IF YES, CHECK THE BOX for YOURSELF or FAMILY MEMBER …



Thank you for choosing Magnolia Family Medicine (MFM) – we do our best to provide quality healthcare to you, your friends and family members, because we love to grow by referrals – you’ve joined our healthcare family and we do consider it to be a family!First Name: ___________________________ Middle Name: _____________________ Last Name: ___________________________ Street Address: _______________________________________________________________________________________________City, State, ZIP: _______________________________________________________________________Marital Status: ____________PO Box Address (if applicable, we need both) ________________________________________________________________________Home Phone #__________________________ Work #_________________________ Cell phone #__________________________ What # should we call first? ______________ Social Security #__________________________ Date of Birth ____________________E-MAIL address for Lab Portal notifications: _________________________________________________________________________Employer Name & Address: ______________________________________________________________________________________CIRCLE how you heard about us? Specialist Existing patient Website Family Friend Insurance Other ___________Emergency Contact: NAME & RELATIONSHIP ______________________________________ Phone #__________________________Who else can we call? NAME & RELATIONSHIP ______________________________________ Phone #_________________________→ Can we leave your LAB RESULTS on your answering machine? (Circle) YES NO Only if they are normal→ WHO are we AUTHORIZED to SPEAK to regarding your labs and medical information/Relationship: No one but meName(s)______________________________________________________________________ RELATION:_________________Name(s)______________________________________________________________________ RELATION:_________________→ Please CIRCLE: I DO / DO NOT give permission to Magnolia Family Medicine (MFM) to link my key medical information to a single, secure electronic patient health record on North Carolina’s Health Information Exchange (NCHIE) system, NC HealthConnex. This mandatory provider participation system was created so providers can share health records across the state to improve patient care. If you choose not to participate, we will provide you with the form you need to mail to the NCHIE to register your response per their requirement.BILLING POLICIES – READ THIS CAREFULLY – YOU’LL WANT TO KNOWMISSED APPOINTMENTS/ LATE CANCELLATIONS Often, we must turn patients away who need medical attention; therefore, in fairness, fees will apply if you do not give us 24 hours notice – this includes SAME DAY Cancels/Reschedules. Providing advance notice of appointment changes allows Dr. Gutsin to see another patient that needs help. Our team is happy to find a better time for you so that all patients get the care they need. Thank you for agreeing to this very important policy.FEES: 1st $25, 2nd $50, 3rd $75 Per the physician’s discretion, you may be discharged due to appointment non-compliance. A $50 fee applies for double appointments and multiple cancellations ex: Health Assessments, procedures. Today’s payment Covers the time you spend with Dr. Gutsin and also takes into account the complexity of your medical conditions, as well as reviewing and potentially changing your medical regimen, writing prescriptions, ordering and reviewing your labs, arranging and managing care coordination with other physicians when necessary, reviewing x rays, prior authorizations, documentation done by the nurse and physician, etc. There’s a lot that goes on behind the scenes!After Hour Phone Calls If a medical issue needs to be handled over the phone, you or your Insurance company may be billed. Returned Check Fees If your check is dishonored, you'll be charged a $35 fee and will be required to pay by cash or CC in futureForm Charges Additional fees ($20 - $50) apply for all FMLA, Work and other forms that may not be listed here.Mail Charges Due to rising costs, $1.00 will be assessed for mailing labs, reports, and paperwork, etc. The patient portal is Free!Administrative Fees You may be responsible to