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PRE-VISIT AND CHANGE OF INFORMATION (PRINTABLE VERSION)Today’s Date: PCP: PATIENT INFORMATIONLast Name: First Name: Middle Name: Legal Name? ? Yes ? NoIf No, your legal Name: DOB: Age: Sex: ? M ? F ? OtherEmail: Address (Street/P.O. Box, City, Zip Code): SSN (optional): Primary Phone: Mobile Phone: Marital Status: ? Single ? Married ? Divorced ? WidowedOccupation: Employer: Employer Phone #: Tricare for Life? Service Member Name: DOB: Service Member SSN: Communication Preference: ? Mobile ? Email Permission to text or email? ? Yes ? NoPreferred Pharmacy: Address: Pharmacy Phone #: Pharmacy Fax #: Family members seen here: Relationship: How did you hear about us? ? Family ? Friend ? Web/Map Search ? Work ? Other INSURANCE INFORMATION (if same enter “same”)Person responsible for bill: DOB: Address: Phone #: Is this person also a patient? ? Yes ? No Covered by Insurance? ? ? Yes ? NoEmployer: Employer Phone #: Primary Insurance: Other Insurance: Subscriber Name: Subscriber Member #: Subscriber DOB: Group #: Policy #: Co-pay: Patient Relationship: ? Self ? Spouse ? Child ? OtherSecondary Insurance (if applicable): Subscriber Name: Subscriber Member #: Subscriber DOB: Group #: Policy #: Co-pay: Patient Relationship: ? Self ? Spouse ? Child ? OtherPATIENT EMERGENCY CONTACT INFORMATION AND SIGNATURE PAGEName of friend or relative (not living at same address): Relationship to patient: Primary contact number: Secondary contact number: The above patient, insurance and emergency contact 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 Lagniappe Medical Clinics, LLC or insurance company to release any information required to process my claims.Patient/Guardian Signature Date: Patient-Provider Partnership AgreementThe health and wellness of our patients is a top concern of Lagniappe Medical team.Providing the best possible care to every patient is our primary goal. The only way we can meet this goal is if we, Physician HealthCare Network and you, the patient, work together. This concept is called the Patient Centered Medical Home.Patient's Responsibilities:Ask questions, share your feelings and be part of your careBe honest about your history, symptoms, and other important information about your healthTell your provider about any changes in your health and well-beingFollow your provider's instructions, including taking your medication(s) as directedMake healthy decisions about your daily habits and lifestylePrepare for and keep scheduled visits or reschedule visit in advance whenever possibleCall your provider first with all problems, unless it is a medical emergencyLeave every visit with a clear understanding of your provider's expectations, treatment goals, and future plansFor coordination of care purposes, you authorize your provider to exchange your medical information (written or electronic), when appropriate, with other providers involved in your care (i.e. admissions, discharges and transferred to/from hospital-based care settings, specialist referrals or any other healthcare encounters outside of your provider's office.)Provider's Responsibilities:Explain diseases, treatments, and results in an easy-to-understand wayListen to your feelings and questions; help you make the best decisions about your careKeep treatments, discussions, and records privateTo care for you to the best of my abilities based on my understanding of current medical methods availableGive my patients clear directions about medications and other treatmentsSend my patients (along with appropriate medical information) to trusted experts, when needed ? End every visit with clear instructions about expectations, treatment goals, and future plansPrescriptions, Phone Messages, and Late ArrivalsPlease bring all prescriptions and over the counter medications including herbals and supplements to your visits.Our clinical staff will return all messages left by the end of the day. Please allow 24 hours for call-in refills and check with your pharmacy first.If you are more than 15 minutes late for your scheduled appointment, we may need to reschedule. Providing the highest quality of professional care to each of our patients is very important to us.Patient/Guardian Signature:Date: Patient Financial Responsibility PolicyWe are pleased to participate in your health care and look forward to establishing a lasting relationship as your health care provider. As part of this relationship, we have outlined our expectations for your financial responsibility in our Patient Financial Responsibility Policy.Please read this document thoroughly.Address Change: It is important that we have your correct address information on file. Please advise us anytime there is any change to your address, telephone or other contact information. We mail out lab results, pathology and appointment information