NEW PATIENT APPTS. Here are a few words about Our Doctor and his Medical Practice:

Transcription

1 ...your health is Our Story NEW PATIENT APPTS Here are a few words about Our Doctor and his Medical Practice: At Our Office, we strive to bring back the personal experience of having an Old-Fashioned Family Physician. As a Medical Practice, Story Family Medicine is fully dedicated and designed to provide our patients with Complete Medical Care, Coordination and the best Community Resources available. * Dr. Story takes his own office phone calls directly, after hours and on the weekends, in case of an emergency. Our office keeps appointments available for urgent visits, if needed, as well as scheduled follow ups for routine care. * Dr. Story is credentialed at Fawcett Memorial Hospital and handles his own hospital admissions. This prevents unnecessary testing and helps decrease hospital stays since your current condition and medical history is reviewed by your Family Physician. Once discharged, our office provides coordination with transitional care and home-based medical services. A few reminders regarding your New Patient Appointment: Please arrive minutes before your appointment time, for processing your paperwork. If your paperwork is not completed by your appointment time, your appointment will have to be re-scheduled. Complete all sections of Paperwork including your Medical, Family and Surgical History, etc. Provide a copy of a Photo ID, Insurance Card and Prescription Drug Card (if applicable) If you need to cancel or reschedule your appointment, please do so within 24 hours, if possible. We try to accommodate urgent visits, walks in and other care coordination activities. This is greatly appreciated. We have a big family. Thank you for your interest in Story Family Medicine. Our Office Location: Toledo Blade Blvd Suite A Port Charlotte FL Main Tele: Fax:

2 STORY FAMILY MEDICINE NEW PATIENT REGISTRATION Health and Social History Have you ever smoked/used tobacco products? Yes No (If Former smoker, when did you Quit?) Do you currently smoke? Yes No (If you currently smoke, how many a day or week?) Do you drink alcohol? Yes No (If yes, how often): Currently use recreational drugs? Yes No Do exercise regularly? Yes No (If yes, how often): What type of exercise? Nutritional Diets: Diabetic Diet Low Sodium Low Fat Low Cholesterol Other: Do you have drug, environment or food allergies? Yes No(If yes, please list type and reactions) Do you currently work? Yes No Are you Retired? Yes No Are you currently Disabled? Yes No Major Events and History No Today's Date: _ Name: Date of Birth: / / Height: Last First Status: Married Single Widowed Child Other Gender: Female Male Gender Re-Assignment Social Security: (For Billing Purposes) Religion: Ethnicity: Phone (Home) Cell Work (if applicable) Address: (Required for Online Medical Records) Address: Is this a seasonal residence? Yes No City State Zip In Case of an Emergency Name: _Relation Spouse Mother Father Grandparent Friend Other: Phone: Is it okay to contact this person in case of an emergency? Yes No Advanced Care Directives, Medical Wishes or Other Preferences *Do you have a living will? Yes No n/a *Are you an organ donor? Yes No n/a *Do you have a DNR? Yes No n/a *Do you have a Power of Attorney? Yes If you have a Power of Attorney or a Health Care Surrogate, please list them below. Name: Relationship Phone Number Are we able to disclose Medical Information with them? YES No Health Insurance Information Do you have Health Insurance? Yes No (Relationship to Insured) Self Dependant Primary Insurance Policy# Plan Type HMO PPO Medicare Federal Veteran Disability Other Secondary Plan: Policy# Is this a Medicare Plan? Yes No Do you have Medicaid? Yes No (Please Advise: We are Out-of Network with Medicaid) Complications to Medical Treatments Yes No Hospital Admissions or Emergency Care? Yes No OTHER PROVIDERS/ SPECIALISTS PAST SURGERIES/OPERATIONS LIST OF PREFERENCES Provider Name Specialty Type Type of Operation Date Hospital Pharmacy Laboratory No other Providers Imaging Do you have any health concerns that need further clarification? Yes No (If yes, please explain) _ How did you hear about Dr. Story? 1

3 Current Medical Conditions Anemia Anxiety ADD/ADHD AIDS/HIV Asthma Blood Clots Blood Disease Blood Deficiency Cancer: Chronic Back Pain Congestive Heart Failure Colitis/IBS COPD Family History _ COPD CoronaryAtherosclerosis _ Depression _ Diabetes _ Fibromyalgia _ Erectile Dysfunction _ Headaches _ Hypertension _ Hypothyroid _ High Cholesterol _ Heart Disease _Heart Attack _ Heart Arrhythmia Mother Father Sibling Other Heart Issues Heart Attack Stroke Alcoholism Breast Cancer Colon Cancer Other Cancer Depression Diabetes Thyroid Issues List of Current Medications Dates of Procedures or Testing Diagnostic Tests: Colonoscopy: Bone Density: Mammogram: Chest Xray: EKG: Echo: Stress Test: Other: Immunizations: Pneumonia 23: Pneumonia 13 Booster: Flu Vaccine: TDap/Tetanus: Shingles Vaccine: Review of Symptoms or New Complaints Eyes: _ Blurred Vision _ Double Vision _ Eye Pain _ Worsening Sight Ears & Hearing: _ Hearing Loss _ Ringing in Ears _ Wax Buildup Head & Neck: _ Headaches _ Dizziness _ Lightheaded _ Memory Loss GI: _ Difficulty Swallowing _ Nausea/ Vomiting _ Stomach Pain _ Loss of Appetite _ Diarrhea _ Constipation Urinary: _ Burning _ Frequent Urination _ Difficulty Urinating _ Incontinence _ Hesitancy Oral: _ Dry Mouth _ Loss of Taste Nose & Throat: _ Sneezing _ Nose Bleeds _ Runny Nose _ Sinus Issues _ Sore Throat Respiratory: _ Asthma _ Cough _ Shortness of Breath _ Wheezing Cardiac: Patient Name: Chest Pain _ High Blood Pressure _ Palpitations _ Irregular Heartbeat Kidney Stones Kidney Disease _ GERD Pacemaker Status _ GOUT Ulcers _ Glaucoma Unsteady Balance _ Gallbladder Disease Urinary Incontinence _ Hepatitis Seiures _ Lung Disease _ Stroke _ Muscle Weakness _ Other: Respiratory Problems _ Rheumatoid Arthritis Osteoporosis Osteopenia No Medical History (Please specify type of Cancer) No Family History Unknown Family History No Current Medications Exams: Last Labs: Health Physical: Breast Exam: Prostate Exam: Muscle/Bones/Joints: _ Back Pain _ Sore/Achy Muscles _ Swollen Joints _ Painful Joints _ Foot Pain _ GOUT _ Leg Pain Neurological: _ Confusion _ Dizziness _ Seizures _ Numbness _ Tingling _ Tremors/Shaking _ Poor Balance _ Poor Coordination No Testing Completed No Current Complaints Skin: Pap Smear: Eye Exam: Foot Exam: Other: Rash/Hives _ Itching _ Bruising _ Abnormal Growth General Mood: _ Anxiety _ Depression _ Stressors _ Mood Changes

4 HIPPA Consent and SFM Policy Agreement Patient Name: Cancellation and No-Show Policy Office Visits when made are reserved for you alone. When you make an appointment, please make sure that you are able to keep it. Emergencies or unforeseen occurrences befall us all. Situations or problems may arise that cause schedule conflicts and other delays. If you have an unexpected medical issue that needs attention, we will do our best to accommodate you. We realize that other patients may be slightly inconvenienced, will understand the nature of a emergency situation. At some point, they may need the same courtesy too and we will be there for them as well! If you cannot keep your appointment, please notify us as soon as possible. We also like to accommodate walk-ins and have a waiting list of other patients that are also in need of appointments. Please contact us to cancel your appointment with-in 24 hours, if possible. There will be a charge of $30.00 per appointment that resulted in a no-show after the 3 rd time.. I acknowledge and understand the Story Family Medicine (Cancellation and No-Show Policy). PATIENT INITIALS: HIPPA-Consent to Treat and Disclosure of Health Information To Provide Treatment: We will use your HPI within the office to provide you medical care. This may include administrative, clinical and office procedures designed to optimize scheduling/coordination of care between the physician and/or other clinical, lab, imaging centers, pharmacies, or other health care providers handling your care. To Obtain Payment: We will use your HPI with an invoice, used to collect payment for the treatment you receive here. HPI will be used on your insurance forms sent by mail or electronically. In Patient Reminders: Phone calls to remind you of a upcoming appointment or situations will be necessary. Additionally, we may also use electronic methods to contact you such as , text message, by phone, online patient accounts, postcards, letters, statements, etc. These methods of communications help optimize our office workflow. Abuse of Neglect: We may notify government or other agencies if we believe a patient is a victim of abuse, neglect, or domestic violence. We will make their disclosure only when we are compelled by our ethic judgement, specially required, authorized by law or with patient s agreement and request. Public Health/National Security: We may be required to disclose to federal/ military officials or other authorities, if HPI is necessary to complete an investigation related to public health or national security. HPI is important to the government if they believe that public safety could benefit from, control or prevent an epidemic. For Law Enforcement: As permitted/required by State/Federal Law, disclosure of HPI may be necessary under certain circumstances, if warranted. Whether being a victim of a crime or reporting a crime. We will revoke access, at any time to also protect the patient, unless there is a warrant in place or consent given from the patient directly. I understand the Story Family Medicine (HIPPA Consent to Treat and Disclosure of Health Information) PATIENT INITIALS: Medical Health Benefits and Patient Responsibly/ Financial Policy IF YOU HAVE HEALTH INSURANCE As a condition of services by our office, a financial arrangement must be made. If you have Health Insurance, you are responsible with becoming familiar with what coverage and financial responsibility you have. Your insurance benefits are a contract between (you and your insurance company). To file claims properly, you must present us a copy of active insurance cards. Services rendered, will be charged directly to your account for any balance owed/pending review/response with the insurance regarding your reimbursement/benefit. Any balances transferred to the patient s responsibility must be paid within a timely manner. There is a $25.00 fee for returned checks. Any fees due at the time of service include: Co-pays, deductibles, non-covered services or patients that are not covered by insurance. IF YOU DO NOT HAVE HEALTH INSURANCE For self-pay patients, we offer discounted rates, though we require payment in full at the time of their office visit. We accept Cash, Visa, Mastercard, Visa, American Express and Discover. I acknowledge and understand the (Medical Health Benefit and Patient Responsibility/ Financial Policy) and accept financial responsibility for my medical care provided by Story Family Medicine. PATIENT INITIALS: Narcotic Prescribing and Medication Adherence Policy Scheduling an appointment, does not guarantee that you will be prescribed Narcotic or other types of medications. Some medications may provide therapeutic relief, though many have more risks than benefits, and may cause harm if used incorrectly. Certain measures must be taken to ensure the patient s safety before prescribing can be done. The patient must disclose all medications that they are currently taking or any illicit drugs being used. Narcotic medications WILL NOT be prescribed at the New Patient Appointment. No exceptions. If there are medications that are medically necessary, blood work and a urine drug screening must be completed before the next appointment. We will also require Medical Records from the former prescribing doctor that managed your medication so we can transition your care properly. I acknowledge and understand the (Narcotic Prescribing/Medication Adherence Policy), I agree to the terms as stated above. PATIENT INITIALS: To the best of my knowledge, all of the preceding answers and information provided are true and correct. I accept the conditions outlined above have read the Office Policies of Story Family Medicine. Signature of patient, parent of guardian or guarantor Date 3