pay a $10 admin fee if you do not present the correct information--(insurance, prescription coverage, etc.) at the time of service. Page 1 of 2 Magnolia Family Medicine Richard A. Gutsin, D.O. Phone: 910-796-3212 Fax : 910-796-3216 TODAY’S DATE: ___________ THE FINANCIAL STUFF: All co-payments, deductibles etc. are due AT THE TIME OF SERVICE – THAT MEANS TODAY!We file insurance on your behalf. If we do not participate, payment is due in full today and we will still file for you if able. We have copies of insurance company fee schedules, so we know what we can collect. If your insurance company says you owe more than we collected, we’ll send you the bill. We take credit cards over the phone, or you can mail in a check. Payment is due when you are notified. If you have any questions or problems – PLEASE ASK NOW!CIRCLE YOUR INSURANCE – YOU MAY HAVE MORE THAN ONE: AETNA CIGNA UNITED HEALTHCARE PPC PHCS BCBS NC BLUE VALUE BCBS TEACHERS BCBS OUT OF STATE MEDCOST TRICARE PRIME TRICARE STANDARD MEDICARE AETNAMEDICARE BCBSMEDICARE HUMANA UHCMEDICARE FIRSTMEDICARESECONDARY: _______________________________________ OTHER: ______________________________________We file to primary & secondary ins only. We provide the papers you need to file to your tertiary ins. (3rd) for reimbursement. POLICY HOLDER INFORMATION Do not complete if YOU are the policy holderCIRCLE RELATIONSHIP TO INSURED: SELF SPOUSE CHILD OTHER/Specify _______________________INSURED INFO: First Name_____________________ Middle Name________________ Last Name________________________Their birthday: ___________ Social Security # of insured, if known: __________________ Their phone #:__________________Their Race: Caucasian Black Asian Other ____________ Their Ethnicity: Hispanic Non-Hispanic DeclineStreet Address: __________________________________________ City, State, ZIP: __________________________________If known, Employer name & address of policy holder: ____________________________________ Phone #:________________* ALL PATIENTS NEED TO COMPLETE SECTION BELOW IN CASE YOUR INSURANCE STATUS CHANGES -- LOSE OR OBTAIN *↙ PLEASE INITIAL THAT YOU UNDERSTAND AND AGREE TO ALL THESE POLICIES:→_____A. As a Self-Pay Patient, I agree to pay ALL charges in full at the time of service and will not accrue a balance due.B. If I think I have insurance coverage and it turns out that I don’t, I will pay ALL charges upon notification →_____Balances NOT paid by insurance or that are assigned by your insurance company to you –YOU OWE. Contact your insurance company to verify your medical benefits, co-pays, deductibles, etc, to prevent any surprise bills. →_____ I understand my PAYMENT IS DUE UPON NOTIFICATION - the service has already been provided. You’ve signed a contract with your insurance company stating that you will pay. We’ve signed one saying that we accept your plan and will collect payment when assigned to you. We won’t break our contract – period. →_____ I agree to the billing policies, including the missed/cancellation policy as stated on these forms.SIGNATURE ON FILE - Signature indicates that you have reviewed and approve of the following written policies: I authorize Magnolia Family Medicine to file all insurance submissions on my behalf.I authorize payment to be made from my insurance company directly to Magnolia Family Medicine. I authorize release of my billing and medical information to my insurance carrier at my or their request.I authorize Dr. Gutsin and his staff to act as my agent in helping to obtain payment from my insurance company.I understand that if I wind up not having insurance (despite the fact I think I do) I will still pay my bill by cash or CC.I UNDERSTAND IT’S MY RESPONSBILITY TO INFORM THE STAFF OF ANY INSURANCE CHANGES AND WILL DO SO IMMEDIATELY.I UNDERSTAND THAT ULTIMATELY, I AM RESPONSIBLE FOR MY BILLS AND WILL PAY UPON NOTIFICATION.SIGNATURE OF PATIENT/ RESPONSIBLE PARTY: _____________________________________________________PRINT NAME ______________________________________________ Today’s Date__________________________ Magnolia Family Medicine Richard A. Gutsin, D.O. 3720 Shipyard Blvd, Wilmington, NC 28403 PHONE: 910-796-3212 FAX: 910-796-3216FIRST Name________________________ MIDDLE Name_______________ LAST Name_____________Nickname_____________ Best Phone # for Contact_____________________ Birth date______________ Answer ALL 3 Questions This is used by Govt Agencies to evaluate Healthcare Disparities Nationally1. Your ETHNICITY: Hispanic Non-Hispanic Decline 2. Your Language: _____________________3. Your RACE: White Black Asian American Indian Pacific Islander Marital Status: Single Married Committed Relationship Engaged Separated Divorced Widowed Needs Work Happy List Doctors (and Specialty) seen in the past 2 years: _____________________________________________________Which Pharmacy do you use? ___________________ Location ________________________ Phone___________ PLEASE DO NOT LEAVE ANY BLANKS. CIRCLE THE BEST ANSWER OR PUT N/A, Question Mark OR DASH We aren't just being nosey – Most questions are required by ins. This info is available to medical staff here & to your insurance co. IF they review your chart.Highest Level of School: Student Grade ______ Finished Grade _______ 2 yr College 4 yr College Degree: _________I work: Full Time Part Time Job Hunter Unemployed Retired Disabled Stay at home I don't workWhat work do (did) you do? _____________________________________________Do you like it? Yes No SometimesTOBACCO: No Yes Daily: ? ? ? 1 pk More Yr Started:______ Yr. Quit: _______ Want to QUIT? Using E-CIG? ALCOHOL: No Yes Past TOTAL/day: Beer______ Wine______ Liquor_____ TOTAL/week:_______ Is it a problem?ADDICTION: No Yes Past Marijuana: No Yes Past Illegal Drug Use: No Yes Past Need Help?SEAT BELTS: No Sometimes Always ARE YOU: Righty Lefty MY NORMAL WEIGHT ________ LBS. HEIGHT ________I get HEADACHES: Never Rarely Sometimes Daily Monthly What Helps? ___________________________________I have FIREARMS: No Yes In Lock Box Loaded Unloaded I have SMOKE/FIRE ALARMS: Got It Need to Get It SEXUAL ABUSE: No Yes Past VERBAL ABUSE: No Yes Past PHYSICAL ABUSE: No Yes Past Do you Feel Safe? GLASSES/CONTACTS: Yes No For Reading For Driving HEARING LOSS: No Right Left Both HEARING AIDS: Yes No CAFFEINE: No Yes Past TOTAL cups daily: ______ I enjoy FAST FOOD: NEVER RARELY YES _____x wk ________x mth My SLEEP is: #_______HRS per NIGHT…..ENOUGH NOT ENOUGH TROUBLED I am DEPRESSED: FREQUENTLY USUALLY SOMETIMES NEVER My ENERGY LEVEL: GREAT GOOD NEED MORE WHAT ENERGY? EXERCISE: DON'T ASK YES _____x wk _______x mth TYPE: _____________When was your last(Write N/A or NEVER)ANNUAL HEALTH EXAM ________BONE DENSITY _______________COLONSCOPY________________EYE EXAM ___________________ PNEUMONIA VACCINE _________ I TAKE MY MEDS: NO MEDS ALL THE TIME USUALLY SOMETIMES WHEN I CAN AFFORD IT MEDICINE I TAKE (include over the counter & vitamins)HOSPITALIZATIONS/PROCEDURES & YEAR DRUG ALLERGIES: None or ______________________________________________________________________________ PATIENT/GUARDIAN SIGNATURE ____________________________________ DATE____________ The information on the Patient Health History Form is correct to the best of my knowledge. I will inform the staff of any changes. Page 1 of 2 Magnolia Family Medicine - Richard A. Gutsin, DO 3720 Shipyard Blvd Wilmington, NC 28403 Phone: (910) 796-3212 Fax: (910) 796-3216 FLIP OVER IF YES, CHECK THE BOX for YOURSELF or FAMILY MEMBER who has or had any problem listed:Medical Condition Me PastMe NowMy MomMy DadMy SisterMy BrotherMy KidsGrandmaGrandpaDETAILSADHDAlcoholismAllergiesAnemiaAnxietyArthritisAsthmaAutismBipolar DisorderBirth DefectsCancer/TypeConstipationDiabetesDepressionDrug UseLung Issues / COPDGoutHearing LossHeart AttackHIV / AIDSHigh CholesterolHypertensionInsomniaIrritable BowelKidney ProblemsLiver DiseaseMigrainesObesityPain Med / MgmtSleep Apnea (CPAP)STDStrokeSuicide / AttemptThyroid ProblemMARK: “A” for ALIVE or “D” if DECEASEDMEN ONLYYESNOSOMETIMESWOMEN ONLYYESNOSOMETIMESTesticular PainDate of Last PAPSexually ActiveUrinary ProblemsDate of Last MAMMOVaginal DischargeErectile Dysfunction# of Pregnancies ____________Vaginal BurningSexually Active# of Abortions ____________Abnormal BleedingALL PATIENTS anything else you’d like to discuss? # of Miscarriages ___________Birth ControlType:Last Period ___ ____________Age Period Started __________ Still Have it? Yes or NoNEED PAP: YES or NONEED MAMMOGRAM: YES or NO ................
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