at with. (Date) (Time) (Physician)

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Jemima Newton
5 years ago
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1 Dear Lombardi Patient: Georgetown University Hospital s physicians and staff would like to welcome you and thank you for choosing the Lombardi Comprehensive Cancer Center for your care. Our goal is to make your experience here at Lombardi as comfortable and smooth as possible. This letter is to confirm that an appointment was scheduled for you on: at with. (Date) (Time) (Physician) Please plan to arrive at least minutes prior to your visit in order to complete our registration process. Let us know if you are running late for your appointment by calling the front desk at (202) For your first visit here, we ask that you bring the following information with you to your appointment: A Photo ID Your Insurance Card(s) Your Referral Form if required by your health plan Documentation from the referring physician with diagnosis Your current list of medications All x-rays, scans (CT/MRI/PET), lab work, pathology reports, and supporting medical records pertaining to your diagnosis The completed health history form (attached) In order for our physicians to treat you appropriately, we may have already informed you that we needed to receive your medical records prior to your appointment. Please fax records at least 48 hours in advance to (202) Someone from our office will contact you if we have any questions or concerns regarding receipt of your records. If you need to get in touch with our office, please call the appointment scheduling desk at (202) Use this number for appointment verification, changes, or cancellations. Feel free to leave a message and someone from our office will call you back within 24 hours. The Lombardi Comprehensive Cancer Center is an outpatient clinic in the hospital. Therefore your insurance will receive a minimum of 2 bills one for the professional fee for the provider, and one for the facility. If x-rays or labs are done, those will be billed to your insurance company separately. On behalf of our physicians and staff, thank you for choosing the Lombardi Comprehensive Cancer Center.

2 Lombardi Comprehensive Cancer Center New Patient Health History Form Name Age Birth date Occupation Birthplace Marital Status: Single Married Widowed Divorced Separated Phone number to use for appointments, lab results, etc.: Home: Work: Cell: Whom should we contact in case of emergency? Relationship: Phone: Do you have: An Advanced Directive Yes No A Living Will.. Yes A Durable or Medical Power Of Attorney.. Yes No No Would you like information on advance directives?. Yes Do you reside alone?...yes If No, Who do you reside with? No No Please briefly explain why you are coming to the Lombardi Comprehensive Cancer Center.

3 Please provide the names of the other Health Care Providers involved in your care. Referring Physician Primary Care Physician Surgeon Radiation Oncologist Other Physician Other Physician FAMILY MEDICAL HISTORY Mother Maternal Grandmother Maternal Grandfather Maternal Aunts Maternal Uncles Maternal Cousins(M/F) Father Paternal Grandmother Paternal Grandfather Paternal Aunts Paternal Uncles Paternal Cousins Siblings(M/F) Members Living/Deceased Health Issues Children(M/F) PERSONAL MEDICAL HISTORY SURGERY ADULT ILLNESSES TONSILLECTOMY.YES DIABETES.YES APPENDECTOMY.. YES HIGH BLOOD PRESSURE YES

4 PERSONAL MEDICAL HISTORY CONT. HYSTERECTOMY..YES HEART PROBLEMS..YES Including the ovaries...yes RESPIRATORY PROBLEMS YES HERNIA REPAIR....YES BLEEDING PROBLEMS...YES GALLBLADDER SURGERY.YES MENTAL ILLNESS YES OTHER (explain)..yes DEPRESSION.YES OTHER(explain)..YES INJURIES SIGNIFICANT ACCIDENTS..YES BROKEN BONES... YES GENERAL MEDICAL INFORMATION HEIGHT WEIGHT Current One year ago Maximum EXPOSURES MEASLES.. YES MUMPS.. YES CHICKEN POX.. YES TUBERCULOSIS... YES OTHER (explain)... YES PNEUMOVAX... YES TETANUS... YES HEPATITIS B VACCINE YES FLU VACCINE.... YES OTHER (explain)... YES WOMEN S HEALTH MENSES: age of onset cycle duration last menstrual cycle ESTROGENS: oral contraceptives.. YES hormone replacement YES PAP SMEAR: last examination abnormal YES MAMMOGRAM: last study abnormal...yes IMMUNIZATIONS PREGNANCIES: total number live births miscarriages complications....yes AGE AT 1st FULL TERM PREGNANCY MEN S HEALTH PROSTATE: last examination abnormal YES PSA: last test abnormal YES TESTICULAR SELF EXAMS YES

5 SOCIAL HISTORY FAT INTAKE TOBACCO USE CAFFEINE INTAKE CAFFEINATED DRINKS PER DAY: EXERCISE ALCOHOL USE PRESCRIPTION MEDICATIONS MEDICATION DOSE FREQUENCY REASON

6 N-PRESCRIPTION MEDICATIONS (PLEASE INCLUDE OVER THE COUNTER MEDICATIONS, VITAMINS, SUPPLEMENTS, ETC) MEDICATION DOSE FREQUENCY REASON MEDICATION ALLERGIES MEDICATION REACTION

7 General Medical Records release and Authorization for Use or Disclosure of Protected health Information Please complete the following information: Patient Name: Address: Phone: SSN: Date of Birth: / / I authorize the custodian of records of: or other person/entity (specifically describe) to disclose/release the following information (check all that apply): All records Laboratory/pathology records Billing records X-ray/radiology records Pharmacy/prescription records Abstract/Summary Other (please describe) These records are for services provided on the following date(s): Please send the records listed above to (use additional sheets if necessary): Name: Address: Phone: Fax: The information may be used/disclosed for each of the following purposes: At my request (only the patient can check this box) For employment purposes For my health care For payment/insurance Other (please describe) This authorization shall expire no later than: / / or upon the following event (whichever is sooner), except this authorization shall automatically expire upon a minor s 18th birthday and may not be valid for greater than one year from the date of the signature for Maryland medical records. I understand that after the custodian of records discloses my health information, it may no longer be protected by federal privacy laws. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment; receive payment; or eligibility for benefits unless allowed by law. By signing below, I represent and warrant that I have authority to sign this document and authorize the use or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information. Signature of patient or patient s legal representative Date Printed name of patient representative Representative s authority to sign for the patient, (parent, guardian, power of attorney for healthcare, executor, etc.) You have the right to revoke this authorization, except to the extent the custodian of records has relied on it, by sending your written request to Privacy Liaison, 3800 Reservoir Road NW, Washington, DC

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

Patient Name:,, Address: Phones:,, Home Work Cell. Primary Physician: Emergency Contact: Phone#: Patient Information Patient Name:,, Last First middle initial Address: Phones:,, Home Work Cell Sex: Female Male E-Mail: Date of Birth: / / Mo. Day Year Primary Physician: Marital Status: Single Married