Comprehensive Health & Wellness Center, P.A. Patient Information Sheet

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Austen Cooper
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1 Please PRINT ALL Information Comprehensive Health & Patient Information Sheet Patient Information Who is responsible for patient Self Parent Other Social Security # - - Sex M F Name Address Street City State Zip Telephone # ( ) Cell # ( ) E- mail of Birth / / Marital Status Single Married Divorced Widowed Partner Employment Status Full- Time Part- Time Retired Other Student Full- Time Part- Time Employer Name Occupation Employer Address Employer Phone ( ) Spouse/ Parent Name SSN# - - DOB / / Emergency Contact Phone # ( ) Relationship Insurance Information INSURED PERSON (If not Patient) Name Social Security # / / of Birth / / Relationship to patient PRIMARY INSURANCE Insurance Carrier Policy No. SECONDARY INSURANCE Insurance Carrier Policy No. Name Address Phone Number Group No. Name Address Phone Number Group No. AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFITS I authorize the release of all medical information necessary to process this claim that is pertinent to my medical care. I assign all medical and/or surgical benefits to my physician. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I AGREE TO BE FINANCIALLY RESPONSIBLE FOR ALL CHARGES. I HAVE READ THIS INFORMATION AND UNDERSTAND IT. Signature MEDICARE AUTHORIZATION TO RELEASE INFORMATION AND MEDICARE ASSIGNMENT I request payment of authorized Medicare benefits to be made on my behalf by my physician for any services furnished to me. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine benefits or the benefits payable of related services. This assignment will remain in effect until revoked by me in writing. Photocopy of this assignment is to be considered as valid as the original. I AGREE TO BE FINANCIALLY RESPONSIBLE FOR ALL CHARGES FOR NON- COVERED SERVICES AS EXPLAINED TO ME BY THE PHYSICIAN. I HAVE READ THIS INFORMATION AND UNDERSTAND IT. Signature

2 Please PRINT ALL Information Patient Medical History Sheet Patient Information Name Today s / / Social Security # - - of Birth / / WHICH OF THE FOLLOWING CONDITIONS ARE YOU CURRENTLY BEING TREATED OR HAVE BEEN TREATED FOR IN THE PAST Seizures Rheumatic fever Asthma Arthritis Headaches/Migraines Heartburn (reflux) Lung Problems/cough Back problems Stroke Liver problems/hepatitis Seasonal Allergies Depression/Anxiety Neurological problems Ulcers/colitis Anemia or blood problems Drug/Alcohol Abuse Heart disease/murmur/angina Kidney/Bladder problems Blood clots Eye disorder/glaucoma High Cholesterol HIV/AIDS Thyroid problems Cancer High blood pressure STD (sexually transmitted disease) Diabetes Please list any current or past medical conditions not listed above Please list your past surgeries Allergies Are you allergic to penicillin or any other drugs? Please List Medications Please List Immunizations (including dates) Hepatitis A Hepatitis B Pneumonia Influenza Tb test/results DPT/TD (tetanus) OPV (polio) MMR (measles, mumps, rubella) Varicella Other

3 Family History Mother Father Sister Brother Living Age (or age at death) Cause of death Has any member of your family (including children and parents) had any of the following illnesses? Illness Anemia or Blood disease Cancer Diabetes Glaucoma Heart disease High blood pressure HIV disease/ AIDS Mental Illness/Depression Stroke Kidney Disease Liver disease Seizures Thyroid Asthma Arthritis High Cholesterol Other serious illness Which family member? Females: Gynecological History How many times have you been pregnant? of last Pap Smear Have you had an abnormal Pap Smear? Diagnosis Follow up Have you had a sexually transmitted disease? of last mammogram Diagnosis Mammogram results Have you ever had a breast biopsy? Biopsy results

4 Social and Preventative History Do you currently smoke or chew tobacco? How many packs a day? If no, have you in the past? Do you drink alcohol, beer, or wine? How many drinks per week? If no, have you in the past? Do you currently drink coffee and/or Tea? If yes, how many cups per day? Do you exercise daily/weekly? Do you use seatbelts while driving? Do you wear a helmet while riding a bike? By signing below, I hereby certify that to the best of my knowledge all the information I have furnished on this form is complete, true, and accurate. Patient/ Legal Guardian Signature