in addition to billing statements.Co-payments, Deductibles and Co-Insurance: Co-payments are collected at the time of check-in.Insurance deductibles: and fees for services not covered by your insurance policy, if known, are due at the time the service is rendered. We accept cash, check and most major credit cards.Billing: If you owe additional money after your visit, you can expect to receive a statement. Statements are mailed out on a monthly basis. Payment is expected within 10 days of receipt of your statement.Failure to Pay: Patients who ignore collection notices and fail to pay their balance risk negative credit ratings and possible dismissal from the practice. Past Due accounts may hinder your ability to have appointments scheduled. Should your account balance become uncollectible or if you file bankruptcy, we will continue to see you on an emergency basis only for 30 days, giving you time to find a new source of medical care.Fees Returned checks are subject to a $25 fee and your account will be placed on a "cash-only basis." We will accept payments only by cash or credit card until the balance is cleared.There is an administrative fee for completing forms such as DMV, physical forms, FMLA, leave of absence, disability etc. Most forms require 5 to 7 working days to research your information and complete the form.Guarantor Any patient over the age of 1 8, or an emancipated minor, will be held financially responsible for all charges incurred. If another party is responsible for payment of your account, you must pay your balance in full and negotiate repayment with them outside of our office. This policy includes individuals negotiating divorce agreements.Insurance It is important for you to be an informed consumer, who understands the specifications of your insurance policy (e.g., vaccine and doctor visit coverage, referral/authorization requirements for specialty care, radiographs, laboratory tests, urgent care facility care). Your health insurance policy is a contract between you and your Health Insurance Company or employer. You must present a current insurance card at each visit. As a courtesy to you, we will bill your insurance company directly for medical services rendered. If problems arise regarding coverage issues, we will attempt to work with your insurance company to help resolve them prior to making it your responsibility. However, please be advised that you are nevertheless ultimately financially responsible for payment of medical services rendered. If you do not present a current insurance card, you will be responsible for payment at the time of your visit. If your insurance carrier is not one with which we participate, you are responsible for payment in full. Insurance plans and Medicare consider some services to be "noncovered," in which case you are responsible for payment in full. You have a responsibility to provide information to our office so a claim can be properly submitted. If your insurance company has not paid a claim on your behalf within 90 days, the balance will be transferred to your account and you will be responsible for payment. If we receive payment at a later date, you will be reimbursed. If you are uncertain about your current health insurance policy benefits you should contact your plan to learn the details about your benefits, out-of-pocket fees and coverage limits. Lagniappe Medical contacts with many insurance plans.Before your appointment, please be sure your doctor is in-network and the services are covered under your plan. If your doctor is out of-network, you will be billed for the cost of care. The information about your plan that we relay to you is in good faith.Medicare Patients: Medicare may not cover some of the services that your doctor recommends. You will be informed ahead of time and given an Advanced Beneficiary Notice (ABN) to read and sign. The ABN will help you decide whether you want to receive services, knowing you are responsible for payment. You must read the ABN carefully.Minors and Dependents: Parent and guardians are responsible for payments for their dependents at the time services are rendered. Minors and dependents must present a valid insurance card at each visit if a claim is to be filed. The accompanying parent or adult is responsible for full payment at the time of service. In case of divorce, please do not place our office in the middle of marital disputes. It is your responsibility to work out the payment of your child's medical care between the custodial and noncustodial parent.Non-Emergency Appointments: Outstanding balances or failure to pay co-payments upon check-in may result in physicals and other routine or screening appointments being rescheduled.Prompt Payment: Just as we make every effort to accommodate you when you are in need to medical care, we expect that you will make every effort to pay your