Patient Registration PATIENT INFORMATION - the person being seen by the doctor

Transcription

1 Patient Registration PATIENT INFORMATION - the person being seen by the doctor Last Name First Initial Home Address Zip City State Mailing address Zip City State I am willing to receive s from Dr. Liz Cruz? Yes / No Home Phone Cell or Pager Primary Care Physician Patient s Relationship to Policyholder (circle one) Self / Spouse / Child / Other Date of Birth Patient Sex Male Female Patient s Social Security Patient Language Preference: Patient s Race: (circle one) American Indian / Alaska Native / Asian / African American / Native Hawaiian / Hispanic / White / Pacific Islander / Other / Refuse to Report Patient s Marital Status: (circle one) Married / Single / Widowed / Legally Separated / Divorced / Other Patient s Employer Occupation Address Zip City State Phone Preferred Pharmacy Name: Cross Streets/City: GUARANTOR INFORMATION - the person who carries the insurance policy or is responsible for payment Last Name First Initial Home Address Zip City State Home Phone Cell or Pager Address Social Security Date of Birth Mailing address Zip City State Guarantor Employer Occupation Address Zip City State Phone Primary Insurance ID# Group# Secondary Insurance ID# Group# Guarantor for Secondary? Social Security Date of Birth Mobile Phone I authorize release of any medical information necessary to process Medicare and/or any insurance claims. I authorize payment of medical benefits to Dr. Liz Cruz Partners in Digestive Health. I understand I am responsible for any deductibles, co-payments, coinsurance or amounts not covered by the Insurance carrier. I also understand if I receive a screening colonoscopy some insurances pay differently depending on what is found during the procedure. It is my responsibility to contact my insurance company directly regarding questions pertaining to this. In the event that my account is assigned to a collection agency, I agree to pay an additional collection fee of 25% of the outstanding balance assigned to the collection agency. I also agree to pay any interest on the principal balance, court cost and attorney fees associated with the collection of my account. In addition, I am aware that if I cannot attend a scheduled appointment I must call at least 24 hours in advance to avoid a $20 no show fee. Patient Signature Date Staff Initials

2 Patient Intake Form Name: Age: Date of Birth: Date: Height: Weight: Who is your primary doctor? Referring Physician? Reason for seeing a Gastroenterologist: Have you had a Colonoscopy or Sigmoidoscopy done in the past 10 years? Yes No If yes, what year was it performed? Anything found? Have you had an Upper Endoscopy done in the past 10 years? Yes No If yes, what year was it performed? Anything found? Has anyone in your immediate family been diagnosed with colon cancer or polyps? Yes No If yes, please explain: CURRENT SYMPTOMS: (check all that apply) Abdominal pain Change in bowel habits Black, tarry stool Food sticking in Nausea Diarrhea Gas / bloating esophagus Vomiting Constipation Heartburn Painful swallowing Bloody vomiting Rectal bleeding Acid reflux Jaundice Fevers Blood in stool Belching/Burping Abnormal liver tests Chills Blood on toilet paper Indigestion Anemia Loss of appetite Hemorrhoids Lactose intolerance Stool incontinence Weight loss Anal pain Difficulty swallowing PAST MEDICAL/SURGICAL HISTORY (check all that apply) None Emphysema/COPD Hemophilia Fatty liver High Blood Pressure Valley Fever GERD/Acid Reflux Diverticulosis Heart Attack/MI Tuberculosis Barrett s Esophagus Diverticulitis Heart Disease/Stents Sleep Apnea Hiatal Hernia Anemia Elevated Cholesterol Lung Clots Stomach / Duodenal Ulcer Depression Heart Valve Problem/Murmur Diabetes Mellitus Celiac Disease Anxiety Disorder Congestive Heart Failure Seizure Disorder Helicobacter Pylori Bipolar Disorder Atrial Fibrillation Stroke/TIA Irritable Bowel (IBS) Schizophrenia Heart Arrhythmia Alzheimer s Disease Crohn s Disease Arthritis Blood Transfusions Parkinson s Disease Ulcerative Colitis Osteoporosis Pacemaker/Defibrillator Thyroid Disease Pancreatitis Fibromyalgia Asthma Bleeding Disorder Hepatitis HIV/AIDS Lupus Kidney problems Hemodialysis Liver Cirrhosis Cancer, type(s): PAST SURGICAL HISTORY (check all that apply) None Tubaligation Stomach ulcer surgery Rectal prolapse Removal of tonsils C-section Hemorrhoidectomy surgery Removal of gallbladder Prostate surgery Inguinal hernia repair Coronary bypass Removal of appendix Thyroid surgery Abdominal hernia repair Heart valve Hiatal hernia repair Lung surgery Total knee replacement replacement Removal of uterus Gastric bypass surgery Total hip replacement Pacemaker placement Removal of ovary/ovaries Colon surgery Bladder suspension Defibrillator (AICD)

