Vaccine and International Travel Health Questionnaire Please print clearly.

Transcription

1 Vaccine and International Travel Health Questionnaire Please print clearly. Name: Age: DOB: Sex: M F Last Name First Name MI MM/DD/YYYY Home Address: Street Address City State Zip Phone: Home/Cell Work Occupation: SSN: Employer: Primary Care MD: Emergency Contact: (required) Name Relationship Phone Number Pharmacy Name/Address: Travel Information Please list the countries you are traveling to, in the order you will visit them: Date of Departure Destination (City, Country) Date of Return or Transfer Length of Stay Please mark all that apply to your travel plans: Purpose: Accommodations: Activities: Leisure Business Resort Hotel Sightseeing Climbing/Hiking Adoption Missionary Cruise Ship Rural Travel Camping Safari Study Abroad Other Staying with Family/Relatives Business Meetings Who arranged your Trip: Name Phone Immunization History: 1) What was the date of your last tetanus/diphtheria (Td/Tdap) injection? 2) Have you had chickenpox, or received two (2) doses of the varicella vaccine? Unknown 3) Have you ever had a reaction to a vaccine that required medical treatment (a doctor s office visit or emergency care)? If yes, please explain the specific type of reaction: 4) Please list any vaccines you have received in the past 30 days: 5) Have you ever travelled outside of the U.S. and received travel vaccinations for that trip? If so, when and where?

2 Medical History: Please circle Do you have any current medical problems? YES NO If, please list: Have you ever had cancer/other medical problems? YES NO If, please list: Please list any past surgeries: Are you allergic to ANY medications, latex, vaccinations or vaccine component, thimerosol, protamine sulfate, or mercury (a preservative)? YES NO If, please list: Are you currently taking antibiotics? Are you currently experiencing any respiratory infections or other acute illness or infections? Are you allergic to eggs, yeast, or any other foods? Do you take any cortisone, prednisone, steroids, chemotherapy, or other biologic (e.g., Humira, Remicade, etc.)? Do you have any immune system problems, such as cancer, HIV, or AIDS? Have you ever fainted from an injection or from having your blood drawn? Have you had your thymus gland removed or a history of problems with your thymus, such as myasthenia gravis, DiGeorge Syndrome, or thymoma? Do you have ANY other health issues for which you see a health professional? Please describe: Do you smoke? Are you currently taking any medications (including oral contraceptive) or planning any new medications during your trip? Please list: Questions for women Do you use a contraceptive or birth control YES NO Are you pregnant? YES NO Do you plan to become pregnant in the next 3 months? YES NO Are you currently nursing? YES NO How did you hear about us? Internet Established Patient School/College Physician Employer Friend/Relative CDC Website Travel Agent Other HIPAA tice of Privacy Policies Acknowledgement of Receipt I have received a copy of the HIPAA tice of Privacy Policies for River Valley Travel Medicine that explains my rights and documents policies and procedures that will safeguard my private health information. Signature Date By signing, I am stating that the above information is true and accurate to the best of my knowledge. I understand that River Valley Travel Medicine, LLC, does not accept any insurance including Medicare and that I am responsible for paying my bill in full today. I understand that I will be provided with a receipt to submit to my insurance company. I understand that River Valley Travel Medicine, LLC, is not responsible for knowing my plan s coverage of vaccinations. I understand that any services or vaccines I receive today may not be reimbursed to me. Traveler/Patient Signature (under 18 years of age must have parent/guardian signature) Date

3 21 Highland Avenue, Suite 5 Newburyport, MA Tax ID: TRAVEL VISIT FINANCIAL POLICY Payment Policy We accept Cash, Visa, MasterCard, Discover, American Express and all debit cards We do not accept personal or business checks as form of payment Please note that preventive travel medicine services may not be covered by your health insurance plan. You will need to check directly with your insurance carrier to verify if your plan covers preventive medicine for travel purposes We will provide you with a detailed statement of medical services to submit to your insurance for possible reimbursement. Dr. Gross and other providers at River Valley Travel Medicine also practice with additional practices, but you are being treated at a private corporation that is not contracted with any health insurance companies and is not required to and does not accept any form of health insurance as payment for services rendered. When you submit a claim, the processing of your claim(s) will be a transaction directly between you and your insurance company. FOR MEDICARE PATIENTS ONLY: River Valley Travel Medicine, LLC, does not accept assignment from Medicare for any services or treatments received during a travel consultation with our providers. Medicare typically does not cover travel consultations or vaccinations, and may not reimburse you for your costs incurred. I have read, understand, and agree to the conditions as explained above. I understand that River Valley Travel Medicine, LLC, does not accept insurance. I understand that I will be provided with a receipt to submit to my insurance company for reimbursement of my travel visit and vaccinations. I understand that I am responsible for paying for my travel consultation and vaccinations today. I understand that River Valley Travel Medicine, LLC, does not know if my plan will reimburse me for services/vaccinations I receive today. Patient s Name Patient s Signature (under 18 years of age must have parent/guardian signature) Date

