Vimali Paul, MD David Alonso, MD Laura Loudermilk, FNP Joy Culp, FNP 85 Declaration Dr., Ste. 110 Chico, CA 95973 (530) 894-6600 phone (530) 894-1321 fax Dear Patient: Welcome to the practice! The forms enclosed in this envelope need to be filled out prior to your scheduled appointment. Please either bring paperwork with you or return by mail. If you have health insurance, please bring your insurance card(s) so that we may verify eligibility and bill correctly. **Please be prepared to pay the co-payment and/or deductible at the time of service, as this is a requirement of the insurance company. Unfortunately, we have been experiencing an increasing number of no shows with new patient appointments. A fee of $50.00 will be assessed if there is a failure to cancel 24 hours prior to the scheduled appointment. We ask that all our patients under 18 years of age be accompanied by the parent(s) or legal guardian(s). Please feel free to call us at (530) 894-6600 if you have any questions. We look forward to meeting you! Thank you. Sincerely, Dr. Paul Dr. Alonso Laura Loudermilk, FNP Joy Culp, FNP and staff Please sign here: Date:
Vimali Paul, MD David Alonso, MD Laura Loudermilk, FNP Joy Culp, FNP 85 Declaration Dr., Ste. 110 Chico, CA 95973 (530) 894-6600 phone (530) 894-1321 fax TO ALL PATIENTS PLEASE READ THE FOLLOWING PATIENT RESPONSIBILITIES WE REQUEST THAT ALL APPLICABLE CO-PAYS BE PAID BEFORE YOU SEE THE DOCTOR All professional services rendered are charged to the patient. It is the patient s responsibility to provide the method of payment (i.e. check, cash, credit card or proof of insurance) to the provider. If insurance is the method of payment, please note that some insurance companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is your responsibility to PAY any co-pay, deductible amount or any balance not paid for by your insurance. Understand that you are FINANCIALLY responsible for ALL charges whether or not paid by your insurance.
Registration Information Patient Name: SS: Phone: Cell: DOB: Sex: M / F Street Address: City: State, Zip: Married Single Widowed Separated Divorced E-Mail Address: Patient Employed by: Work Phone: Occupation: Spouses Name: DOB: SS: Employer: Work Phone: Occupation: Do you have a designated Power of Attorney? Name and number: In case of emergency, who should be notified? Name and number: RELEASE OF MEDICAL INFORMATION IN THE EVENT IT BECOMES NECESSARY FOR VIMALI PAUL, MD / DAVID ALONSO, MD / LAURA LOUDERMILK, FNP / JOY CULP, FNP TO REFER ME TO ANOTHER FACILITY OR PHYSICIAN FOR ADDITIONAL TESTS, XRAYS OR MEDICAL CARE, I AUTHORIZE TO RELEASE MEDICAL RECORDS AND INFORMATION TO THOSE PHYSICIANS OR FACILITIES. ASSIGNMENT OF INSURANCE BENEFITS THE UNDERSIGNED HEREBY AUTHORIZES THE RELEASE OF ANY INFORMATION RELATING TO ALL CLAIMS FOR BENEFITS SUBMITTED ON BEHALF OF MYSELF/DEPENDANTS, I FURTHER AGREE AND ACKNOWLEDGE THAT MY SIGNATURE ON THIS DOCUMENT AUTHORIZES MY PHYSICIANS TO SUBMIT CLAIMS FOR BENEFITS OF SERVICES RENDERED, OR FOR SERVICES TO BE RENDERED, WITHOUT OBTAINING MY SIGNATURE FOR EACH AND EVERY CLAIM TO BE SUBMITTED FOR MYSELF/DEPENDANTS. I WILL BE BOUND BY THIS SIGNATURE AS THOUGH THE UNDERSIGNED HAD PERSONALLY SIGNED THE PARTICULAR CLAIM. I HEREBY AUTHORIZE MY INSURANCE COMPANY TO PAY AND HEREBY ASSIGN DIRECTLY TO VIMALI PAUL, MD AND DAVID ALONSO, MD AND LAURA LOUDERMILK, FNP AND JOY CULP, FNP ALL BENEFITS, IF ANY, OTHERWISE PAYABLE TO ME FOR THEIR SERVICES AS DESCRIBED ON THE ATTACHED FORMS. I UNDERSTAND I AM FINANCIALLY RESPONSIBLE FOR CHARGES INCURRED. I FURTHER ACKNOWLEDGE THAT ANY INSURANCE BENEFITS, WHEN RECEIVED BY AND PAID TO VIMALI PAUL, MD AND DAVID ALONSO, MD AND LAURA LOUDERMILK, FNP AND JOY CULP, FNP WILL BE CREDITED TO MY ACCOUNT, IN ACCORDANCE WITH THE ABOVE SAID ASSIGNMENT. SIGNATURE: DATE:
New Patient History Form Please fill out the following questions to ensure that we have accurate and complete information regarding your health. Name DOB Today s Date: Reason(s) for seeing the doctor today (current symptoms): Medical History Previous surgeries: Past and present medical illnesses and current symptoms (circle all that apply): Eyes: Stomach/Intestinal: Allergy/Immunology: Glaucoma Acid Reflux/Heartburn Seasonal Allergies Blindness Hemorrhoids Recurrent Infections Blurred Vision Hepatitis Easy Bruising Double Vision Gallstones Blood Clots Eye Pain Hiatal Hernia Unusual Lymph Node Enlargement Other: Irritable Bowel Syndrome Anemia Crohn s Disease Other: Ear / Nose / Throat: Nausea or Vomiting Hearing Loss / Ringing Difficulty Swallowing Cancer: Dizziness Frequent Diarrhea or Constipation Prostate Cancer Recurrent Sinusitis Other: Breast Cancer Chronic Nasal Congestion Colon Cancer Nose Bleeds Lung/Respiratory: Lung Cancer Hoarseness COPD Skin Cancer Other: Asthma Other: Sleep Apnea Heart: Chronic cough Musculoskeletal: Heart Attack Pneumonia Back Pain Heart Murmur Recurrent sinusitis Shoulder Pain High Blood Pressure Other: Knee Pain Atrial Fibrillation Hip Pain Angina (heart related chest pain) Trouble Walking Arrhythmia Other: Arthritis Muscle Weakness Other: New Patient History Form Page 1
Endocrine: Breast: Penile Discharge Diabetes Breast Lump Painful Urination Hypothyroidism Breast Pain Urinary Incontinence Hyperthyroidism Nipple Discharge Other: Intolerant of Heat / Cold Abnormal Mammogram Unusual Thirst Other: Genitourinary (Women): Goiter Frequent Urination Other: Psychologic: Painful Urination Lapse in Memory Blood in the Urine Neurologic: Difficulty with Concentration Urinary Incontinence / Leakage Headaches / Migraines Frequent Worrying Recurrent Urinary Tract Infections Stroke / TIA Depression Vaginal Prolapse (protrusion) Seizures Anxiety Vaginal Dryness Loss of Consciousness History of Physical or Mental Abuse Vaginal Pain History of Serious Head Injury Other: Decrease in Sexual Desire Tremors / Shaking Painful Intercourse Balance Difficulty Skin: Hot Flashes Numbness / Tingling Frequent Itching Painful Periods Other: Rash Number of Pregnancies: Unusual Dryness Number of Live Births: Infectious: Changes in Hair Age at Onset of Periods: HIV New or Growing Moles Periods Last for: Tuberculosis Periods Occur Every (days): Polio Genitourinary (Men): Onset of Last Periods: Chicken Pox Frequent Urination at Night Other: Chlamydia Dribbling Gonorrhea Blood in the Urine Rheumatic Fever Other: Health Screening and Vaccinations: Pain or Swelling of the Penis Urinary Hesitancy Decrease in Sexual Desire Vaccine history: Health Screening Tests: Are childhood vaccines up to date: Yes No Date Last Performed Adult Vaccines Date given Mammogram: Tetanus / TDAP: Pap Smear: Pneumovax: DEXA (Bone Density): Zostavax: Colonoscopy: Gardasil: PSA: Hepatitis B: Eye Exam: Aortic Aneurysm Screening: New Patient History Form Page 2
Current Medication(s): Please list all Prescription Medications including eye drops and inhalers Name Strength Dosing Instructions (If more space is required please attach additional list) Please list all Over the Counter medications, vitamins and supplements Name Strength Dosing Instructions (If more space is required please attach additional list) Family History: Living Dead Age Chronic Condition(s) / Cause of Death Mother: Father: Brothers: Sisters: Children: Other Health Problems in the Family: New Patient History Form Page 3
Personal History: Occupation: Education: Grade College Major Smoking Status: None Former Smoker Quit Date: Current Smoker Amount/day: How long: Type: Cigarettes Pipe Cigars Smokeless Tobacco Marijuana Alcohol Consumption: Type: Amount per week: Recreational Drugs: Exercise: Type: Amount per week: Type: Amount per week: Seat Belt use: All the time Most of the time None of the time Sexual History: Sexually Active: Yes No Partner Preference: Men Women Both Number of Partners: Two or Less More than Two Living Arrangements / Independence: Live with: Alone With Spouse With Family Location: Home Independent Living Facility Nursing Facility Need Assistance with: None Bathing Dressing Eating Meals Toileting Grooming Walking Transferring Walking Assistance: None Cane Walker Wheelchair Any recent falls?: No Yes Other Comments or Concerns: New Patient History Form Page 4
Medical Records Release I,, Printed Name Date of Birth am requesting my medical records from: Doctor, Facility or Hospital ( ). Phone Address, City, State, Zip ( ). Fax To be released to: North Valley Internal Medicine Vimali Paul, MD David Alonso, MD Laura Loudermilk, FNP Joy Culp, FNP 85 Declaration Drive, Ste. 110 Chico, CA 95973 (530) 894-6600 ph (530) 894-1321 fax For the purpose of review/examination, I further authorize you to provide such copies thereof as may be requested. I give my permission to release any information regarding the checked applicable lines: Entire Record Specific Information. Old records from previous physicians. Reason for request:. This authorization will automatically expire one year from the date signed. I understand that I may revoke this consent at any time except to the extent that action has already been taken. Signature: Date:. Witness: Date:.
Privacy Notification and Consent PATIENT CONSENT FORM The Department of Health and Human Services has established a Privacy Rule to help ensure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patient s consent for uses and disclosures of health information about the patient to carry out treatment, payment or health care operations. As our patient we want you to know that we respect the privacy of your personal medical record and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or health care operations, in order to provide health care that is in your interest. We also want you to know that we support your full access to your personal medical record. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may have to disclose personal health information for purpose of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent. You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed document. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer. You have the right to review our policy notice, to request restrictions and revoke consent in writing after you have reviewed our policy. Print Name: Signature: Date: To Our Patients: COMPLIANCE ASSURANCE NOTIFICATION FOR OUR PATIENTS The misuse of Personal Health Information (PHI) has been identified as a national problem causing patients inconvenience, aggravation and money. We want you to know that all of our employees, managers and doctors continually undergo training so that they may understand and comply with government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the Privacy Rule. We strive to achieve the very highest standards of ethics and integrity in performing services for our patients. It is our policy to properly determine appropriate uses of PHI in accordance with the governmental rules, laws and regulations. We want to ensure that our practice never contributes in any way to the growing problem of improper disclosure of PHI. As part of this plan, we have implemented a Compliance Program that we believe will help us prevent any inappropriate uses of PHI. We also know that we are not perfect. Because of this fact, our policy is to listen to our employees and our patients without any thoughts of penalization if they feel that an event in any way compromises our policy of integrity. More so, we welcome your input regarding any service problem so that we may remedy the situation promptly. Thank you for being one of our highly valued patients.
North Valley Internal Medicine Vimali Paul, MD David Alonso, MD Laura Loudermilk, FNP Joy Culp, FNP 85 Declaration Dr., Ste. 110 Chico, CA 95973 Text/Email Authorization Form TEXT MESSAGE AUTHORIZATION OK to contact me using text messaging Send Appointment Reminders Send Clinical Information and updates Phone: ( ) - EMAIL AUTHORIZATION OK to contact me using email Send Appointment Reminders Send Clinical Information and updates Email: Cell phone carrier: DO NOT contact me using text messaging DO NOT contact me using email Purpose: To improve communication between the office and patients. The intended use is for notification / reminders of appointments and notifications of certain tasks, including but not limited to, completion of medication refills and normal test results. Text messaging is not to be used in emergent / urgent situations. Disclaimer: NVIM will make every effort to ensure the privacy of the information sent. The undersigned acknowledges the inherent security limitations of SMS and the potential for disclosure of protected health information. Print name Date
Dr. Vimali Paul Dr. David Alonso Laura Loudermilk, F.N.P. Joy Culp, F.N.P. 85 Declaration Drive, Suite 110, Chico CA 95973 Phone: 530-894-6600 Fax: 894-1321