5 1) PATIENT INFORMATION: Name Address City State Zipcode ( ) Date o fb irth Daytime P hone Previous Name 2) PATIENT AUTHORIZES (HEALTHCARE PROVIDER/FACILITY): Name of Healthcare Provider or Agency Address 3) TO DISCLOSE TO: MEDICAL RECORD RELEASE URGENT REQUEST YES NO Date Needed by: Dr. Curtis Story MD of Story Family Medicine Name of Healthcare Provider Health Care Provider Ph# Toledo Blade Blvd Suite A Port Charlotte, FL Address Fax# DELIVERY OPTIONS: Self Pick up Fax Mail to address above To be picked up by, I hereby authorize: (Photo ID required) 4) DATE(S) OF INFORMATION TO BE DISCLOSED: From to (If left blank, information from the past (2) years will be disclosed) (month/year) (month/year) 5) INFORMATION TO BE DISCLOSED: All medical records related to (specify condition, treatment, etc.): All billing records related to (specify condition, treatment, etc.): Radiology films/images (specify test): Specific records/information as follows: I DO NOT WANT THE FOLLOWING INFORMATION DISCLOSED (as defined by applicable state and federal laws): Alcohol/Drug Abuse HIV Test Results Mental Health / Developmental Disabilities 6) EXPIRATION: This Authorization is good until the following date / event: Note: If this item is left blank, the authorization will expire in one (1) year from the date signed. 7) PURPOSE (Check all that apply - copy fees may apply) Further Medical Care Legal Investigation /Action Insurance Eligibility/Benefits Personal (at my request) Other: 8) YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION: I am aware that I have the right to inspect and receive a copy of the health information I have authorized to be used and/or disclosed by this Authorization. I understand that I may be charged a fee for record copies. In addition, I understand that I do not need to sign this Authorization in order to receive treatment. I also am aware that I may revoke this Authorization by notifying the disclosing medical records/health information department in writing. However, I understand that my revocation will not be effective as to uses and/or disclosures: (1) already made in reliance upon this Authorization; or (2) needed for an insurer to contest a claim/policy as authorized by law if signing the Authorization was a condition to obtaining insurance coverage. I realize that the information used and/or disclosed pursuant to this Authorization may be subject to re-disclosure and no longer protected by federal privacy law. If you have issues receiving your records or information or need assistance in filing a civil rights or health information privacy complaint, please OCR at OCRMail@hhs.gov or call for more information. 9) SIGNATURE OF PATIENT / LEGAL REP: DATE: If signed by a person other than the patient, complete the following: 1. Individual is: a minor legally incompetent or incapacitated deceased 2. Legal authority: parent* legal guardian next of kin / executor of deceased activated POA for Health Care * By signing above, I hereby declare that I have not been denied physical placement of this child. For Office Use Only: Signature/ID verified Yes No Completed by: # of pages Name / Date released Fax # AUTHORI ZATION FOR DISCLOSURE OF HEALTH INFORMATION (Pre Tab / Corres) PRACTICE LOCATION Toledo Blade Blvd Suite A Port Charlotte, FL tele: fax: Health Care Provider Ph# 4