4 Health Information Consent I give my consent to representatives of River Valley Travel Medicine to leave messages on my home or cell phone answering system or with individuals that I will designate below. Relating to my care Appointments Reminders List individuals River Valley Travel Medicine is authorized to speak to about your care: Spouse Name Phone. w/area code Family Member - Relationship Phone. w/area code Family Member - Relationship Phone. w/area code Other Name Relationship Phone. w/area code I understand and agree that this authorization will stay in effect until such time I give written notice to change or withdraw my authorization. Signature

5 Travel visit costs subject to change (includes administration fee) Type Price Travel medicine visit $105 Each additional person Established patient Yellow Fever only Hepatitis A Hepatitis A Pediatric (both series of 2) Hepatitis B (series of 3) Twinrix (A/B) (series of 3 or 4) $75 $75 $75 $110 $65 $100 $145 Typhoid $115 Yellow Fever $190 Japanese Encephalitis (series of 2) $415 Influenza Intradermal $50 Influenza High Dose $65 Influenza Regular $45 Meningoccal $180 MMR $110 Cholera $335 Polio $60 Pneumovax $135 Rabies (series of 3) $425 Tdap $75 Prevnar 13 $245 Zostavax $305 Varicella $170

6 Patient Consent Form 1. I understand the risks and benefits of having my information in Wellport. I know that Wellport does not replace speaking or meeting with my physician or other healthcare clinicians. 2. I release any and all of my personal health information (including information I might consider sensitive) from any participating health care provider delivering my healthcare for the purpose of creating my Clinical Health Summary and Personal Health Summary. This includes physicians, nurses, hospital professionals, nursing home and home health professionals, and other clinicians when appropriate to my healthcare. 3. I understand and accept that my Personal Health Summary is not my official medical record, and that it might be incomplete (it might not contain all of the information that the hospital or each of my doctors may keep regarding the care that I receive) or inaccurate (it might not contain the most recent or corrected information about me). 4. I understand and accept that neither my Clinical Health Summary nor my Personal Health Summary is an official medical record. My physician and other clinicians are not required to be aware of the contents of my Clinical and Personal Health Summaries. They may not access it unless they have a need-to-know at the time they are involved in my care. 5. I understand and accept that if I wish to receive a copy of, or access to, information that is a part of my official medical record, I must contact my clinician or other provider about how I can make such a request. 6. I understand and accept that I am responsible for maintaining the secrecy of any user name and password I am provided to access my Personal Health Summary or to allow my designated Authorized Representative to access my Personal Health Summary. If I misplace my username and/or password or think that someone might have gained access to my Personal Health Summary who should have access, I shall notify Wellport immediately. 7. I understand and accept that neither Wellport nor any of my clinicians nor other providers are liable for any unauthorized access to my health information that may result from my not keeping my username and password secret. 8. I understand that I am not required to have a Clinical Health Summary. Clinical and other providers may not withhold treatment because I don t share my health information with Wellport. 9. I understand that I have the right to change my mind and stop sharing my health information. I may cancel or deactivate my Clinical and Personal Health Summaries at any time by completing Request to Withdraw Permission for Sharing of Health Information available at Wellport is a service product owned and operated by Whittier IPA, Inc. Transmitting this document to Whittier IPA confirms an assertion by the transmitting medical practice, hospital or other care organization that it has taken the reasonable precautions to confirm the identity of the signatories.

7 Patient Consent Form 10. I agree and accept that neither Wellport nor any of my clinicians nor other providers is obligated to make a Personal Health Summary available to me, and if Wellport chooses to end its Personal Summary technology for any reason, then I will no longer have access to my personal health information through a Personal Health Summary. 11. I understand that Wellport will use the Massachusetts Health Information Highway (Mass HIway) to share clinical and administrative information with appropriate clinicians in more distant locations. Some of this information may be considered sensitive. I permit the sharing of my clinical and administrative information with other clinicians and insurers appropriately involved in my care over the Massachusetts Health Information Highway or by another secure encrypted (coded) communication method. I permit the Mass HIway to list which clinicians have provided my care. 12. I hereby accept and confirm that information about the risks and benefits of using Wellport is available to me at I understand that some of the personal health information released may contain: HIV test results and other information about sexually transmitted diseases Genetic Screening test results Reproductive health concerns and any pregnancy history including abortion Alcohol and Drug Abuse Records Details of Mental Health Diagnosis and/or Treatment Social, family, and interpersonal issues mentioned during an office visit Signature of Patient (age 12 and over) Date of Signatures Signature of Parent or Guardian (for all patients under age 18) Relationship to Patient _ Print Patient Name Patient Date of Birth Patient s address Wellport is a service product owned and operated by Whittier IPA, Inc. Transmitting this document to Whittier IPA confirms an assertion by the transmitting medical practice, hospital or other care organization that it has taken the reasonable precautions to confirm the identity of the signatories.