (if different from guarantor):Address:Gender: Male FemaleDay Phone: ( ) Cell Phone: ( )SSN:Date of Birth:Relation to Patient: EMERGENCY CONTACT INFORMATIONEmergency Contact Person:Relation to patient:Phone Number: ( ) CONSENT FOR MEDICAL TREATMENTCONSENT FOR TREATMENT: I, _______________________________, hereby authorize and consent to medications being administrated, diagnostic studies and/or procedures considered necessary of advisable in the judgment of the physician, physician assistant (PA) or nurse practitioner (NP) on duty. I understand that the treatment provided during the published hours of operation and that no responsibility will be taken for long-term patient care.CONSENT TO THE PHYSICIAN ASSISTANT/NURSE PRACTITIONER MEDICAL CARE: HMH Medical Clinic is staffed by physician assistants and nurse practitioner who are supervised and monitored in all medical care delivered by a physician. Where indicated, a physician is available for direct or indirect consultation. The PA or NP is not a doctor but a physician assistant and nurse practitioner and is a certified health care professional who has received training in the provision of medical services. A PA or NP has three or more years of college level training in a health care center of medical school setting. Physician assistants and nurse practitioners are certified by the Texas State Board of Medical Examiners.PAYMENT GUARANTEE: I hereby guarantee that I, the undersigned, will be responsible to the HMH clinic for all charges incurred for services rendered in my medical or surgical care. The total account is due in full at discharge with allowance for charges covered or approved under Medicare Medicaid or the indigent health care plans that are verifiable and assigned to the clinic prior to dismissal.PATIENT’S AUTHORIZATION TO RELEASE INFORMATION AND PAYMENT REQUEST: I certify that the information given by me in applying for payment under the Title XVII of the Social Security Act is correct. I authorize any holder of medical or other information about me to be released to the SSA and/or its intermediaries or carriers for information needed for this or a related Medicare claim. I request that payment of the authorized benefits be made on my behalf.DISCLOSURE OF REQUIRED HIV/AIDS TESTING: Texas law authorizes a hospital or physician to require that a patient be tested for possible exposure to HIV, the virus associated to AIDS, in the following situation: if a donation of blood, blood products, organs or tissues is contemplated,(2) if a health care worker is accidently exposed to a patient’s blood or bodily fluids, such as through a needle stick; or (3) if a medical or surgical procedure is to be performed which could expose health care workers to the patient’s blood or fluids. This disclosure is to inform you that you will be tested if any of these situations occur.The undersigned certifies that he/she has read and expressed understanding of this document by the signature below, does hereby agree to be attended, treated, and followed by a physician assistant.PATIENT NAME: _______________________________________________SIGNATURE: __________________________________________________PATIENT REPRESENTATIVE NAME: ____________________________________SIGNATURE: __________________________________________________RELATION: ________________________________ DATE/TIME OF SIGNATURE: ______________________________220980019050000AUTHORIZATION TO DISCLOSE INFORMATIONHealth Insurance Portability and Accountability Act of 1996(HIPAA)I, _________________________ give my authorization to release my protected health information including results of my laboratory tests, x-ray, and/ or other test results to the following designated representative(s): PLEASE INITIAL (Patient or Legal Guardian) _____ My Spouse (Name) ________________________________________________________ _____ My Child (Name) _________________________________________________________ _____ Other (Name) ____________________________________________________________ _____ Personal Representative (Name) ______________________________________________ _____ May be left on my home answering machine (Phone #) ___________________________ _____ May be left on my work answering machine (Phone #) ____________________________ _____ May be left on my cell phone (Phone #) ________________________________________ _____ Other (Specify) ___________________________________________________________ _____ MAY NOT BE GIVEN TO ANYONE OTHER THAN MYSELF Patient Name________________________________________ Patient Signature _____________________________________ Date: ____/____/____ HEALTH CARE INFORMATION MEANS ANY INFORMATION RECORDED IN ANY FORM OR MEDIUM THAT IDENTIFIES THE PATIENT AND RELATES TO THE PATIENT’S HISTORY, DIAGNOSIS, TREATMENT OR PROGNOSIS. IT IS KNOWN COMMONLY AS YOUR MEDICAL RECORD. NOTE: THE TEXAS LAW AUTHORIZES THE RELEASE OF MEDICAL INFORMATION WITHOUT THE AUTHORIZATION OF THE PATIENT IN A NUMBER OF SITUATIONS INCLUDING BUT NOT LIMITED TO INSURANCE COMPANIES IF THE DISCLOSURE IS TO REIMBURSE THE HEALTH CARE PROVIDERS OR THE PATIENT FOR MEDICAL SERVICES OR SUPPLIES.262255016637000Fair Patient Billing Act concerning Out-of-Network ProvidersHuntsville Memorial Hospital, in compliance with the “Fair Patient Billing Act” concerning out-of-network providers, would like to notify the patients of the following:You may receive separate bills for services provided by healthcare professionals affiliated with HMH.Some healthcare professionals may not be participating providers in the same insurance plans and networks as HMHYou may have greater financial responsibility for services provided by healthcare professionals at HMH who are not under contract with your healthcare planYou should direct questions about coverage or benefit levels to your healthcare plan and certificate of coverage.Itemized bills are available upon request.If you are uninsured, you may be eligible for financial assistance under the terms and conditions the hospital offers to qualified patients.If you would like to ask questions, dispute your account, request an itemized statement, need assistance in making arrangements or need to speak with a patient financial services representative, please call (936)291-4500.With my signature, I understand that I am responsible for any charges that may be incurred, that are applied toward my deductibles or are considered out-of-pocket expenses, such as out-of-network bills or co-pays. SIGNATURE DATE/TIME201930045720000HMH Medical ClinicSelf-Pay Agreement FormPatient Name: ___________________________________________ DOB: _________________Welcome to the HMH Medical Clinic, where our staff is committed to providing you with quality medical services.The following is a statement of our self-pay financial policy, which we require you to read and sign prior to receiving services. Please be aware as a new patient, your office visit will range from $54 to $150. Established patient charges range from $32 to $105. Charges are based on the complexity and duration of your visit. In addition to the office visit charge, there may be additional charges for in-office testing, immunizations, etc.______At time of registration, you are required to pay the minimum as noted above. If any other charges incur during the visit, you are responsible to pay the remaining balance at check out. I have read and fully understand the Self-Pay Agreement form as outlined above. In the event it is necessary to turn my account over to collections, I have been made aware that I am completely responsible for any and all costs associated with the collections process.By signing this form, I understand I am financially liable for all services provided to me, my dependents or any other person for which I have assumed responsibility. Print Patient Name/Responsible Party Name Patient/Responsible Party Signature HMH Employee Signature Date/Time of Agreement205740051308000ADVANCE DIRECTIVE ACKNOWLEDGEMENTThis hospital is required by federal law to provide written information to you about your rights under state law to make decisions about medical care and the right to execute advance directives.I have been given written materials about my right to accept or refuse medical treatments.I have been informed of my rights to formulate advance directives such as a living will.I will understand that I am not required to have an advanced directive to receive medical treatment from Huntsville Memorial Hospital.I understand that the terms of my advance health directive may only be followed by Huntsville Memorial Hospital and my health care professional to the extent permitted by law.Please check the following statements as appropriate:______I have executed an advance directive______I have not executed an advance directive______I have made a durable power of attorney for my health care decisions and my health care agent is: ________________________________.______I have not made a durable power of attorney for health care decisions.I have received the information handout about advance directivesName: ____________________________________ Date/Time:____________________Signature: _________________________________Relations:____________________Preferred Pharmacy Name City Phone Number Fax NumberMedication or Food Allergies ReactionPlease list your current prescription medications and/or over the counter medications or vitamins:Name of Medication/Herbal Medication Dosage How often?Vaccine HistoryVACCINE NAME Date GivenTdAP/TDPNEUMOCOCCALVARIACELLAINFLUENZAHEPATITIS BFAMILY HISTORYRELATIVE TYPE PROBLEM AGE OF ONSET ALIVE/DECEASED?SOCIAL HISTORY **Please circle/answer all that applies to you**Smoking Status - Current Former Never If you are a current smoker, how much per day?How many years have you used tobacco?If you are not a smoker, are you exposed