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 of care more efficient. Prescription refills We ask that our patients contact their pharmacy for any medication refills. Please call a week prior to the medication being needed so that they have time to contact us if necessary. We accept faxes at (919) 552-8955, 24-hours a day. Please allow us 48-72 hours to refill the medication; approval from your medical provider is required on all refills. Please contact your pharmacy at 72-hours to ensure they have received the refill authorization. Please do not call the nurses to verify completion. Patients that need refills for any controlled substance may continue to call our office as previously directed. As always, our nurse will call when the prescription is ready for pick up. Test results Our nurses are given explicit direction by the medical providers on every patient s test results. Results will be mailed to your home within 14 business days for normal test results. Any patient with abnormal labs will be called by our nursing staff under the direction of the medical providers. These results will be called within five business days depending on the severity of the abnormality. Our nurses prioritize abnormal lab results and will make three attempts at calling, if there is no response, a letter will be mailed asking you to call our office. If you have any additional questions regarding your labs, you may be asked to make a follow-up appointment with your medical provider to discuss your concerns in detail. Physical exams A physical exam or wellness visit is a great time to ensure your overall health is at its best. If you have any new health concerns you that need to address during a physical exam or wellness visit, please note that you may be charged an office visit in-conjunction with the physical exam. This may prompt an out-of-pocket expense. (919) 552-8911 rexhealth.com/holly-springs-primary-care 781 Avent Ferry Road, Suite 206 Holly Springs, NC 27540
Physical exam labs At the patient s request, for exams scheduled at least 14 days in advance, we will mail you a lab order along with fasting instructions and a list of labs. If your exam is scheduled less than 14 days in advance, you will be given the lab order on the day of your physical exam. No results for labs performed prior to the exam will be given unless there is a significant abnormal value. Form completion We are happy to complete forms for our patients. We ask that you drop the form off and allow five business days for completion. Our nursing staff will call you when the form is complete and ready for pick up. We are unable to complete any form for patients who have not received a yearly physical in the last 12 months. Some forms may require an office visit to be completed properly. Cancellation and no-show Appointments must be cancelled at least 24-hours prior to the scheduled appointment time. A no-show fee may be assessed for any patients not calling to cancel. In the event a patient has incurred three documented no-shows, and/or late cancellations the patient can be discharged from the practice. Messages left for nurses and after hours phone calls During regular office hours, our telephone will be answered by our staff. We will make every effort to return calls within 24-hours. Calls requiring review by a medical provider may take up to 72-hours. After hours and on weekends, our answering service receives calls and forwards them to the covering board-certified family physician. If you are having an emergency, including chest pain, shortness of breath or abdominal pain, call 911. Referrals Many insurance plans do not require a referral from your primary care provider to see a dentist, ob-gyn, dermatologist or other specialist. If a referral is required we will provide one, but occasionally an office visit is required first. If we are recommending you to see a specialist, please allow five business days for the nurses to complete the process. The office we refer you to will contact you directly to schedule an appointment. Thank you for the opportunity to care for you and your family! (919) 552-8911 rexhealth.com/holly-springs-primary-care 781 Avent Ferry Road, Suite 206 Holly Springs, NC 27540
REX PRIMARY CARE OF HOLLY SPRINGS NOTICE OF SEPARATE BILLING The physician may order Laboratory and/or Radiology services for you while you are in our facility. Although the services are performed in this facility, the Laboratory and Radiology are extensions of the hospital and you will receive a separate bill from them. We do not bill for x-rays and lab tests. Billing for Laboratory services is done by Rex Outreach Laboratories, not through this office. Please be advised that some insurance companies mandate where your lab tests can be performed. The physician in this facility may be in-network with your insurance company but Rex Laboratory may not be. The same may be true with LabCorp or other outside Laboratories that your insurance does not cover. Billing for Radiology services is done by Rex Hospital, not through this office. Radiology services are billed in two parts. The first part of the bill is for the service itself, and a bill from Rex Hospital will be sent to you for the actual testing. You will also receive a bill from Raleigh Radiology for the professional reading by a radiologist. Some insurance companies may also apply lab and/or x-ray charges to your deductible. If you have questions as to whether your charges will be managed in this manner, please consult with your insurance company. If you have any questions, please ask our staff at check-out. Thank you for choosing Rex Primary Care of Holly Springs. Patient/Guardian Signature Date 22589 (01/08)