bill promptly. Payment is due at the time services are provided or upon receipt of a statement from our billing office.Referrals and Authorizations: Please be aware of and provide any required referrals or authorizations in advance of the appointment of service. If you do not provide these before care is provided, you will be responsible for the cost of the care. When in doubt contact your plan directly for clarification.Refunds: A refund is issued when an overpayment has been identified. If you feel a refund is due, please contact our office.Self-Pay Patients: Self-pay patients should be prepared to pay at the time of each visit.Worker's Compensation: The patient must provide at time of service: a claim number, name of the carrier, the date of injury, employer at time of injury and name and number of the claim adjuster. Without this information, the patient will be held responsible for all charges, and payment will be collected at time of service.Cancellations: If you are scheduled for a yearly physical and miss your pre-physical testing (labs, x-rays, ultrasounds) your physical will need to be rescheduled. Lagniappe has a 24-hour cancellation policy for all office visits. If you do not give a 24-hour notice for an appointment to be cancelled, you will be charged a $25 administrative fee. This time is needed so that patients waiting for appointments can be contacted and scheduled appropriately.Printed Name of Patient: Patient/Guardian Signature:Date: Acknowledgement: Receipt of Notice of Privacy PracticesI have received a copy of Lagniappe Medical Center’s Notice of Privacy Practices effective December 1, 2019.Name (please print): Signature: Date: I am a parent or legal guardian of (Patient Name). I have received a copy of Lagniappe Medical Centers Notice of Privacy Practices effective October, 2019.Parent or Guardian Name (please print): Signature: Date: Your Protected Health Information Designees: If you are not available at the time that we call, please list below those individuals (designees) with whom we can leave a message or briefly discuss your medical information (e.g. lab or test results, prescription information). This person (designee) will also be able to call the office on your behalf. Please print the name and relationship to you/patient of each designee below:NamePhone numberRelationship? Check here if you do not want your health care information discussed with anyone other than yourself.Confidential Voice Mail: Please check below where we have your permission to leave a confidential voice mail (e.g. lab or test results, prescription information). ? Home Phone? Cell Phone? Emergency Phone(Leave blank if you do not wish to receive voice mails)For Office use only;If the individual or parent/legal guardian did not sign above, staff must document when and how the Notice was given to the individual, why the acknowledgment could not be obtained, and the efforts that were made to obtain it.The following good faith efforts were made to obtain the individual or parent/legal guardian's signature. Please document with dates, times, individuals spoken to, and outcome, as applicable, the efforts that were made to obtain the signature. More than one attempt must be made. Reason individual or parent/legal guardian did not sign this form:? Did not want to ? Did not respond after more than one attempt ? Other: Notice of Privacy Practices effective 10/1/19 given to individual on (Today)? In Person ? Mail ? Email ? Other Staff Name: Title: Date: HEALTH HISTORY QUESTIONNAIREUse Name/DOB/Gender/Marital Status responses from previous pages? ? YesIf No please fill in the following:Last Name: First Name: Middle: DOB: Gender: ? Male ? Female ? OtherMarital Status: ? Single ? Married ? Divorced ? Separated ? Partnered ? WidowedPrevious or Referring Physician: Date of Last Physical Exam:PERSONAL HEALTH HISTORYChildhood Illness: ? Measles ? Mumps ? Rubella ? Chicken Pox ? Rheumatic Fever ? PolioImmunizations and dates: ? Tetanus (Date) ? Pneumonia (Date) ? Hepatitis (Date) ? Chickenpox (Date) ? Influenza (Date) ? MMR (Date) (measles, mumps, rubella)List any other medical problems that other physicians have diagnosed:SurgeriesYearReasonHospitalOther HospitalizationsYearReasonHospitalHave you ever had a blood transfusion? ? Yes? NoList your prescribed and over-the-counter drugs (such as vitamins and inhalers)Name of DrugStrength or DosageFrequency TakenAllergies to MedicationsName of DrugReaction You HadHEALTH HABITS AND PERSONAL SAFETYThe Following Questions Are Optional and Will Be Kept Strictly ConfidentialAlcoholDo you drink alcohol? ? Yes ? NoIf yes, what kind? How many drinks per week? Are you concerned about the amount you drink? ? Yes ? NoHave you considered stopping? ? Yes? NoHave you ever experienced blackouts? ? Yes? NoAre you prone to binge drinking? ? Yes? No Do you drive after