to second-hand smoke? YES NODo you live alone or with others? Alone With OthersDo you have an advance directive? YES NOWhat is your level of education?What is your occupation?Number of Children?Are guns present in the home? YES NOWhat is your alcohol intake? NONE OCCASIONAL MODERATE HEAVYWhat is your caffeine intake? NONE OCCASIONAL MODERATE HEAVYDo you use any of the following drugs? MAJIUANA COCAINE METHAMPHETAMINES HEROIN PRESCRIPTION PILL ABUSE SYNTHETIC MARIJUANA PCP LSDWhat is your level of exercise? NONE OCCASIONAL MODERATE HEAVY How many times a week do you exercise?Are you hard of hearing in one or both of your ears? YES NOAre you legally blind in one or both of your eyes? YES NOSEXUAL HISTORYAre you sexually active? YES NOMale or Female partner?Do you use protection? ALWAYS USUALLY NO Current Number of Female Partners: ________Current Number of Male Partners: _________Do you have history of STDs? YES NOIf yes, were you previously treated? YES NODo you have a current concern for STDs? YES NOHave any of your partners recently told you that they had an STD? YES NOSURGICAL HISTORYSURGERY TYPE DATE/YEAR HOSPITAL PERFORMING DOCTOR Are you under the care of any other physician or specialist? YES NOIf yes, please list physician/specialist name and phone number below:Please list the date of the most recent below:PAP SMEAR________ Last Menstrual Period______________ Colonoscopy_____________PSA Test____________ DEXA Bone Scan ____________ MammogramEGD________________ U/S of Abdominal Aorta____________Number of Pregnancies? Carried to term?______________Premature deliveries?Miscarriages?Abortions? PAST MEDICAL HISTORY*** Please circle any of the following that you have been diagnosed with by a medical provider***ADD/ADHD DIVERTICULITISOVARIAN CANCERABUSE/DOMESTIC VIOLENCE HEARING PROBLEMSPOLYPSANEMIA EATING DISORDERPULMONARY EMBOLISMANXIETY DISORDER ECZEMA/SKIN PROBLEMSREFLUX/GERDARTHRITIS ENDOMETRIOSISSEIZURES/EPILEPSYASTHMA FIBROMYALGIASTROKEAUTISM SPECTRUM DISORDER GI PROBLEMSTHROMBOPHLIBITISBIRTH DEFECTS OR INHERITED DISEASE GOUTTUBERCULOSISBLADDER OR KIDNEY PROBLEMS HEADACHESBLOOD DISEASE HEART DISEASEBLOOD TRANSFUSION HEPATITISBREAST CANCER HIGH CHOLESTEROLCANCER HOSPITALIZATIONSCHICKEN POX HYPERTENSIONCHRONIC EAR INFECTIONS HYPERTHYROIDISMCONSTIPATION KIDNEY DISEASECORONARY ARTERY DISEASE KIDNEY STONESDEPRESSION LIVER DISEASEDEVELOPMENTAL/BEHAVIOR DISORDER LUNG DISEASEDIABETES MENIERE’S DISEASEDIFFICULTY SWALLOWING OSTEOPOROSISHepatitis C Personal Risk AssessmentThe following questions may help you and your provider to assess your risk for being infected with hepatitis C.? Answer only the questions that apply.Any health information that is provided by you as part of your participation in this screening will not be used in any way that could identify you. All information is used in screening only. For additional information, please see our?HIPAA Privacy Statement.How many blood transfusions have you had?Many groups of people have statistically higherleft571500Prior to 1990? (1)risks of infection (some of these for unknownleft825500 Between 1990 and 1993? (1)reasons). Please select all that apply:left762000 Since 1993? (1) I have served in the military. (2) I served in the Vietnam War. (4)I.V. Drug use represents an important risk factorfor Hepatitis C. I am a healthcare or emergency worker that I have never tried I. V. drugs. (0) comes into contact with blood. (2) I have tried I. V. drugs. (3) I have had direct exposure to blood (needle I have tried I.V. drugs for less than 6 months. (4) stick injury or other injury). (3) I have tried I.V. drugs for more than 6 months. (5) I have been mucosally exposed to blood (2) (splash to eyes, nose or mucous membranes)Tattooing and body piercing has been shown Someone in my household has Hepatitis C. (1)to transmit Hepatitis C. I have tattoos or body piercings. (1) I had a cesearean section prior to 1990 (you may have unknowingly been given a blood Sexual activity can represent a limited risk for transfusion). (2)transmitting Hepatitis C. Select all that apply. My mother contracted Hepatitis C before I I have multiple sex partners. (2) was born. (3) My sexual partner or I have been diagnosed or I was ill as a newborn. (2) Treated for a STD/STI. (2) My sexual partner has Hepatitis C. (2) I am an alcoholic. (3) My sexual partner is in a high risk group for I have AIDS. (3) Hepatitis C. (2) I have Hepatitis B. (3) I have been in prison. (5)Blood Transfusions:Prior to 1990 - Prior to 1990, there were no tests for hepatitis C made against donated blood. The risks of infection from blood transfusion are estimated to have been between 8 and 10%. If you received a blood transfusion prior to 1990, you are at a low risk and should probably be tested for hepatitis C. Between 1990 – 1993 - Between 1990 -1993, the introduction of the first tests for hepatitis C significantly lowered the risk of infection