Patient Name:,, Address: Phones:,, Home Work Cell. Primary Physician: Emergency Contact: Phone#:

Transcription

1 Patient Information Patient Name:,, Last First middle initial Address: Phones:,, Home Work Cell Sex: Female Male Date of Birth: / / Mo. Day Year Primary Physician: Marital Status: Single Married Widowed Divorced Separated Emergency Contact: Phone#: Relationship: Father Mother Guardian Sibling Child Other Address: same, If different: Insurance Information (Only if card is not provided): Primary Insurance Company: ID#: Group#: Co-Payment: Additional Insurance: ID# Assignment of Benefits: I request that payment of authorized insurance benefits, including Medicare, if I am a Medicare beneficiary, be made on my behalf to Cape Regional Physicians Associates for any medical services provided to me. I understand that I am financially responsible to the organization for any charges not covered by my health care benefits. I understand that it is my responsibility to notify the organization of any changes in my health care coverage. I understand that by signing this form I am accepting financial responsibility for all services received. Privacy Notice Acknowledgement: By signing below, I acknowledge that I was provided access to Cape Regional s Notice of Privacy Practices. Additional Information: (circle the applicable response) Race: White, Black/African American, Asian, American Indian/Alaska Native, Native Hawaiian Ethnicity: Hispanic/Latino, Not Hispanic/Latino, Prefer not providing. Primary Language: English, Spanish, Other: Preferred Contact Number: Home, Work, Cell

2 Authorization to Share Health Information Patient Name Date of Birth Please indicate by your signature below if voic may be used to communicate Health Information with you and your caregiver. Signature Date Certain diagnoses require specific approval to release information. Please indicate by your signature below if we have permission to communicate the following Health Information with your caregiver: Alcohol or Drug Treatment/Counseling Psychological / Psychiatric Treatment STD, HIV, Hepatitis C or B Treatment Please provide the names of people with whom we may share your Health Information: Name Relationship Phone # Name Relationship Phone # Signature Date The authority for this release will expire one year from this signature date. Caregiver signature if patient is unable to sign Witnessed Date Privacy Notice Acknowledgement: By signing below, I acknowledge that I was provided access to Cape Regional s Notice of Privacy Practices Signature Date Caregiver signature if patient is unable to sign Witnessed Date

3 Record Release Authorization NOTE: Bolded Sections to be completed by Cape Regional as needed for continuity of care purposes. Patient should only provide name and date of birth and sign / date form. Thank you! Facility: Fax#: I hereby authorize you to release a copy of the medical records/information described below to: Cape Regional Health System Address: Phone#: Fax#: Requested Information: Dates of Service: Date of Request: Patient Name: Date of Birth: I understand that I have a right to revoke this authorization at any time. I understand that If I revoke this authorization I must do so in writing. I understand that the revocation will not apply to information that has already been released in response to this authorization. This authorization will remain in effect for a period of one year from the date stated below unless revoked. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality and privacy regulations.

4 Please complete and return our new patient intake form in advance of your upcoming appointment or arrive for your visit 30 minutes early to permit us to load the information in advance of your appointment. New Patient Information Name: Date of Birth: Date: Previous Primary Care Physician: Reason for Today s Visit: Medical History: Please circle any health condition that applies to you and specify/comment if needed. If you have any questions, please ask a member of our staff for assistance. Thank you. Medical History (For Other, Please Specify) Alcohol/Drug Problem Breast Lump, Other breast problem Cardiac Congestive Heart Failure, Heart attack, Heart Disease, High blood pressure, High cholesterol, Valve problem, Other Cancer Brain, Breast, Cervical, Colon, Lung, Ovarian, Prostate, Rectal, Skin, Thyroid, Uterine, Other Digestive/Stomach Barrett s Esophagus, GERD, Hernia, Intestinal problem, Liver Disease, Ulcer, Other Endocrine Diabetes, Thyroid Disease, Other Eyes/Ears/Nose/Throat Hematology Anemia, Bleeding disorder, Clotting disorder, Other Immune Disorder AIDS, HIV, Lupus, Other Kidney Disease, Kidney stone, Other kidney problem Musculoskeletal Arthritis/Joint problem, Hernia, Osteoporosis/Osteopenia, Other Neurological Nerve Disease, Stroke, Other Psychiatric Anxiety, Depression, Other Respiratory Asthma, COPD, Other Skin Eczema, Psoriasis, Other Urinary / Reproductive Abnormal pap test, Bladder problem, Menstrual abnormality, Prostate problem, Sexually transmitted infection, Other Vascular (Arteries, veins) Other Medical History: Specify/Comments

5 Name: Date of Birth: Past Surgical History/Past Procedures: Medication: Please list all medications with dose and frequency. (Please include non-prescription medications, vitamins, and supplements) Medication Dose Frequency (i.e., how many times daily?) Prescribed By Allergies: Please list ALL medication, food, and/or environmental allergies, and specify reaction type that occurs (i.e. rash, itching). Pharmacy: Where would you like us to send your prescriptions? Local pharmacy name, location: Mail order pharmacy name: Family History: Please note any serious family medical history Father: Mother: Brother: Sister: Other Family History: Father s Father: Father s Mother: Mother s Father: Mother s Mother: Social History: Please circle the following that apply to you: Are you: Single Married Divorced Other Are you sexually active? Yes No What is your employment/occupation? Please outline your use of the following products, past or present: Product Current Use? Yes/No Daily Amount Weekly Amount Past Use? Yes/No Tobacco Alcohol Recreational Drugs Caffeine Pregnancy/Birth History: Number of Pregnancies: Number of abortion(s): Miscarriage(s): Number of children born alive: Number of current children:

6 Name: Date of Birth: Recent Diagnostic Studies: (within the last 3 years) 1. Heart Testing (Type / Where / When) 2. Lung Testing (Type / Where / When) 3. X-Ray (Where / When / Specify Body Part) 4. Ultrasound (Where / When / Specify Body Part) 5. CT (Where / When / Specify Body Part) 6. MRI (Where / When / Specify Body Part) 7. Biopsy (Where / When / Specify Body Part) 8. Other (Type / Where / When) 9. Most Recent Blood Testing/Labs (Where / When) Health Maintenance: Please note the most recent date you received any of the below health services. Service Date (Month/Year) Physician Yearly Physical Eye Exam (If Dilated Eye Exam, please specify) Dental Exam Pap Smear Prostate Exam Mammogram Colonoscopy Diabetic Foot Exam Immunizations: When was your last: Flu Shot? Tetanus Shot? Pertussis (Whooping Cough)? Pneumonia Shot (Prevnar, Pneumovax)? Zostavax (Shingles)? Current Medical Specialists: (Name/Specialty) Do you have a Living Will/Advance Directive? Have you been in the hospital recently? Do you need any medication refills today? (Please specify)