drinking? ? Yes? No TobaccoDo you use Tobacco? ? Yes? No?Cigarettes – pack/day? Chew - #/day? Pipe - #/day? Cigars - #/ day? # of Years? Year Quit DrugsDo you use recreational or street drugs?? Yes? NoHave you ever give yourself street drugs with a needle?? Yes? NoSexAre you sexually active?? Yes? NoIf yes, are you trying for a pregnancy?? Yes? NoIf not trying for a pregnancy list contraceptive or barrier method used:Any discomfort with intercourse? ? Yes? NoIllness related to 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 to speak to your provider about your risk of this illness?? Yes? NoPersonal SafetyDo you live alone?? Yes? NoDo you have frequent falls?? Yes? NoDo you have vision or hearing loss?? Yes? NoDo you have an Advance Directive and/or Living Will?? Yes? NoWould you like information on the preparation of these? ? Yes? NoPhysical 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. . Would you like to discuss this issue with your provider? ? Yes? NoFAMILY HEALTH HISTORYMemberAgeSexSignificant Health ProblemsFatherMotherChild #1? M ? FChild #2? M ? FChild #3? M ? FChild #4? M ? FSibling #1? M ? FSibling #2? M ? FSibling #3? M ? FSibling #4? M ? FSibling #5? M ? FGrandmother (Maternal)Grandfather (Maternal)Grandmother (Paternal)Grandfather (Paternal)WOMEN ONLYDataYesNoAge at onset of menstruation?Date of last menstruation?Frequency of periods (# of days)Heavy periods, irregularity, spotting, pain or discharge???Number of pregnancies?Number of live births?Are you pregnant or breastfeeding???Have you had a D&C, hysterectomy, or Cesarean???Any urinary tract, bladder, or kidney infections within the last year???Any blood in your urine???Any problems with control of urination???Any hot flashes or sweating at night???Do you have menstrual tension, paid, bloating, irritability, or other symptoms at or around the time of period???Experienced any recent breast tenderness, lumps or nipple discharge???Date of last pap and rectal exam?MEN ONLYDataYesNoDo you usually get up during the night to urinate???If yes, # of timesDo you feel pain or burning with urination???Any blood in your urine???Do you feel burning discharge from penis???Have you had any kidney, bladder or prostate infections in the last 12 months???Do you have any problems emptying your bladder completely???Any difficulty with erection or ejaculation???Any testicle pain or swelling???Date of last prostate and rectal exam?OTHER PROBLEMSCheck if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.? Skin? Chest/Heart? Recent Changes in:? Head/Neck? Back? Weight? Ears? Intestinal? Energy Level? Nose? Bladder? Ability to Sleep? Throat? Bowel? Other Pain/Discomfort:? Lungs? CirculationEPWORTH SLEEPINESS SCALEHow likely are you to doze off or fall asleep in the following situations? (In contrast to just feeling tired ). Use the following scale to rate your chance of dozing.SituationsChance of Dozing: 0 = Never, 1 = Slight Chance, 2 = Moderate Chance, 3 = High Chance0123Sitting and reading????Watching TV????Sitting, inactive, in a public place????As a passenger in a car for an hour????Lying down in the afternoon????Sitting and talking to someone????Sitting quietly after lunch without alcohol????In a car, stopped for a few minutes in traffic????TOTAL SCOREGAD-7Over the last 2 weeks have you been bothered by any of the following problems?Not at All0Several days1More than half the days2Nearly every day3Feeling nervous, anxious or on edge????NOT being to stop or control worrying????Worrying too much about different things????Trouble relaxing????Being so restless that it’s hard to sit still????Becoming easily annoyed or irritable????Feeling afraid as if something awful might happen????A12 – GAD7 TOTAL SCOREIAPT Phobia ScalesChoose a number from the scale below to show how much you would avoid each of the situations or objects listed below. Then write the number in the box opposite the situation.012345678Would not avoid itSlightly avoid itDefinitely avoid itMarkedly avoid itAlways avoid itA17Social situations due to a fear of being embarrassed or making a fool of myselfA18Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting, or dizziness)A!(Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying)COPD screening questionsQuestionsYesNoHave you been coughing a lot and producing thick mucus (sputum) coughed up from your lungs???Have you had shortness of breath???Have you heard wheezing from your lungs when you breathe???Do you smoke cigarettes or did you smoke cigarettes in the past???If no to #4, did you live with someone who smokes cigarettes???Does anyone in your family have asthma and/or allergies???In your work, have you been exposed to dust or chemicals that you often breathed in???Have you often been exposed to smoke from cooking fires inside of your house??? ................
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