from blood transfusions. However, it is estimated that the risk of infection was still around 5%. If you received a blood transfusion during this period, you are at a low risk and should discuss being tested with your physician.Since 1993 - Since 1993, the risks of infection from blood transfusion have been negligible, due to the introduction of more reliable testing in donated blood. However, the risk of infection does increase with the frequency of transfusions. If you feel yourself at risk, you are at a low risk and should discuss being tested with your physician.IV Drug Use: I.V. drug use is the single most significant risk factor for hepatitis C. Studies have shown that 80% of I.V. drug users contract hepatitis C between six months to a year of using I.V. drugsI have tried IV drugs – If you have used these drugs, you are at a high risk and should discuss being tested for hepatitis C with your provider.I have tried IV drugs for less than 6 months - If you have used these drugs, you are at a dangerously high risk and should discuss being tested for hepatitis C with your provider.I have tried IV drugs for more than 6 months - If you have used these drugs, you are at a critically high risk and should discuss being tested for hepatitis C with your provider.Tattooing and body piercing:I have tattoos or body piercings – Tattooing and body piercing has been shown to transmit hepatitis C, you are at a low risk and should discuss being tested for hepatitis C with your provider.Sexual activity: Sexual activity can represent a limited risk for transmitting hepatitis C.I have multiple sexual partners – you are at a medium risk and should discuss being tested for hepatitis C with your provider.My sexual partner or I have been diagnosed or treated for an STI/STD - you are at a medium risk and should discuss being tested for hepatitis C with your provider.My sexual partner has hepatitis C - you are at a medium risk and should discuss being tested for hepatitis C with your provider.My sexual partner is in a high-risk group for hepatitis C - Sexual activity can represent a limited risk for transmitting hepatitis C, you are at a medium risk and should discuss being tested for hepatitis C with your provider.Other High Risk Groups:I have served in the military - Service in the military places you at a statistically higher risk of infection, mostly due to the increased risks of exposure to blood. You are at a medium risk and should discuss being tested for hepatitis C with your provider.I served in the Vietnam War - Vietnam veterans are at particularly high risk. During the Vietnam War, blood donations were regularly accepted from I.V. drug addicts to fill the enormous shortages of blood during the war. Some studies have suggested that more than 80% of these donors may have been infected. You are at a dangerously high risk and should discuss being tested for hepatitis C with your provider.I am a healthcare or emergency worker who comes into contact with blood - Virtually any type of exposure to blood (and direct exposures to some body fluids) can transmit hepatitis C. You are at a medium risk and should discuss being tested for hepatitis C with your provider.I have had a direct exposure (needle-stick) to blood - Virtually any type of exposure to blood (and direct exposures to some body fluids) can transmit hepatitis C. You are at a high risk and should discuss being tested for hepatitis C with your provider.I have been mucosally exposed to blood - Virtually any type of exposure to blood (and direct exposures to some body fluids) can transmit hepatitis C. You are at a medium risk and should discuss being tested for hepatitis C with your provider.Someone in my household has hepatitis C - Virtually any type of exposure to blood (and direct exposures to some body fluids) can transmit hepatitis C. You are at a low risk and should discuss being tested for hepatitis C with your provider.I had a cesearean section prior to 1990 – women who received cesearean section are at a medium risk and should discuss being tested for hepatitis C with your provider.My mother contracted hepatitis C before I was born – newborns born to mothers who had hepatitis C are at a high risk and should discuss being tested for hepatitis C with your provider.I was ill as a newborn – newborns who were seriously ill are at a medium risk and should discuss being tested for hepatitis C with your provider.I am an alcoholic – Certain diseases increase risk, you are at a high risk and should discuss being tested for hepatitis C with your provider.I have AIDS - Certain diseases increase risk, you are at a high risk and should discuss being tested for hepatitis C with your provider.I have hepatitis B - Certain diseases increase risk, you are at a high risk and should discuss being tested for hepatitis C with your provider. ................
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