3 PLEASE LIST OTHER MEDICAL/SURGICAL HISTORY THAT MAY HAVE NOT BEEN LISTED: Allergies to Medicine: Are you allergic to any medication? Yes No If yes, please name medications & reactions: Medications: Do you take aspirin or arthritis medication (ibuprofen, naproxen, Aleve, Motrin, Advil)? Yes No If yes, please name medication & frequency: Do you take blood thinners (Coumadin, Warfarin, Heparin, Lovenox, Plavix)? Yes No If yes, please name medication & frequency: Please list other medications you are taking (include over-the-counter medicine and doses if possible) Preferred Lab: (please circle one) Sonora Quest Lab Corp. Other Social History/Marital Status: Single Married Divorced Separated Widowed Your occupation: Retired Unemployed Disabled Do you / have you ever used tobacco? Yes No Packs per day? Years? Date Quit? Do you use alcohol? Yes No Beer Wine Liquor How often? How much? Have you ever used street drugs? Yes No Type Last use FAMILY HISTORY Does anyone in YOUR FAMILY have the following illnesses? Check all that apply and write in the relationship of family member, ie. Mother, maternal aunt, paternal uncle, sister. Colon polyps Stomach cancer Liver cancer Ulcerative Colitis Colon cancer Small bowel cancer Pancreatic cancer Celiac Disease Rectal cancer Esophageal cancer Crohn s Disease Gallbladder Disease Uterine / Cervical cancer Skin cancer (ie. Melanoma) Other Cancer (please describe) I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any member of her/his staff responsible for any errors or omissions that I may have made in the completion of this form. Signature: Date:

4 Contact Information I may be contacted in the following manner (circle all that apply): -OK to leave message with detailed information: Home Work Cell No -OK to send mail to: Home Work No Those who may receive information regarding me: The first person on this list will be your emergency contact (please provide a phone number other than your home) You must have at least one person on this list. Name Relationship Phone # Name Relationship Phone # Do you have an advanced directive for Healthcare (living will or medical Power of Attorney)? If yes, we are required to have a copy on file. Copy Received Copy Requested Acknowledgement of Receipt of Privacy Notice Original to be maintained in patient s permanent medical record. I acknowledge that the office s Notice of Privacy Practices has been made available to me. Patient or legally authorized individual signature Printed Name if signed on behalf of the patient Date Relationship (legal guardian, personal rep., etc.) Notification of Outpatient Practice & Practice Policy I understand that through Dr. Liz Cruz Partners in Digestive Health, Dr. Elizabeth Cruz has established an outpatient practice. I understand that if I were to be hospitalized for any digestive related issue (not including issues relating to procedures performed by Dr. Cruz directly) I will be seen by the physician on call at that particular hospital and not Dr. Cruz. Out of respect for our providers and the large number of patients we care for on a daily basis we have implemented the following cancellation / rescheduling policy. If you cancel or reschedule a procedure or in-office appointment 3 times in a row you will be discharged from the practice. In addition, we strive to treat all patients with the utmost care and respect. We request the same respect from our patients. We will not tolerate verbal abuse, profanity or any other form of disrespect to the members of our team. This behavior will be grounds for immediate discharge from the practice. Patient Signature Date Emergency Medical Care Notice If you feel any of your symptoms have worsened at any time after your office visit YOU are responsible for obtaining Emergency Medical Care at the nearest emergency room. If YOU choose not to seek prompt medical care for your symptoms, please be advised we are not responsible for the outcome. I have read and understood the information on emergency services provided above and agree to seek emergency medical care if my symptoms worsen. If I choose not to seek prompt medical care, I will not hold my provider responsible in any capacity for the outcome. Patient Signature Date

5 TO: FROM: RE: All Dr. Liz Cruz Partners in Digestive Health Patients Dr. Liz Cruz Partners in Digestive Health Providers and Staff Access to our new patient portal We are honored that you have chosen us as your healthcare provider. Today we have exciting news regarding your health management! As we continue in our efforts to provide our patients with the highest quality of care, we are constantly looking for methods of working together with you to ensure that you are not only aware of, but also involved in the management and improvement of your health. We are proud to inform you that our practice now offers the opportunity to use the power of the web to track the most important aspects of your healthcare through our office. The Patient Portal enables our patients to communicate with our doctors, nurse practitioners, and staff members easily, safely, and securely via the Internet. Participating patients are given secure User IDs and passwords, enabling them to access the Portal to view their personal and private documents, including lab and diagnostic test results, educational information, billing statements, and other health information. Through the Patient Portal, you are able to: ask questions of doctors, nurse practitioners, and staff members request prescription refills and referrals view your lab and imaging results request appointments view your personal health record examine your current and past statements all from the comfort of your home, whenever it is convenient for you! By using the Patient Portal, you no longer have to call the office, leave a message, and wait for a response to get the results of your lab work; those results will be available to you through the Portal. You can also send a message to the office through the Portal and expect a prompt reply. To learn more or to sign up, please make sure to give us your address upon check-in then follow the instructions you are given to get registered. Begin today to take an active role in managing your healthcare! Yours truly, Liz Cruz, M.D. Maureen Tyner, FNP-BC

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