Dear Patient, Welcome to Annadel Medical Group Urology.

Transcription

1 Dear Patient, Welcome to Annadel Medical Group Urology. Our priority is your health and we will strive for excellence in all aspects of medical care. Achieving this goal requires a partnership between you as a patient and our new office. We are located at 121 Sotoyome Street, Suite 201 across from Santa Rosa Memorial Hospital on Montgomery Drive. To schedule an appointment, please call (707) during our phone hours between 9am-12n and 1:30-4:30pm on weekdays. Messages left on our voic box will be returned as soon as possible. If you are new to Annadel Medical Group, there is required paperwork for you to register as a patient in our system. Enclosed is an Authorization to Obtain Records, Health Questionnaire* and Registration Forms. Please complete and return all of these forms and include a current list of your medications. Please plan to arrive 30 minutes prior to your scheduled appointment time and have the forms ready. If you have any questions about the registration process, insurance coverage, need directions, or if you want speak with the physicians or nursing staff, please call (707) On behalf of the physicians, our staff and for Annadel Medical Group, I want to thank you for your support and for choosing us to be part of your medical home. Sincerely, Lauren Pavich Urology Site Supervisor * Established Annadel patients: Please complete the Urology Health Questionnaire 121 Sotoyome Street, Suite 201 Santa Rosa, CA T: (707) F: (707)

2 Authorization to Release/Obtain Medical Records Autorización para el uso o compartir información médica protegida Name of Patient: Date of Birth: / / (mbre del Paciente) (Fecha de nacimiento) Previous/Maiden Name: Phone #: ( ) (Otros nombres usados/mbre de soltera) (Teléfono) Address (Dirección de correo postal): (Street/P.O. Box) (City) (State) (Zip) Records disclosed FROM (Pedir información médica DE) : Name of Physician / Facility Address (City) (State) (Zip) Phone: ( ) Fax: ( ) Records disclosed TO (Compartir información médica A) : Name of Physician / Facility Address (City) (State) (Zip) Phone: ( ) Fax: ( ) Please send the following records for this period (Fechas de servicio): to LIMITATIONS: The information to be released is limited to (Solo expedients relacionados con): All Medical Records (SJHF s policy is the last 2 years) (Todo mi expediente médico) History Progress tes (tas de oficina) X-ray/EKG Reports (Radiografías/EKG) Immunizations (Vacunas) Laboratory/Pathology Reports (Laboratorios) Physical Exams (Examenes físicos) GYN Records (tas gynecologicas) Other (Otro Por favor especifique) SPECIFIC AUTHORIZATIONS: The following information will not be released without your specific authorization by checking the relevant box(es) below ( será divulgada la información notada abajo sin marcar especificamente) : I specifically authorize the release of information pertaining to drug and alcohol abuse, diagnosis or treatment. (Información sobre el abuso de drogas y alcohol.) (42 C.F.R and 2.35) I specifically authorize the release of information pertaining to mental health diagnosis or treatment. (Información sobre el diagnóstico o tratamiento de una condición mental.) (Welfare and Institutions Code 5328, et seq.) I specifically authorize the release of HIV/AIDS test results. (Información sobre análisis de sangre para VIH/SIDA.) (Health and Safety Code (g)). Expiration Date of Authorization (Fecha de vencimiento de esta autorización): This authorization is effective through / / unless revoked or terminated by the patient or the patient s representative. (Esta autorización se vence / / al menos que el paciente o su representante lo suspenda antes de la fecha notada.) (If no date is indicated, this authorization will expire 12 months after the date of signing this form. Si no se nota una fecha de vencimiento, esta autorización se vence en 12 meses.) Right toterminate or Revoke Authorization (Derecho de suspender esta autorización): You may revoke or terminate this authorization by submitting a written revocation to St. Joseph Heritage Healthcare. You should contact the Office Manager to terminate this authorization.. (Tiene derecho de suspender esta autorización con presenter una carta en escrito a St. Joseph Heritage Healthcare y al supervisor de la oficina médica.) Potential for Re-Disclosure: Information that is disclosed under this authorization may be disclosed again by the person or organization to which it is sent. The privacy of this information may not be protected under the federal privacy regulations. (Información divulgada con esta autorización puede ser divulgada de nuevo por la persona u organización a donde mandamos esta información. Es possible que esta infomación no sea protegida por las leyes federales de privacidad.) Copies of this signed authorization form are considered as valid as the original. Upon request a copy of this form will be given to the patient (Una copia de esta autorizació se considera igual al original. Puede pedir una copia de esta autorización.) (Self / Parent / Guardian) Signature of Patient or Legal Representative Date Physician Approval

3 Health Questionnaire Patient Name: Date of Birth: Today s Date: Preferred pharmacy? Have you seen a urologist before?, reason(s) why? Please indicate any Past Medical History Asthma High Blood Pressure Pneumonia Bladder Cancer Jaundice Prostate Cancer Cataracts Kidney/Renal Failure Rheumatic Fever Diabetes Kidney/Bladder Stones Scarlet Fever Glaucoma Lung Condition Seizure(s) Hearing Loss Measles Stroke Heart Condition Mental Illness Tuberculosis Hepatitis Mumps Urinary Frequency Obstetrical Past pregnancies: Number of births: LMP: Surgical History Year Year Ankle Surgery Left Right Bilateral Heart Surgery Appendectomy Hysterectomy Arthroscopy Left Right Bilateral Knee Left Right Bilateral Breast Surgery Left Right Bilateral Prostate CABG (Coronary Artery Bypass Graft) C-Section Gallbladder Tonsillectomy Total Hip Replacement Vasectomy Personal/Social History Occupation: Number of Children: Marital Status: Single Married Divorced Widowed Smoking Status: Never Socially Former Current Smoker, PPD#: Caffeine Use: Coffee, cups: Tea, cups: Soda Chocolate Alcohol Use: /none /occasional, drinks per day or week: Daily Aspirin Use: Coumadin:, current dose: Medications ne/ Reported Medications, medication list attached Drug Allergies/Sensitivities ne/ Known Drug Allergies, medication/non-medication allergy details attached