5 AUTHORIZATION TO RELEASE INFORMATION TO FAMILY MEMBERS We require your signed consent in order to provide any medical information about you to anyone other than one of your healthcare providers or your medical insurance company. I,, hereby grant to the physicians or staff of Comprehensive Health & Wellness Center, P.A. to release information related to my condition, including data about mental illness, alcoholism, sexually transmitted diseases, HIV, AIDS, and the use of drugs or any other medical information to the following individuals: Name Relationship ADVANCED DIRECTIVES In order to comply with Omnibus Budget Reconciliation Act of 1990 and Chapter 754, Florida Statues, please answer the following questions. Declaration to decline life- prolonging procedures (living will) ( ) I have made such a declaration ( ) I have not made such a declaration Health Care Surrogate ( ) I have designated a Health Care Surrogate ( ) I have not designated a Health Care Surrogate Durable Power of Attorney ( ) I have appointed Durable Power of Attorney ( ) I have not appointed Durable Power of Attorney ACKNOWLEDGEMENT FORM Our notice of Privacy Practices information about how we may use and release protested health information about you. You have the right to review our notice before signing this form. You have the right to restrict how protected health information about you is used or released for treatment, payment, or health care operations. By signing this form you consent to our use and release of protected health care operations as described in our notice. You have the right to revoke this consent in writing, except where we have already made releases on reliance of your prior consent. Our office is affiliated with various pre- medical, medical and residency programs. Therefore students and/or residents may assist in your health care. If at any point you would rather not participate in these teaching programs please let us know and we will make other arrangements for your continuing health care. Signature

6 OFFICE PROCEDURE AGREEMENT Mark D. Chin- Lenn, M.D. President, CH&WC, P.A Sheridan Street Hollywood, FL PATIENT LATE CANCELLATION AND NO SHOW FEES: Patients are required to give Comprehensive Health & a minimum of 24 hour notice for a cancelled appointment. Appointments cancelled less than 24 hours in advance or patients who fail to show up for a scheduled appointment will be charged $25.00 per missed appointment. SICK PATIENTS: Sick patients must call the office as early as possible in the morning to be seen the same day. Otherwise, patient will be seen within 24 hours. LABS AND LAB FEES: Patient must fast for at least 8 hours prior to all labs unless instructed otherwise. Labs may be drawn up to 3 p.m. as long as patient remains fasting. Patients that desire for CH&WC, P.A. to draw blood understand that they will be charged a convenience fee from $ $ It is understood that this convenience fee is not to draw blood and is not a covered service. Patients have the option to go directly to a local lab where there is no similar charge. PRESCRIPTIONS: Prescription refills will be processed within 24 hours. ALL HMO PATIENTS: All referral requests must be made at least 72 hours (3 business days- not including weekends and holidays) prior to specialist appointments. If adequate time is not given, patient will be asked to reschedule the appointment. It is the patient s responsibility to notify CH&WC, P.A. CELL PHONE USAGE: Cell phones must be placed on silent or vibrate mode upon entering the exam rooms. INSURANCE: Current insurance cards must be presented at each and every visit. PAYMENT OF SERVICE: Co- pays and unpaid balances are required to be paid in full at the time of the visit (no exceptions without prior authorization from the office manager or insurance billing department). NSF: Returned checks will be charged a service fee of $25.00 FORM FEES: Fees range from $ $ These include handicap forms, disability forms, specialized forms and letters. I have read and agree to abide by the office polices as stated above. Patient Signature Print Name

7 4040 Sheridan Street Hollywood, FL AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS Patient Information (please print): Name: of Birth: Social Security Number: Address: City: State: Zip: Phone: Please release my records from: Name: Address: Phone: Fax: To: Comprehensive Health & Mark D. Chin- Lenn, M.D Sheridan Street Hollywood, FL Phone: (954) ; Fax (954) Please release a copy of all my medical records, including but not limited to, progress notes, operative notes, laboratory results and diagnostic tests. BY MY SIGNATURE I AUTHORIZE RELEASE OF MEDICAL RECORDS Patient: :

LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W

PATIENT REGISTRATION LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W D OTHER: SPOUSE S NAME: EMAIL ADDRESS: