MARATHON HEALTH CENTER a benefit of CHG Health and Wellness
|
|
|
- Garey Morrison
- 6 years ago
- Views:
Transcription
1 Health & Wellness MARATHON HEALTH CENTER a benefit of CHG Health and Wellness WE ARE A DIFFERENT KIND OF HEALTHCARE COMPANY. OUR MISSION IS TO INSPIRE PEOPLE TO LEAD HEALTHIER LIVES. CHG Healthcare Services 2012/07 BEN-032 V-5
2 What is the Marathon Health Center? The Marathon Health Center, a benefit of CHG Health and Wellness, will provide valuable services for minor and non-emergency care as well as health coaching. This benefit is designed to increase access to high quality care, help you better understand your own health, and provide you with the tools you need to address any areas of concern. The center will be staffed by a Marathon Health nurse practitioner (NP) who can perform most services available at a PCP or urgent care setting. This benefit is a convenient place to obtain preventive and sick care as well as health coaching and disease management services. You can save time and money by visiting the Marathon Health Center. Who is Marathon Health? Marathon Health, our program partner, is dedicated to bringing quality health services to the workplace by providing medical care, guidance about health risks and conditions, and support for managing your health. Marathon Health operates nationwide and is focused on helping people become more engaged in their own health and healthcare. Your Marathon ehealth Portal Marathon Health also offers a comprehensive website, the Marathon ehealth Portal, which provides helpful and easy-to-use tools you can access anywhere, including: Relevant health information and news Appointment scheduler Fitness and nutrition logs Health History and Risk Assessment (HHRA) Secure system that allows you to communicate with your health coach Each CHG employee received a welcome letter via that included a username and password to access the Marathon ehealth Portal. If you did not receive this , please contact Marathon Health at or Your spouse or domestic partner will receive a letter containing his/her login and password information.
3 When is the Marathon Health Center open? The center will open in early August with appointments available Monday through Friday from 8 a.m. 5 p.m. What is the cost for these services? Health coaching is free to all CHG employees and their immediate family members. For a medical appointment, if you are insured through CHG s health plan there is no cost to you or your immediate family. If you are not insured through CHG, a visit costs $38. How do I schedule my appointments for primary care or for health coaching? To schedule appointments for either health coaching or non-emergency care, visit Just click on the appointments tab in the top menu bar and use the appointments wizard to schedule a time that works for you. Or you can call to schedule your appointment.
4 Primary Care Services Abdominal pain Acne Allergy shots Ankle sprain or injury Annual exams and screenings Anxiety Asthma flare-ups Arthritis Bell s palsy Birth control Bloody sputum Blood in the urine Blood pressure screens Bladder infections Bronchitis Callus and corn removals Care coordination Chronic disease management Circulation issues Cough/Cold Constipation Chest pain Depression Diabetes Digestive problems Difficulty breathing Diarrhea Diverticular disease Dizziness/Vertigo Ear pain Ear wax removal Eczema Eye infections Elbow pain or injury Fatigue Fever Flu Fractures evaluation Gallstones Gout Headache Hip pain High blood pressure High cholesterol Hemorrhoids Hernia Herpes simplex and herpes zoster Irritable bowel disease Immunizations/ Injections Kidney stones Knee pain or injury Leg edema Low back pain Migraines Mouth sores Minor burns Nausea Neck pain Nose bleeds Palpitations Pneumonia Pregnancy education Prescription management Referrals managment Runny nose Strep throat Sinus infection Shoulder pain Skin infections/rashes Sleep disturbances Sports/camp physicals Splinter removal Stress reduction Sutures/removal Tobacco cessation Thyroid disease Travel medicine Upper respiratory infections Vomiting Warts/removal Weight gain/loss Wrist pain or injury Yeast infections
5 What is health coaching? As part of the serivces provided by Marathon Health, you will be able to receive health coaching through a Marathon Health NP. The coach will help you identify and prioritize health concerns. Working together with you, action plans are developed to help reduce health risks, achieve health goals and, most important, to celebrate success. Health coaching is available for an array of personal issues or concerns, including weight loss, stress management, tobacco cessation and low back pain. Additionally, coaches are available to help with disease management for conditions such as diabetes, heart disease and high blood pressure. Health coaching services: Weight management Cholesterol Tobacco cessation Pre-diabetes Pre-hypertension Fitness Nutrition Stress management Blood pressure screening Cholesterol screening Depression screening Diabetes screening
6 Why should I participate in health coaching? You can improve your health and receive information about managing health issues. Coaching is convenient, and your first consultation is held in a confidential setting at work; subsequent consultations can be in person or by telephone. Wait times are minimal because coaching appointments are scheduled in advance. How long does the coaching session take? Most appointments take about 30 minutes, unless it is a one-time Comprehensive Health Review; this may last 45 minutes. How much will it cost? Do I need to use PTO for my session? Health coaching is provided free to all employees and no, you do not need to use PTO for the session. However, please inform your manager when you will be away from your desk. Who has access to my information? Marathon Health uses health information about you for treatment, to obtain payment for treatment, to evaluate the quality of care you receive and for administrative purposes. Your health information is contained in a medical record that is the physical property of Marathon Health. For more information about how your medical information may be used or disclosed, visit Will my private health information be shared with CHG? No. Marathon Health is a third-party provider contracted to provide healthcare services to you at work and will not release personally identifiable health information to CHG, in accordance with federal Health Insurance Portability and Accountability Act (HIPAA) requirements.
7 However, in an effort to better understand the overall health needs of employees and their families, Marathon Health will provide summary information (general statistics and aggregate information) about activities and results, such as how many employees use health coaching how many people participate in the health screenings the prevalence rate of risk factors such as smoking, obesity and high blood pressure benefits associated with health coaching reasons employees use health coaching Marathon will also provide completion lists for specific WellnessPays activities, such as flu shots, preventive visits, health screenings or coaching programs. These lists will only show who completed the activities to earn points and will not include results, diagnoses, treatments or other personal health information. If you have questions, please contact a member of CHG s benefits team at or via at benefits@chghealthcare.com.
8 Marathon Health is dedicated to bringing health services to you at the workplace. We help you understand your health risks and conditions and guide you to make changes to live the healthiest possible lifestyle. We provide our services with clinicians who offer one-on-one healthcare, coaching and support. We believe in using technology to help make the best healthcare decisions. Our technology includes an ehealth Portal and Personal Health Record with clinical decision support tools, consumer content, and interactive diet and nutrition trackers. Our focus is on helping you set and achieve health goals, manage your own health, and to make better use of your healthcare resources. Health & Wellness
MARATHON HEALTH CENTER AND HEALTH COACHING a benefit of CHG Health and Wellness for our North Carolina office
Health & Wellness MARATHON HEALTH CENTER AND HEALTH COACHING a benefit of CHG Health and Wellness for our North Carolina office WE ARE A DIFFERENT KIND OF HEALTHCARE COMPANY. OUR MISSION IS TO INSPIRE
Marathon Health Center and Health Coaching
Marathon Health Center and Health Coaching a benefit of CHG Health and Wellness for our Utah offices We are a different kind of healthcare company. Our mission is to inspire people to lead healthier lives.
Marathon Health Center and Health Coaching
Marathon Health Center and Health Coaching a benefit of CHG Health and Wellness for our Utah offices We are a different kind of healthcare company. Our mission is to inspire people to lead healthier lives.
ADULT PATIENT INFORMATION. Patient Name: Last Name First Name Address: City: State: Zip Code: Phone #: Cell Phone #: Social Security:
716 S. Goldenrod Road n 3315 Orange Blossom Trail Fax (407) 658-2536 Fax (407) 343-1907 ADULT PATIENT INFORMATION Patient Name: Last Name First Name MI Address: City: State: Zip Code: Phone #: Cell Phone
NEW EMPLOYEE HEALTH PLAN BENEFIT. Care When You. Need
NEW EMPLOYEE HEALTH PLAN BENEFIT Care When You Care When You Want It Need It What is Access Health? WHAT IS ACCESS HEALTH? Access Health offers cost savings worksite solutions by providing a medical clinic
Allergies Drug Food Environmental. Previous Surgeries & Hospitalizations (Please list date, reason, and hospital)
Allergies Drug Food Environmental Previous Surgeries & Hospitalizations (Please list date, reason, and hospital) Habits Do you ever use the following? If yes, how often? Tobacco Alcohol Recreational Drugs
DOUGLAS JAY SPRUNG MD, FACG, FACP The Gastroenterology Group
DOUGLAS JAY SPRUNG MD, FACG, FACP The Gastroenterology Group Date: NAME: AGE: DOB: Why are you here to see the doctor today? REFERRED BY: INSURANCE HEALTH GRADES INTERNET FRIENDS/RELATIVES PCP OTHER: Medications
Walk-in Clinic. Dear Patients. Frequently Asked Questions (FAQ)
Walk-in Clinic Klamath Tribal Health & Family Services 330 Chiloquin Boulevard Chiloquin, OR 97624 (541) 882-1487 Frequently Asked Questions (FAQ) Monday Friday, 8:00 a.m. 3:30 p.m. * First Wednesday of
Age: Birthdate: Date of Last Physical exam:
Name: : Age: Birthdate: of Last Physical exam: SYMPTOMS: Check symptoms you currently have OR have had within the past YEAR. General Fever Chills Weight loss Weight Gain Headache Depression Vertigo Ringing
Benefits That Benefit You
Benefits That Benefit You Liisa Granfors-Hunt Director of Account Management Corporate Synergies & Cathy Sapp Executive Director Teladoc WHAT IS TELEMEDICINE? A modern way of delivering care that is becoming
Welcome to Pinnacle Chiropractic Spine and Sports Center
Welcome to Pinnacle Chiropractic Spine and Sports Center Name: Social Security Number: : Address: City: State: Zip: _ Telephone Home: Work: Mobile: _ Age: of Birth: Height: Weight: Gender: M / F Employer:
Welcome to Pinnacle Chiropractic Spine and Sports Center
Welcome to Pinnacle Chiropractic Spine and Sports Center Name: Social Security Number: : Address: City: State: Zip: _ Telephone Home: Work: Mobile: _ Age: of Birth: Height: Weight: Gender: M / F Employer:
FAQ S. Frequently Asked Questions: WellCare Clinic Logistics
Frequently Asked Questions: FAQ S WellCare Clinic Logistics 1. What is the City of Lawrence WellCare Clinic? The City of Lawrence WellCare Clinic is a part of the CHAMP Wellness Program. The WellCare Clinic
Pediatric New Patient Form
Pediatric New Patient Form Internal Medicine & Pediatrics Patient Information Today's Date: Legal Name: Gender: M / F Date of Birth: Age: Race : Ethnicity: E-mail Address: Other: Home Address: Primary
New Patient Registration Form NJR_NP_F100
New Patient Registration Form NJR_NP_F100 Patient Last Name First Name Middle Name Maiden Name Address (Street or Box) City State Zip Code Home Phone Number Cell Phone Number Work Phone Number E-Mail Patient
Patient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name
*SHAREDID-42* Date of Birth: Page 1 of 2 Patient Registration Account # Patient Name Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex City, State & Zip Code
Anne C. Roulo, DC 7501 Murdoch Ave, Shrewsbury, MO, Patient Data Sheet
Anne C. Roulo, DC 7501 Murdoch Ave, Shrewsbury, MO, 63119 314.484.0690 Patient Data Sheet Date Name: Address: City: State: Zip: Social Security Number: - - Email: Home Phone: ( ) Cell Ph.: ( ) Work Ph.:
PATIENT INFORMATION SHEET:
PATIENT INFORMATION SHEET: LAST NAME: FIRST NAME/MI: ADDRESS: CITY: STATE: ZIP CODE: SOCIAL SECURITY #: HOME: CELL: WORK: SEX: M F BIRTHDATE: MARITAL STATUS: SINGLE MARRIED WIDOWED OTHER EMPLOYER NAME:
R. B. KO L A C H A L A M M. D. GENERAL SURGERY
GENERAL SURGERY Patient Information (Please Print and Circle or check the appropriate response) Patient s Name: DOB: _ Address: City: _ Zip: Home Phone: Cell: Work:_ Email Address: Patient s SSN: Male
Male Female Mailing Address: Apt. #: City: State: Zip Code:
Patients ame: (Last, First, MI): DOB: SS: Circle One: / / Male Female Mailing Address: Apt. #: City: State: Zip Code: Driver s Lic or ID #: How would you like to be contacted for appointment reminders?
PATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION Patient Name: Date of Birth: SSN: Cell Number: Cell Phone Provider: Home Number: Work Number: Home Address: City/State: Zip: Employer: Occupation: E-Mail: Relationship Status: S M W
Welcome to our office! Please fill out this form as completely as possible and return it to the desk.
Welcome to our office! Please fill out this form as completely as possible and return it to the desk. Name of Doctor you wish to see: Today's Date Name Email Address Address Home Male Female Cell City
WITHOUT YOUR WRITTEN CONSENT, WE CAN NOT SPEAK TO ANYONE REGARDING YOUR MEDICAL CARE due to privacy laws. You have the right to list anyone you
PATIENT REGISTRATION FORM PLEASE PRINT : Referring Physician: Primary Care: Patient s Name: Last First: M.I. Address: City: State: Zip: Home Phone: Cell: Work: Email: Preferred Contact Method Race: Ethnicity:
Patient s Full Name DOB Age. Patient s SSN Sex: Male Female Preferred Language. Place of Birth: City State Country
Hoover Hearing Clinic A division of Hoover ENT Hoover, Alabama 35244 205-733-9694 Tel PATIENT INFORMATION ACCOUNT # DATE MD NEW UPDATE Patient s Full Name DOB Age Patient s SSN Sex: Male Female Preferred
SMG OB/GYN Lake Lansing St. Johns Returning Patient Questionnaire (Please print clearly and Fill out Entirely)
SMG OB/GYN Lake Lansing St. Johns Returning Patient Questionnaire (Please print clearly and Fill out Entirely) Name: Former/ Maiden Name: Date of Birth: Age: Today s Date: *Language: Race: Ethnicity: *Do
Welcome to MDLIVE. consultmdlive.com /7/365 access to U.S. board-certified doctors. Request a consultation
Welcome to MDLIVE Welcome to MDLIVE 24/7/365 access to U.S. board-certified doctors Request a consultation *Important: Prescriptions are issued only when clinically appropriate. No controlled substances
PATIENT INFORMATION. Address: Sex: City: State: address: Cell Phone: Home Phone: Work Phone: address: Cell Phone:
PATIENT INFORMATION Name: _ DOB: _ Age: Address: _Sex: City: _ State: _ Zip: _ Email address: Cell Phone: _ Home Phone: Work Phone: _ Responsible Party (if different from above) Name: DOB: Address: E-mail:
SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet
SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet DATE Name (First, Middle, Last): Date of Birth: SSN: Mailing Address: City, State and Zip: Phone: Home Cell Other Alt Phone: Home Cell
Our office hours are Monday, Tuesday and Thursday, 7 a.m. to 7 p.m, Wednesday, 8 a.m. to 5 p.m. and Friday, 8 a.m. to 4 p.m.
BAPTISTMEDICALGROUP.ORG Primary Care - Gulf Breeze Dear Patient, Thank you for choosing Baptist Medical Group Primary Care - Gulf Breeze to provide you with compassionate care for your health care needs.
The Home Doctor. Registration Checklist
The Home Doctor Registration Checklist All enrollees: ( ) Enrollment Form ( ) Copy of Insurance card(s) ( ) Medication List ( ) POA/Guardianship documents NOTICE Please allow two weeks for processing this
Health & Safety Packet for Incoming Students
Health Occupations Division 707-256-7600 Health & Safety Packet for Incoming Students This packet has been designed to help Health Occupations students comply with CPR and health/physical documentation
Name DOB / / SS# / / Street Address City/State/Zip. Home ( ) - Cell( ) - Work( ) - Emergency Contact Day Phone( ) -
Wellesley Women s Care, P.C. PPG Thank you for taking the time to complete this form. We ask that you complete this entire form once a year or when you have any NEW information. PATIENT INFORMATION (Please
Workers Compensation Demographic
Workers Compensation Demographic Account #: Physician: Last Name First Name MI: Address City State Zip Home Phone o OK to Leave Msg. Work Phone o OK to Leave Msg. Cell Phone o OK to Leave Msg. Email Do
FLORIDA MEDICAL CLINIC, P.A. Your Life, Our Specialty
FLORIDA MEDICAL CLINIC, P.A. Your Life, Our Specialty Consent for Purposes of Treatment, Payment and Health Care Operations I consent to the use or disclosure of my protected health information by Florida
May Family Chiropractic Health Information and Health History Patient Name: Gender: Male Female
1 Health Information and Health History Patient Name: Gender: Male Female Marital Status: (Circle one) M S D W Other: Date of Birth / / Spouse Name: How many children: Patient Social Security Number: -
A Department of Adena Regional Medical Center 60 Capital Drive Chillicothe, OH (740) (740) WELCOME TO OUR CLINIC!
A Department of Adena Regional Medical Center 60 Capital Drive Chillicothe, OH 45601 (740) 779-4100 (740) 779-4149 WELCOME TO OUR CLINIC! We are pleased that you have chosen Adena Chillicothe Family Physicians
Patient Communication Request
Patient Communication Request Name: Date of Birth: Address: ZIP: Home Phone: Work Phone: Cell Phone: E-mail address: It is the policy of Capstone Family Practice to contact patients for any lab results.
SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet
SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet DATE Name (First, Middle, Last): Date of Birth: SSN: Mailing Address: City, State and Zip: Phone: Home Cell Other Alt Phone: Home Cell
PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT.
PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: 516-354-8597 ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT. THANK YOU - 1 - NEW PATIENT MEDICAL INFORMATION Steven J.
Would you like to follow us on: Twitter Facebook Physician's Signature
PATIENT REGISTRATION INFORMATION TODAY S DATE: / / Last Name First Name MI Soc. Sec. # Date of Birth Sex Male Female Patient Address Apt. City, State, Zip Single Married Divorced Widow Home Phone Work
Welcome to the Southeastern Urology Associates meridianemr Patient Portal
New Patients: Please register for our Portal following the instructions below and send us a Message though the New Message Message for Office Section to let us know you received this packet and are confirming
Patient Name: Last First Middle
Wilmington Ear Nose & Throat Associates, PA Patient Information Form Patient Name: Last First Middle Mailing Address: Street Address (if different from above): City: State: Zip Code: Social Security #:
Wellness Guide for LCRA Retirees
2016 Wellness Guide for LCRA Retirees Contents 2 How the EmPOWER program works 3 How to register 3 Text message reminders 4 Member health assessment 4 Biometric screening 5 Earning points and saving money
State of NM Group Benefits Plan Plan Year: January-December 2015
State of NM Group Benefits Plan Plan Year: January-December 2015 Who We Are Founded in 1908, Presbyterian Healthcare Services has served New Mexicans for more than 100 years. Presbyterian Health Plan was
Dear Patient, Sincerely, Gastroenterology Associates of North Jersey
GASTROENTEROLOGY ASSOCIATES OF NORTH JERSEY, P.A. Doctors Park 369 West Blackwell Street, Dover, NJ 07801 16 Pocono Road, Suite 210, Denville, NJ 07834 Tel (973) 361-7660 Fax (973) 361-0455 Tel (973) 627-7600
A doctor is always IN
A doctor is always IN Your company has selected MDLIVE to provide you with 24/7/365 access to board-certified primary care doctors and pediatricians by online video or phone. Go to mdlive.com/duquesne
THANK YOU FOR JOINING
WELCOME KIT THANK YOU FOR JOINING Priority Private Care is New York s leading healthcare curator and urgent medical service provider. From our 24/7 facility on the Upper East Side, we provide our members
PATIENT REGISTRATION
PATIENT REGISTRATION Date: Patient Name Last First Middle Initial (Nickname) Home Address Street Apt# City State Zip ( ) Male ( ) Female Body part being evaluated Marital Status: ( ) Single ( ) Married
Bellevue Neurology PATIENT DEMOGRAPHIC FORM
PATIENT DEMOGRAPHIC FORM Name Today s date / / Last First M.I. Mailing Address Age Number, Street, Apartment Number City State Zip Home Phone ( ) Work Phone ( ) Cell Phone ( ) Date of Birth / / SS # Marital
PATIENT INFORMATION & CONDITION FORM
PATIENT INFORMATION & CONDITION FORM Patient Name: Today's Date: / / Social Security Number Birth Date: / / Age: Gender: F M Email Height : Weight: Specify Right or Left Handed Have you ever been in our
Patient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other. Address
Patient Information Patient Information Date of Birth Sex Marital Status Male Female Single Married Other Social Security Number - - Why We Ask for Race and Ethnicity Patient Goes By: Email Address In
Name (First): (MI) (Last) Date: Address: City: State: Zip: Home Phone: Cell Phone: Driver s License #: Driver s License State: Occupation:
Board Certified & Fellowship Trained in Sports Medicine & Orthopaedic Arthroscopic Surgery 9980 Central Park Blvd North, Suite 222 Boca Raton, FL 33428 Please Print: Name (First): (MI) (Last) Date: Address:
Patients Name. Insurance policy holders name and Social security number. Address. Home Phone number. Work Phone Number
Patient Registration Form Print out this form and also the Health History Form. Bring both fully completed forms and your insurance card with you and give them to our staff as you check in for your appointment.
Patient Information: Last Name First Name MI. Address Apt/Room # City Zip. Community name (if not at home) Martial Status: S M W D
HouseCalls-MD 2998 W. Montague Ave. Suite 117 N. Charleston, SC 29418 Info@housecalls-md.com Office 843-501-2031 www.housecalls-md.com Fax 888-453-0810 Patient Information: Last Name First Name MI Gender
Columbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR fax Physician
Columbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR 97031 541-387-6125 fax 541-387-6315 Physician Welcome to the Columbia Gorge Heart Clinic. We welcome you as a patient and
Hello and Welcome! I truly look forward to working with you and your child on the journey towards optimal health. Warmly, Amanda H.
Hello and Welcome! Attached you will find pediatric intake forms. Before your child s scheduled appointment, please fill out the forms as thoroughly as possible. I know your time is valuable and by bringing
Office Hours Our office hours are Monday through Friday 7:30 am to 5:30pm. Our office is closed on all major Holidays.
Dear New Patient: We would like to welcome you to our practice. Our goal is to make your experience with us as pleasant as possible. In order to help us meet this goal we have listed some helpful hints
COLON & RECTAL SURGERY, INC.
COLON & RECTAL SURGERY, INC. Please complete attached paperwork and bring to your appointment with your insurance card, co-pay and photo ID. If a referral is required, please be sure to contact your insurance
College of Sequoias Physical Therapist Assistant Program Student Health Release Form
Part A: College of Sequoias Physical Therapist Assistant Program Student Health Release Form To be completed by the Student Name: Telephone: Cell Number: Address: City: ZIP Code: Birth Date: Family Health
PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip
PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip Primary Phone ( ) Secondary Phone ( ) Other Phone ( ) SS# - - Race Ethnicity Email address Preferred language Marital Status Minor Single
ALASKA COMMUNITY HEALTH AIDE/PRACTITIONER PROGRAM Standing Orders
CHA/P Name: Village: Tribal Health Organization: is authorized to treat patients with the CHAM ASSESSMENTS that are initialed below according to the PLAN listed in the 2006 Alaska Community Health Aide/Practitioner
Entrance Case History (Please write or print clearly)
Stony Brook Medical Park 2500 Nesconset Highway Suite 4-A Stony Brook, NY 11790 (631) 675-9000 Fax (631) 675-9002 www.naturalapproach.us Entrance Case History (Please write or print clearly) Today s Date
Date: Name: Date of birth: Reason for today s visit: If yes, what are you allergic to and what type of reaction/symptoms did you have?
Date: Name: Date of birth: Nickname/prefer to be called: Date that your last menstrual period began: Reason for today s visit: Allergies to medications/foods/substances? Yes No If yes, what are you allergic
Julie Gussenhoven, OD 3416 Bechelli Lane Redding, CA 96002
Julie Gussenhoven, OD OCULAR AND MEDICAL HISTORY QUESTIONNAIRE Name: M F Date: Date of Birth: Home Phone: Social Security #: Cell Phone: Address: Work Phone: City: Zip: Email: Please complete all personal
Frequently AskedQuestions
Virtual Care, Anywhere. Telehealth Program Frequently AskedQuestions What is MDLIVE? With MDLIVE, you can access a board-certified doctor via secure online video, phone or the MDLIVE App anytime, anywhere,
Pediatrics How-to Guide for TRICARE Beneficiaries. Readiness Better Care Trusted Care, Anywhere Best Value Better Health
Pediatrics How-to Guide for TRICARE Beneficiaries Pediatric Clinic Operations How to Set Up an Appointment Appointment Line 722-1802 (0700-1630) Call early for same day appointment! 1. The Appointment
The process has been designed to be user friendly and involves a few simple steps.
HOW DO I ENROLL A PATIENT WITH HOUSECALL MD? The process has been designed to be user friendly and involves a few simple steps. It is the patient s/family s/dpoa s/guardian s decision, if they want to
Date: Name: Date of birth: Reason for today s visit: If yes, what are you allergic to and what type of reaction/symptoms did you have?
Date: Name: Date of birth: Nickname/prefer to be called: Date that your last menstrual period began: Reason for today s visit: Allergies to medications/foods/substances? Yes No If yes, what are you allergic
Middle Initial: Street Address: City: Date of Birth: Age: Marital Status: Occupation: Employer: Name of Spouse: Emergency Contact:
SALT LAKE EYE ASSOCIATES, LLC (801) 281-2020 1025 E 3300 S, SLC, Utah * Patient Information Sheet First Name: Last Name: Middle Initial: Referred By Family Doctor EMAIL Street Address: City: State: Zip:
TODAYS DATE WHICH PHYSICIAN ARE YOU SEEING TODAY? NAME (LAST) (FIRST) (MI) ADDRESS CITY STATE ZIP DATE OF BIRTH
TODAYS DATE WHICH PHYSICIAN ARE YOU SEEING TODAY? NAME (LAST) (FIRST) (MI) ADDRESS CITY STATE ZIP HOME PHONE CELL PHONE WORK PHONE MALE FEMALE DATE OF BIRTH EMAIL SOCIAL SECURITY # DRIVERS LICENSE # DRIVERS
DAILY ACTIVITIES (Q1)
THE QUESTIONS OF HOWSYOURHEALTH ADULT AND SCORING CONVENTIONS 1/2017 * ARE USED IN THE CALCULATION SHOWN IN THE CUMULATIVE REPORTS ++ ARE USED IN THE WHAT MATTERS INDEX Gender: Male Female Age Groups:
Fulcrum Orthopaedics Patient Registration Packet
Fulcrum Orthopaedics Patient Registration Packet 2 Patient Information Form 8 Consent for Use and Disclosure of Information 9 Authorization for Use and Disclosure of Protected Health Information 10 Notice
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM PATIENT INFORMATION Name: Date of Birth: Age: Address : Social Security #: City: Sex: Marital Status: State: Zip: Language: Pt Declines Home Phone#: Race: Pt Declines Work Phone#:
PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU!
PATIENT INFORMATION FORM PATIENT DATA: - - PATIENT NAME (LAST, FIRST, MIDDLE) SOCIAL SECURITY # SEX ( ) - ( ) - ADDRESS HOME PHONE NUMBER MOBILE PHONE NUMBER CITY STATE ZIP CODE OCCUPATION / / DATE OF
How telemedicine can help make employees happier, healthier, and more productive.
How telemedicine can help make employees happier, healthier, and more productive. 50% of emergency room visits are non-emergencies. 1 2 $38B per year is wasted by U.S. emergency rooms as a result of overuse.
CONTENTS. 4 How to Use the Program. 5 How to Register. 6 Awareness
CONTENTS 4 How to Use the Program 5 How to Register 6 Awareness 7 Earning Points Incentive Programs 8 Wellness Rate Program 9 Healthy Rewards Program 10 Prevention 11 Employer & Peer Challenges 12 Education
Pediatric Patient History
Pediatric Patient History Childs Name: Today s Date: Primary Doctor: Date of Birth: Age: Reason for visit: List all chronic medical problems: List all medication dosages and frequency taken (including
BBVA Compass Employee Health Center
BBV Compass Employee Health Center Rev. January 2016 Introduction Wellness is an important part of the culture at BBV Compass, and we encourage healthy diet, exercise and lifestyle choices for all team
Welcome to Fosston Chiropractic Clinic, P.A.
Welcome to Fosston Chiropractic Clinic, P.A. www.fosstonchiro.com Chiropractic Acupuncture Sport and Spinal Rehabilitation Thank you for choosing us for your chiropractic care. Please complete this form.
Please allow us hours to refill the medication; approval from your medical provider is required on all refills.
Thank you for choosing Rex Primary Care of Holly Springs for your primary care needs. To keep our patients better informed we have created a list of our office policies to make your visit and continuation
Address City, State Zip Code Phone
Email Correspondence Authorization Patient Name Date of Birth Address City, State Zip Code Phone By signing this form, I authorize Angela Pifer, Certified Nutritionist and 28 Day Health Solutions Co. (Angela
Last Name First Middle. Mailing Address. City State Zip Phone. Date of Birth Age Soc. Sec# Cell. Employer Work Phone
Last Name First Middle Mailing Address City State Zip Phone Date of Birth Age Soc. Sec# Cell Employer Work Phone Email Address Emergency contact Phone # Relation: Name of Primary Insurance Policy # -----
Naturopathic Wellness Center
Naturopathic Wellness Center Ashley G. Lewin, N.D. Erica Waters, ND Mychael Seubert, ND Pediatric Intake Birth to 3 years Name Sex Date of Birth / / Age Parent(s)/Guardian(s) Address City/State/Zip Telephone
Virginia Heartburn & Hernia Institute
Virginia Heartburn & Hernia Institute PATIENT INFORMATION FORM (Please make sure to print clearly and sign at the bottom of this page) Patient s Last Name: First: Middle Initial: Marital Status: Married
New Patient Intake Questionnaire
New Patient Intake Questionnaire NAME: DATE: / / BIRTHDATE: / / REFERRED BY: AGE: REASON FOR VISIT: LOCATION OF PAIN: BACK HIP BUTTOCK LEG FOOT RIGHT LEFT NECK ARM SHOULDER HAND RIGHT LEFT OTHER (DESCRIBE)
What to Expect If you need care
What to Expect If you need care in the United States Online Consumer Portal Backed by the power of UnitedHealth Group, the largest single carrier in the United States, UnitedHealthcare Global is committed
WELCOME TO THE UPMC LIVER CANCER CENTER PLEASE FILL OUT AND BRING WITH YOU TO YOUR APPOINTMENT
WELCOME TO THE UPMC LIVER CANCER CENTER PLEASE FILL OUT AND BRING WITH YOU TO YOUR APPOINTMENT You are scheduled to have an appointment at the UPMC Liver Cancer Center which is located in the UPMC Montefiore
Thank you for choosing Southern WV Endocrinology. Enclosed you will find your new patient
Welcome, Thank you for choosing Southern WV Endocrinology. Enclosed you will find your new patient paper work that must be completed and mailed back to us as soon as possible. Please bring your medication
PHONE: (813) FAX:
Welcome to Natural Healing of Tampa Bay! We look forward to meeting you and also working with you towards your wellness goal. We have enclosed a new patient packet which should be filled out prior to your
2200 Northern Boulevard, Suite 133 East Hills, NY Fax (516) Transitional Care
2200 Northern Boulevard, Suite 133 East Hills, NY 11548 855-670-6077 Fax (516) 918-9039 Transitional Care Dear New Patient: We welcome you to our practice as a transitional patient. We will be managing
Stage 2 GP longitudinal placement learning outcomes
Faculty of Life Sciences and Medicine Department of Primary Care & Public Health Sciences Stage 2 GP longitudinal placement learning outcomes Description This block focuses on how people and their health
Family Medicine Division. Nyree Bryant DO George R. Davis DO
Family Medicine Division Nyree Bryant DO George R. Davis DO 11/12/17 Dear New Patient, Welcome to Florida Medical Clinic! We are happy that you have made our office your choice for your medical care needs.
ACKNOWLEDGEMENT OF HIPAA PRIVACY INFORMATION CONSENT TO USE OR DISCLOSE MEDICAL INFORMATION
Patient Name (PLEASE PRINT): Date of Birth: ACKNOWLEDGEMENT OF HIPAA PRIVACY INFORMATION The & Center of Southern Oregon, PC s Notice of Privacy Practices contains information about the uses and disclosures
Rosati Family Chiropractic Intake Form
Patient Data Date Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name I prefer to be called by Address City State Zip Code Home Phone ( ) - Work Phone ( ) - Cell Phone (
Virtual Care, Anywhere. Telehealth Program Frequently Asked Questions
Virtual Care, Anywhere. Telehealth Program What is MDLIVE? With MDLIVE, you can access a doctor from your home, office or on the go- 24/7/365. Our Board Certified doctors can visit with you by secure video
DAHIYA FACIAL PLASTIC SURGERY AND LASER CENTER CONSULTATION AND MEDICAL HISTORY. Name Date of Birth Today s Date Address: Street City State Zip
DAHIYA FACIAL PLASTIC SURGERY AND LASER CENTER CONSULTATION AND MEDICAL HISTORY Name Date of Birth Today s Date Address: Street City State Zip Home phone: May we contact you on your home phone? YES NO
MEDICAL HISTORY QUESTIONNAIRE Last name First Name MI DOB. Please answer the following questions about your current eye problems and medical history:
MEDICAL HISTORY QUESTIONNAIRE Last name First Name MI DOB Please answer the following questions about your current eye problems and medical history: 1. What problems are you CURRENTLY having with your
Yavapai Combined Trust. Offering as of July 1, 2018:
Yavapai Combined Trust Offering as of July 1, 2018: Talk to a anytime Teladoc is a national network of U.S. board-certified doctors available on-demand 24/7/365 to diagnose, treat and prescribe medication,
Filling out this form will help us provide the best possible care for you. What are the main questions or problems you would like help with?
Filling out this form will help us provide the best possible care for you. What are the main questions or problems you would like help with? 1. 2. 3. IMPORTANT PLEASE BRING A COMPUTER DISK WITH ANY BRAIN
International School Bangkok Instructions for Completion of Returning Students Medical Package
Instructions for Completion of Returning Students Medical Package All returning students must complete the returning students medical package unless a New Student Medical Package has been done in the preceeding