(rev 1/5/2012) Date: REX PRIMARY CARE OF HOLLY SPRINGS 781 Avent Ferry Road, Suite 206 Holly Springs, NC 27540 Phone: (919) 552-8911 Fax: (919) 552-8955 Patient Acct No I. PATIENT INFORMATION Lab/Radiology Information SS# Last Name First Name MI Street Address City State Zip Home Phone Work Phone Cell Phone Date of Birth Sex Male Female Marital Status Race Employer Employer Address Phone Number Mother s Maiden Name Father s Name Contact Person in Case of Emergency Phone Number Pharmacy Name, Address & Phone # II. POLICY HOLDER INFORMATION (Other than Patient) SS# Last Name First Name MI Street Address City State Zip Relationship to Patient Home Phone Cell Phone Date of Birth Sex Male Female Marital Status Race Employer Employer Address Phone No III. PARTY/PERSON ACCOMPANYING A MINOR SS# Last Name First Name MI Street Address City State Zip Relationship to Patient Home Phone Cell Phone Date of Birth Sex Male Female Marital Status Race Employer Employer Address Phone No IV. MEDICAL INSURANCE INFORMATION Primary Insurance Policy Holder Secondary Insurance Policy Holder Card(s) attached Verified Updated Initials/Date Patient Signature: Date:
NAME: Rex Primary Care of Holly Springs - HEALTH QUESTIONNAIRE DATE: Family History ALIVE & WELL CAUSE & AGE OF DEATH DECEASED Hypertension Heart Disease Diabetes Cancer Prostate Prob Stroke Cholesterol Asthma/Lung Kidney Disease Arthritis or Gout Migraine/Seizure Depression/Anxiety Anemia Dementia Blood clots Smoker OTHER Alcohol/Drug Abuse FATHER MOTHER Brother / Sister Brother / Sister Brother / Sister Brother / Sister Mother's Relatives Father's Relatives SPOUSE HOSPITAL ADMISSIONS and SURGERY YEAR NAME MEDICATIONS DOSE HOW OFTEN NAME DOSE HOW OFTEN ALLERGIES: SOCIAL HISTORY YOUR MEDICAL HISTORY Check box for current or past problems with: Smoke: packs x yrs- Stopped: Caffeine: cups/day Eye Problems Bowel Problems Thyroid Problems Seizures Onset Age: y/o Hearing Problems Liver Problems Arthritis Tremors/shaking Regular or Irregular Throat problems Cancer: Migraine Muscle weakness # Days: Hvy Med Light Lung Problems Bladder Problems Skin Problems Numbness or tingling Pain: Severe Mod Min Heart Problems Kidney Problems Sleeping Problems Gout Birth Control: High blood pressure Prostate Problems Use of drugs (IV, other) Excessive fatigue # Children: Circulation Problems Leg/Back/Neck Pain HIV-AIDS Nervous / Depressed # Pregnancies: Blood Clots Weight Loss or Gain Sexually transmitted infection Memory Problems Painful Intercourse Bleeding Problems Anemia Transfusions or Tattoo Abnormal Pap History Ulcer/ GERD Problems Diabetes Use snuff or chew tobacco Bleed between periods When was your last: Beer/Wine/Alcohol: Labs: Chest Xray: Flu shot: Pap test: Prostate exam: Abnorm Mammogram History EKG: TB test: Tetanus: Mammogram: Colonoscopy: Breast Biopsy History Stress Test: /day /wk Cardiac Cath: Pneumonia shot: Bone Density: Female Menstrual History Menopause: y/o Do you: Exercise Routinely: Y N Use Seatbelt: Y N r History of Hormone Use Comments: rev 5.09
Consent to Treatment I am a patient at UNC Physicians Network (UNCPN). By signing this form, I give my consent to be treated by the doctors of this practice. My doctor needs medical facts about my health. I,, ask for and allow the doctors and staff of UNCPN to give me the needed medical treatment and services they recommend. I understand treatment and services may include: lab tests, screening tests (tests that can find an illness early, before a person shows signs of having the disease), diagnostic tests (tests that shows if a person has a certain illness or health problem), and routine exams. My doctor may need to photograph or videotape me to learn more about my health problem. I understand that no promises have been made to me about the results of any treatment or services. Release of Health Information UNCPN may release my health information to other doctors and staff who treat me. This could include healthcare providers who treat me who are not part of UNCPN. UNCPN may release my health information to insurance companies or other companies that UNCPN uses to bill for services. UNCPN may release my health information to companies that help UNCPN improve the quality and cost of care provided to patients by reviewing the health care provided by the practice. If I cannot be reached, a representative of UNCPN can give information about my test results, my care or my bills to: Name: Relationship: Phone Number: Name: Relationship: Phone Number: I do NOT want my information given to my family, friends or others. UNC Physicians Network Consent to Treatment 3.2012
Financial Policies The doctors and other healthcare providers of UNCPN charge fees for the care provided to me. The fees may not be exactly the same as the estimate given to me. I know that my health insurance company may not pay the full amount of the fees charged by UNCPN. This means I may have to pay UNCPN for the cost of care that is not paid by my health insurance company. If I have not given UNCPN the right health insurance information, then I may have to pay the fees for my care. If I do not have health insurance, then I will have to pay the fees for my care. If I have paid UNCPN too much money for my care, then the dollar amount can be used to pay the balance of some other account that I have with UNCPN. Medicare will only pay for the care that is acceptable and needed under section 1862(a)(1) of the Medicare Law. The facts I have given to UNCPN for payment under Titles XVIII and XIX of the Social Security Act are correct. UNCPN can bill my health and liability insurance companies for my care. Payments will be made to UNCPN on my behalf. