Patient Registration Form Full Version Use For New Patients/Initial Visit

Transcription

1 Patient Registration Form Full Version Use For New Patients/Initial Visit Preferred language to discuss your care: Would you like an interpreter? No Yes (language: ) Check if any of the following apply: Deaf/Hard of Hearing Visually Impaired N/A Patient Information Name: Date of Birth: Social Security #: Sex: Male Female Mother s Maiden Name: Street Address: City, State, Zip: Mailing Address: City, State, Zip: Marital Status: (Please check one) Single Married Divorced Separated Widow(er) Home Phone # ( ) Work # ( ) Cell # ( ) What is the preferred number at which to reach you? Home Work Cell For cell phones, do you have text capability? Yes No How did you hear about our practice? Primary Care Provider: Primary Dental Provider: For WHP Patient Portal Use (Online access to request appointments, refills, receive lab results, immunization records, etc. Terms and Conditions for Use are posted on our practice website or available by request at our office) Address: Emergency Contact: Used Only If Unable To Reach You - No Health Information Will Be Shared Name: Phone: # ( ) Relationship to Patient: Parent/Legal Guardian (If patient is under 18 or over 18 and unable to make decisions for him/herself) Name of Parent/Guardian 1: Name of Parent/Guardian 2: Street Address: Street Address: Mailing Address: Mailing Address: City, State, Zip: City, State, Zip: Date of Birth: Date of Birth: Best phone # to reach you: ( ) Best phone # to reach you:( ) Relationship to Patient: Relationship to Patient: Married Divorced Separated Not Married Civil Union (Please provide a copy of relevant court documents if you claim sole legal custody of a minor or are the legal guardian for patient over 18.) Primary Insurance Name: Secondary Insurance Name: Name of Subscriber: Name of Subscriber : Subscriber s Address If Different From Patient s: Subscriber s Address If Different From Patient s: Subscriber s Date of Birth: Subscriber s Date of Birth: Relationship to Patient: Relationship to Patient: Employer : Employer: Page 1 of AMR Revs: 06/18/2018 Vers 5.0

2 Patient Name: Date of Birth: Race (Please Check One) or Decline American Indian or Alaskan Native Asian Black or African American Hispanic Indian Multi-Racial Native Hawaiian or Other Pacific Islander White Unknown/Unavailable Ethnicity (Please Check One) or Decline Hispanic or Latino Not Hispanic or Latino Unknown/Not Reported Unavailable Language (Please Check One) or Decline English Gujarati Khmer Panjabi Tai (Other) Arabic Hebrew Khotanese Persian Tamil Balinese Hindi Korean Philippine (Other) Telugu Bengali Hungarian Lao Polish Tagalog Bosnian Igbo Lushai Portuguese Thai Bulgarian Igala Malayalam Provencal Turkish Burmese Indonesian Marathi Romani Urdu Chinese Indo-European Mandar Romanian Vai Chamic Languages Minangkabau Russian Vietnamese Dutch Italian Neopolitan Italian Sign Languages Unknown French Japanese Nepali Spanish German Kamba Nyoro Swahili Greek Kabardian Old Norse Swedish Other: Religion (Please Check One) or Decline Anglican Episcopal Jehovah s Witness Muslim / Islam Unitarian Universalist Atheist Evangelical Lutheran Pentecostal United Church of Christ Baha i Greek Orthodox Maronite Catholic Presbyterian Wiccan Baptist Hindu Methodist Protestant Buddhist Judaism Mormon / Latter Quaker / Friends Non-Religious Christian Day Saints Roman Catholic No Preference Congregational Unknown Conservative Jewish Other: Page 2 of AMR Revs: 06/18/2018 Vers 5.0

3 Patient Name: Date of Birth: Advance Directive is a legal document with instructions you give regarding your future care if you are unable to make decisions about your care. There are two sections; you may have completed one or both of the sections: 1. Durable Power of Attorney for Health Care (DPOAH) - you name another individual to make healthcare decisions for you when you are unable to. Your provider determines that you can no longer make decisions for yourself and activates the DPOAH. 2. Living Will - you instruct your health care provider to give no life-sustaining treatment if you are near death or are permanently unconscious, with no hope for recovery. Do you have an Advance Directive? Yes If Yes, please provide us a copy. Do you only have a Living Will? Yes If Yes, please provide us a copy. Do you only have a Durable Power of Attorney for health care? If Yes, please provide us a copy. Do you have a Durable General Power of Attorney for finances? Yes If Yes, please provide us a copy If you answered No to any of the above, please ask us for an information packet. Financial Assistance If you require financial assistance to enable you to afford the health care that you need, please ask any staff member and they will provide you with a WDH Financial Assistance Application and a copy of the Financial Assistance Policy. If I am a self pay patient pursuant to RSA 151:12 b, I will receive a discount off charges at the time of billing that is consistent with discounts provided to patients covered by commercial health insurance as required by state law (NH RSA 151:12 b). An additional prompt pay discount for self pay balances and balances after insurance is available if payment is received within 30 days of receiving a bill. For questions regarding your bill, please call For questions regarding Financial Assistance, please call (603) Insurance Authorization and Assignment of Benefits While we participate with many insurance plans, if we do not participate with your insurance carrier, you will be responsible for the entire balance for all services rendered. If we participate with your insurance carrier, you will be responsible for any co-payments and/or deductibles at the time the services are rendered. I authorize and assign insurance benefit payment directly to the practice for any medical services I receive. I understand and agree that I am ultimately responsible for the charges on my account for any professional services rendered. I will be responsible for payment in full of all balances not paid by my insurance company. In an effort to help ensure accurate insurance billing, we ask that you present your insurance card and photo ID at each visit. Acceptable forms of payment are cash, check, debit and credit card (MasterCard, Visa, and Discover). Partners HealthCare Notice of Privacy Practices I have received/was offered a copy of the Partners HealthCare Notice of Privacy Practices. The Partners HealthCare Notice of Privacy Practices describes how my health information may be used or disclosed and explains my rights as a patient. I understand that I should read this document carefully and that it may be changed at any time. I may obtain a copy of the Partners HealthCare Notice of Privacy Practices by calling the practice. This practice uses an electronic medical record that is shared with Wentworth-Douglass Hospital and other affiliated practices. I consent to evaluation and treatment by any provider affiliated with WHP. I hereby authorize release of medical information that is necessary for my further treatment and for the purpose described in the Partners HealthCare Notice of Privacy Practices. WHP providers may query databases that contain information about current medications provided by other providers or through our pharmacy. Patient Name or Legal Guardian (please print) Patient or Legal Guardian Signature Date Page 3 of AMR Revs: 06/18/2018 Vers 5.0

4 ADULT HEALTH QUESTIONNAIRE Name: DOB: AGE: Sex: M F Who was your previous primary care provider? What is your preferred Pharmacy? Preferred language? Written Spoken Are you currently active in a religious community? Yes No Religious Affiliation: Education: What is the highest level of education you have completed?: Grammar school High school or equivalent Some college Bachelor s degree Masters degree Doctoral degree Other Employment: Are you currently employed? Yes No If yes, Employer: Occupation: History of hazardous work conditions (i.e. asbestos etc.) Type: CURRENT MEDICATIONS (may bring own list to visit if you prefer) Name of Medication Strength of Medication Dosing Instructions Example: Tylenol Example: 500 mg Example: 1 pill three times a day * Note this information may be taken directly from the pharmacy label on prescription products ALLERGIES No Known Allergies Medication Allergies Environmental/Seasonal Allergies Latex Allergy List Allergies Reaction PAST MEDICAL HISTORY (Check all that apply) Acid Reflux/GERD Bleeding Disorders Hearing Loss Stroke ADHD Cancer Heart Disease Thyroid Disease Alcoholism Depression High Blood Pressure Chronic Pain Allergies Diabetes High Cholesterol Anemia Anxiety Emphysema/Bronchitis/COPD Epilepsy/Seizure Disorder Irritable Bowel Kidney Disease Arthritis Glaucoma/Cataracts Liver Disease Asthma Headaches Osteoporosis Other (please list) - Page 1 of MR Vers /2017

5 PAST SURGICAL HISTORY Date of Surgery (Operations) Type of Surgery (Operations) FAMILY HISTORY (Check all that apply) Asthma Dementia/Alzheimer s Depression Diabetes Heart Disease High Blood Pressure High Cholesterol Thyroid Disease Stroke Cancer (please specify) - Other (please list) - GYN HISTORY Number of Pregnancies: Number of Living Children: SOCIAL HISTORY Personal History Marital Status Single Significant Other Married Divorced Widowed Name of Significant Other/Spouse if applicable: Children: Yes No Number of Sons Number of Daughters Name and Ages of Children: Living Situation: Live Alone With Significant Other/Spouse With Children/Family Members Other Occupation: Hobbies/Interests: Tobacco Have you ever smoked? Yes No If yes, what do you (did you) smoke? Are you still smoking? Yes No If no: How many years ago did For how many years did you How many packs/day did You quit? smoke? you smoke? If yes: How many years have you smoked? How many packs/day do you smoke? Have you ever tried to quit? Alcohol Do you drink alcohol including beer, wine, or other alcohol? Yes No If yes please specify frequency Daily Almost Daily (4-6 times/week) 1-3 times per/week Less than one time/week Do you drink caffeine? Yes No If yes, how many cups per day? Illicit Drugs Do you use any drugs or prescription medications not prescribed to you? (including marijuana, cocaine, amphetamines, pain or anxiety medications, etc) Yes No If yes please specify type of drug and frequency of use - Diet/Activity Are you on any special diet? Yes No If yes, how would you describe your diet? (e.g. South Beach, Atkins, calorie intake, renal, diabetic, low sodium, low fat, etc.) Page 2 of MR Vers /2017

6 Do you currently participate in any regular activity to improve or maintain your physical fitness (either on your own or in a formal class)? Yes No If yes, please describe: Health Planning Do you have Advanced Directives in place? Yes No Living Will Durable Power of Attorney Health Care Proxy Advanced Directives HEALTH MAINTENANCE Please provide the dates and results of the following immunizations, examinations, and tests to the best of your ability. If you have not had one of these services please indicate N/A (not applicable). All Patients: Last Tetanus Booster Within past 10 years More than 10 years ago Unknown Last Eye Examination Date: Normal Abnormal Unknown Last Hearing Exam Date: Normal Abnormal Unknown Last sigmoidoscopy/colonoscopy/ Date: Normal Abnormal Unknown Or stool test Last DEXA Bone Scan Last Pneumonia Vaccine Flu shot this season? Date: Date: Yes No Normal Abnormal Unknown Women: Last Pap Smear Date: Normal Abnormal Unknown Last Mammogram Date: Normal Abnormal Unknown Men: Last Prostate Specific Antigen-PSA Date: Normal Abnormal Unknown Last Prostate Exam Date: Normal Abnormal Unknown CONCERNS Please indicate any concerns regarding your health in the space provided. Patient Name (printed) Patient Signature: Date We would like to personally thank you for taking the time to complete this form. Doing so provides us with the information necessary to make the most out of each and every healthcare visit together. Page 3 of MR Vers /2017

7 Permission for Health Care Providers to Discuss my Health care with Family Members and Friends Patient Name: (Please print) Patient DOB: I allow my treating health care providers to discuss my health care with the individual(s) named below. These individuals play some role in my care, either by assisting me directly or by offering support to me and other family members. I understand that this form does NOT give the individuals named below any authority to make health care decisions for me. It also does NOT allow them to access my medical record. This document is not a health care power of attorney. The sole purpose of this form is to protect my privacy by ensuring that my health care will be discussed only with individuals I have chosen. I understand that I am not required to designate any such individuals. Printed Name of Individual Relationship Phone Number Authorized to Receive Information Printed Name of Individual Relationship Phone Number Authorized to Receive Information Please Note: This authorization will expire 12 months from the date this form is signed. If I wish to continue this authorization after that date, a new form must be completed. Printed Name of Patient or Legal Representative/Guardian Date Signature of Patient or Legal Representative/Guardian Revocation of Permission to Discuss my Health care with Family Members and Friends I revoke all privileges of one or both of the following individual(s) / effective: (Date) / / Patient Name: Signature: I understand that Wentworth Health Partners cannot take back any information that it shared when it had my permission to do so. Page 1 of MR 01/08/2016 Vers 2.0

8 Patient Name: D.O.B.: I give my permission to share my protected health information. Please enter where you would like information sent from and to whom you would like the information sent to. From: Name: Address: To: Name: Address: MR#: Phone: Fax: Phone: Fax: Purpose: Information to Be Disclosed. Medical Care Insurance Legal Matter Personal School Transfer of Care I authorize disclosure of the following information: Medical Record Abstract/dates (e.g. History & Physical, Operative Report, Consults, Test Reports, Discharge Summary) Billing Records Cardiology Records Emergency Room Records Records for specific dates: to Sensitive Information to Be Disclosed: Method of Delivery: Mail to receiving entity above I will pick up Designee will pick up (specify below) Other HIPAA AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION r*ri0020*r RI MR Rev. 06/14/18 Laboratory Reports Office Notes Operative Reports Pathology Reports Other (please specify below) Page 1 of 2 Radiology Images on CD Radiology Reports Radiation Reports Rehab Services Please check YES to indicate if you give permission to release the following information if present in your record: HIV/AIDS Related Test results (PATIENT AUTHORIZATION REQUIRED FOR EACH RELEASE REQUEST) SPECIFY DATES Format of Records: Paper (or other physical) copies Electronic (CD) There may be a charge for copying and shipping records. I will be notified of the cost prior to receiving/sending records. Wentworth Douglass Genetic Screening test results (SPECIFY TYPE OF TEST) Alcohol and Drug Abuse Treatment Records Protected by Federal Confidentiality Rules 42CFR Part 2 (FEDERAL RULES PROHIBIT ANY FURTHER DISCLOSURE OF THIS INFORMATION UNLESS FURTHER DISCLOSURE IS EXPRESSLY PERMITTED BY WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS OR AS OTHERWISE PERMITTED BY 42 CFR PART 2). This consent may be revoked upon oral or written request. Details of Mental Health Diagnosis and/or Treatment provided by a Psychiatrist, Psychologist, Mental Health Clinical Nurse Specialist, or Licensed Mental Health Clinician (LMHC) (I understand that my permission may not be required to release my mental health records for payment purposes) (EXCLUDES PSYCHOTHERAPY NOTES) Confidential communications with a Licensed Social Worker Details of Domestic Violence Victims Counseling Details of Sexual Assault Counseling

9 Patient Name: D.O.B.: To be completed if Designee will pick up records: MR#: I allow, my designee, to pick up the medical records identified above since I am unable to Print Name do so myself. One time only once my designee picks up my medical records, that person may not pick up my medical records in the future unless I sign another copy of this document. Indefinitely my designee may pick up my medical records until I revoke the authority of my designee or until this PHI Release form expires or is revoked by me. I MAY REFUSE TO SIGN THIS AUTHORIZATION. Wentworth Douglass Hospital, and its related entities, will not refuse to treat me based on my refusal to sign the Authorization unless the sole purpose of the requested treatment is to create records for disclosure to someone else. For example, the Hospital may refuse to perform a pre employment physical for me if I refuse to authorize the release of information obtained during that physical to my employer. I may revoke this Authorization at any time, in writing, except to the extent that we have already relied upon it in making a disclosure. Your written revocation will become effective when we receive it. If you are providing this Authorization to obtain insurance coverage, you may not have the right to revoke the Authorization in the future to the extent that it pertains to the insurer s right under law to contest a claim under your insurance policy. If you wish to revoke this Authorization, please send your written request to: Wentworth Douglass Hospital, Attn: Medical Information Department, 789 Central Avenue, Dover, NH I understand that if I authorize disclosure of protected health information, the recipient may further disclose this information, and Federal law may no longer protect it. I understand that I have the right to inspect or receive a copy of the information I am consenting to release within the established policies of Wentworth Douglass Hospital, and its related entities. This authorization will automatically expire 12 months from the date signed unless limited to the following date/event. Printed Name Signature of Patient or Legal Representative / Guardian (Legal Handwritten Signature Accepted Only) Date Authority or Relationship of Representative (Attach copy of documentation of authority) AUTHORITY: This form is designed to comply with CFR 45 Sec A copy of this authorization must be provided to the patient. For Hospital Patient Transfer: Request Processed and Records Sent with Patient By: Staff Initials Date For Medical Information use only: Patient picked up Mailed to patient Mailed to receiving entity Other Date Completed By: Staff Initials Date A copy of this signed authorization has been included with the records provided to the patient. For Designees/Patients picking up records only (signature will be obtained by Medical Information at time of pick up): Signature Wentworth Douglass HIPAA AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION r*ri0020*r RI MR Rev. 06/14/18 Printed Name Page 2 of 2 Date