PATIENT REGISTRATION LAST NAME: FIRST NAME: MI: STREET ADDRESS: CITY: STATE: ZIP CODE: DOB: AGE: SEX: M F: TELEPHONE#: ( ) CELL PHONE#: ( ) SSN#: MARITAL STATUS: S M W D OTHER: SPOUSE S NAME: EMAIL ADDRESS: RACE/ETHNICITY: LANGUAGE: EMERGENCY CONTACT: TEL#: RELATIONSHIP: PLEASE LIST NAME OF OTHER FAMILY MEMBERS WHO ARE/WILL BE PATIENTS AT THIS OFFICE: NAME: DOB: RELATIONSHIP: NAME: DOB: RELATIONSHIP: PATIENT EMPLOYER INFORMATION: EMPLOYER NAME: TEL#: ( ) EMPLOYER ADDRESS: OCCUPATION: INSURED PERSON (IF NOT PATIENT) NAME: DOB: RELATIONSHIP: STREET ADDRESS: CITY/STATE: ZIP: RELATIONSHIP TO PATIENT: INSURANCE: PLEASE PRESENT CURRENT PRIMARY AND SECONDARY (IF APPLIES) INSURANCE CARDS AT FRONT WINDOW!!! MEDICAL INFORMATION RELEASE AND ASSIGNMENT OF BENEFITS: I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM, AND/OR THE RELEASE OF INFORMATION NEEDED FOR CONTINUITY OF CARE. I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL. SIGNATURE: DATE:
Page 1 of 2 ADULT COMPREHENSIVE PATIENT HISTORY New Patient Established Patient Name: D.O.B.: Age: Past History: Check all that apply Acid Reflux Alcohol or Drug problems Allergy problems Anemia Artery problems Arthritis Asthma Autoimmune disease Bleeding problems Surgery/Procedures: Please list dates Appendix Bladder suspension Blood vessel surgery Arteries Veins Dental surgery Eye surgery Gallbladder Cancer Colitis Crohn s disease Depression, Anxiety Diabetes Emphysema Other lung disease Esophagitis, ulcers Gallstones Headaches Heart disease Heart valve problems High blood pressure High cholesterol Irritable bowel Kidney stones Kidney disease Liver disease Blood clots Glaucoma Migraines Other diseases not listed Explain any of the above if necessary Hospitalizations/Dates Heart surgery Bypass Heart valve surgery Angioplasty (balloon) Stents Hysterectomy Complete Partial (ovaries preserved) Osteoporosis Recurrent skin infections Recurrent UTI Seizures Sexually transmitted infections Stroke Thyroid diseases Vein problems Joint replacement Orthopedic surgery Prostate surgery Tonsils and/or adenoids Tubal ligation Vasectomy Other surgery not listed above Significant injuries Medication List: Name of medication, vitamin OTC supplements or herbal medicine Dosage Supplies Times/day Disease or Reason
Name: Medication allergies or reactions: Medication Reaction Medication Reaction 1) 2) 3) 4) Family History: Family Member Date of Birth Living Deceased Diseases Page 2 of 2 Diseases in the family: Check all that apply Arthritis Addiction problems Bleeding problems Cancer(s) Breast Colon Social History: Married? No Yes Divorced? No Yes Children? No Yes If yes, number of children?: Family members living in the home: Mother Father Siblings Others: Do you smoke?: Currently Past Never packs/day for years. Other tobacco use? No Yes If you do smoke, would you like information about our smoking cessation program? No Yes Do you drink alcohol? No Yes Beer Wine Liquor How many drinks per week? How many servings of caffeine per day? Coffee Tea Sodas Other: Any illegal drug use? No Yes Type: Occupation: Any known occupational exposures? Do you exercise regularly? No Yes How many times per week? Type of exercise Preventative Care: Date of last Colon and Rectal screening: Rectal exam Sigmoidoscopy Colonoscopy Date of last eye exam: Have you had a bone density (DEXA) exam? No Yes Date: Immunizations: Date Immunizations: Date Tetanus Influenza Pneumonia Whooping cough Cancer(s) Prostate Other: Depression/Anxiety Diabetes Heart disease Hepatitis A Hepatitis B Shingles HPV For our FEMALE patients only: Do you have a Gynecologist? No Yes Name: Date of last PAP test: Date of last mammogram: Do you do breast self-exams? No Yes Have you gone through menopause? No Yes Menstrual or period problems: Irregular Heavy Change in frequency: Number of pregnancies: Number of live births: Vaginal C-section Miscarriages Abortions Can you think of anything else that you think we should know about your health and lifestyle that is not listed here? Do you have Advanced Directives (Living Will, Durable Medical Power of Attorney)? No Yes High Blood Pressure High cholesterol Kidney disease Liver disease Mental illness Other:
CONSENT TO RELEASE MEDICAL INFORMATION I Date of Birth (Please Print Name) Give Dublin Family Care permission to release my medical information to the following individuals. Name: Date of Birth: Relationship: Name: Phone #: Date of Birth: Relationship: Phone #: I refuse to have my medical information released to any individual. I give Dublin Family Care permission to leave detailed medical information on my voice mail at the following phone number: Signed: Date: Witness: Date:
CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS I hereby acknowledge receipt of written notice of my privacy right and I consent to DUBLIN FAMILY CARE, INC. using and disclosing my protected health information to carry out treatment, payment, or health care options. I understand and have been provided with a Notice of Privacy Practices, which provides a more complete description of how my protected health information may be used or disclosed. I understand that I have the right to review the notice prior to signing this consent. I understand that DUBLIN FAMILY CARE, INC. reserves the right to change their notice and information practices and that I may obtain a copy of the revised notice by written request addressed to JOSEPH CARDUCCI, MD. c/o DUBLIN FAMILY CARE, INC., 205 W. BRIDGE STREET #101, DUBLIN, OH 43017. I understand that I have the right to restrict how DUBLIN FAMILY CARE, INC. uses or discloses my protected health information to carry out treatment, payment or health care operations; that DUBLIN FAMILY CARE, INC. is not required to agree to the restrictions and; that DUBLIN FAMILY CARE, INC. is bound by restrictions to which it agrees. I consent to all payments for these services to DUBLIN FAMILY CARE, INC. I understand that I am responsible for all copayments, amounts applied to deductibles and other amounts that may be deemed my responsibility by the payment sources as required by my contract with my insurance plan and state regulation. I further understand that my contract with my insurance entity may or may not cover some services: BWC claims, self-insured organizations, and auto accidents. If your account is sent to a collection agency a 50% surcharge will be added to the balance due. IT IS MY RESPONSIBILITY TO OBTAIN INFORMATION FROM MY HEALTH PLAN ABOUT SERVICE COVERAGE. If I seek care outside of the contract, I am aware that I may be responsible for all charges that are incurred. We participate in one or more Health Information Exchanges. Your healthcare providers can use this electronic network to securely provide access to your health records for a better picture of your health needs. We and other healthcare providers, may allow access to your health information through the Health Information Exchange for treatment, payment or other healthcare operations. This is a voluntary agreement. You may opt-out at any time by notifying the Health Information Management Services/Medical Records Department OR the office administrator. I wish to opt out of Health Information Exchanges at this time I request the following restrictions to how my health information is used or disclosed: I have the right to revoke this consent by notifying DUBLIN FAMILY CARE, INC. in writing, except to the extent that DUBLIN FAMILY CARE, INC. has taken action in reliance on my consent. Signature of patient or patient s representative Printed name of patient or patient s representative Date Relationship to patient or representative s authority to act for the patient
CONSENT FOR CARE CONSENT FOR CARE I authorize Dublin Family Care, Inc. and any employee working under the direction of a physician to provide medical care for me, or to this patient for whom I am the legal guardian. This medical care may include services and supplies related to my health (or the health of the identified person) and may include but not be limited to preventative, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body. This consent includes contact and discussion with other health care professionals for care and treatment. RECEIPT OF NOTICE OF PATIENT RIGHTS AND RESPONSIBILITIES I have been given the opportunity to receive a copy of Dublin Family Care, Inc. s Notice of Patient Rights and Responsibilities. I understand that the terms of the Notice of Patient Rights and Responsibilities may change and I may obtain these revised notices by contacting the practice by phone or in writing. RECEIPT OF NOTICE OF PRIVACY PRACTICES I have been given the opportunity to receive a copy of Dublin Family Care, Inc. s Privacy Notice. I understand that the terms of the Privacy Notice may change and I may obtain these revised notices by contacting the practice by phone or in writing. RECEIPT OF NOTICE OF FINANCIAL POLICY I have been given the opportunity to receive a copy of Dublin Family Care, Inc. s Financial Policy. I understand that the terms of the Financial Policy may change and I may obtain these revised notices by contacting the practice by phone or in writing. ASSIGNMENT OF BENEFITS I hereby assign to Dublin Family Care, Inc. any insurance or other insurance company benefits be made on my behalf for any services furnished me by the practice for health care services provided. I understand that the practice has the right to refuse or accept assignment of such benefits. If these benefits are not assigned to the practice, I agree to forward to the practice all health insurance and other third-party payments that I receive for services rendered to me immediately upon receipt. RELEASE OF INFORMATION I authorize Dublin Family Care, Inc. to release all medical information requested by my health insurance carrier, Medicare or any other third-party payers. I authorize the practice to release all medical information to my referring physician and or primary care physician. I authorize the practice to contact my insurance company or health plan administrator and obtain all pertinent financial information concerning coverage and payments under my policy. I direct the insurance company or health plan administrator to release such information to the practice. In addition, I authorize my medication history to be obtained in an electronic format. I understand that I have the right to refuse to sign this consent or revoke this consent at any time. I am aware that the Practice may refuse to treat me (as long as it is not life threatening). I am aware that if I refuse to sign the consent for operations, payment, or treatment and the practice provides treatment to me; I will become Self Pay as the practice cannot bill the insurance carrier without a signed consent. Patient s Name (Please Print) Patient / Guardian Signature Date of Birth Today s Date