4 Patient Name: DOB: / / Review of Systems Constitutional Integumentary: Fever Skin rash Chills Boils Headache Persistent itch Eyes Musculoskeletal: Blurred vision Joint pain Double vision Neck pain Pain Back pain Allergic/Immunologic Ear/se/Throat/Mouth: Hay fever Ear infection Drug allergies Sore throat Sinus problems Other: Neurological Genitourinary: Tremors Urine retention Dizzy spells Painful urination Numbness Urinary frequency Endocrine: Respiratory: Excessive thirst Wheezing Too hot/cold Frequent cough Tired or sluggish Shortness of breath Gastrointestinal: Abdominal pain Nausea or vomiting Indigestion or heartburn Hematologic/Lymphatic: Swollen glands Blood clotting problem Cardiovascular: Psychological: Chest pain Are you generally satisfied with life? Varicose veins Do you feel severely depressed? High blood pressure Other: Have you considered suicide? Men Penis symptoms Scrotal symptoms Testicular symptoms Inadequacy of penile erection Women Vaginal bleeding Vaginal dryness Pain with intercourse Other:

5 Patient Name: DOB: / / Medication List Medication Name Strength (mg) Dose (times taken per day) Allergy Details Medication/n-Medication Reaction

6 REGISTRATION FORM PATIENT INFORMATION Patient Name AKA Last First M.I. Date of Birth / / Age Sex M F SS# - - Mailing Address (Street or P.O.B.) (City) (State) (Zip code) Do you reside at a skilled nursing facility? Y N If so, please provide the Facility Name Facility Address City Zip code Home Phone ( ) Work ( ) Cell Phone ( ) Preferred method for routine communication Cell Home Mail Work Text (Portal Users only) Primary Spoken Language English Spanish Other Ethnicity Primary Care Physician How were you referred? Driver s Lic.# Marital Status Single Married Separated Divorced Widowed Other Do we have permission to contact you via ? Y N Employer s Name Address Name of spouse or significant other N/a EMERGENCY CONTACT REQUIRED: Adults - Contact can be anyone. Minors - Contact other than a parent/guardian. Contact Name Relation to Patient Address (Street or P.O.B.) (City) (State) (Zip code) Home Phone ( ) Work Phone ( ) Cell Phone ( ) RESPONSIBLE PARTY 1 RESPONSIBLE PARTY 2 Same as above. I am the responsible party. Parent/Guardian Name Parent/Guardian Name Mother Father Guardian Other Mother Father Guardian Other Date of Birth / / Date of Birth / / Marital Status Single Married Separated Marital Status Single Married Separated Divorced Widowed Other Divorced Widowed Other Mailing Address (Street or P.O.B.) Mailing Address (Street or P.O.B.) City) (State) (Zip) City) (State) (Zip) *Check the box for preferred method of communication Home Phone ( ) Mail Cell Phone ( ) Work Phone ( ) Driver s Lic.# SS# Occupation Employer Address * Check the box for preferred method of communication Home Phone ( ) Mail Cell Phone ( ) Work Phone ( ) Driver s Lic.# SS# Occupation Employer Address Office Use: Patient Name MRN

7 ELIGIBILITY GUARANTEE FORM I hereby certify that I am eligible for the health insurance company under the subscriber listed in my registry sheet. I also certify that I have chosen Annadel Medical Group to provide healthcare services. I understand that, were the aforementioned statement not true or if I were not eligible under the terms of the Subscriber s Medical and Hospital Agreement, I d be responsible for any and every charge for the services rendered. Also, if the aforementioned were not true, I agree to pay completely all the services rendered within thirty days after receiving an invoice from said medical group or doctor. ASSIGNMENT OF BENEFITS I hereby authorize that the benefit payment be made directly to ST. JOSEPH HERITAGE HEALTHCARE for services provided to me by ANNADEL MEDICAL GROUP, and also declare that I assume responsibility for the payment of charges not covered in this allocation. I authorize the refund of payments in excess of insurance benefits, when the coverage is subject to benefit coordination. In the event of payment default, I hereby pledge to pay every collection cost, including reasonable legal fees. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION I authorize any holder of medical information about me to release said medical information requested by insurance companies with whom I have coverage or any public agency and its agents to determine benefits for services received or benefits for related services. NOTICE OF PRIVACY PRACTICE HIPAA (Health Insurance Portability and Accountability Act) regulations require us to provide to you, the patient or personal representative, a copy of our tice of Privacy Practice and that you acknowledge with your signature that you have received the brochure. Initials You may share health information about the patient s condition with: (List here the names of individuals, family members, or other relations to whom you wish to grant authorization to share medical information.) INSURANCE SUBSCRIBER INFORMATION Thank you for providing copies of your insurance card(s). If someone other than yourself, the patient, is the insurance subscriber, please fill in the following information (this also applies to minors whose insurance is under a parent/guardian): Primary Insurance Company Name Subscriber ID # Subscriber s Name Date of Birth / / Relation to patient Subscriber s Address if other than the patient s Subscriber s SS# - - Secondary Insurance Company Name Subscriber ID # Subscriber s Name Date of Birth / / Relation to patient Subscriber s Address if other than the patient s Subscriber s SS# - - Office Use: Patient Name MRN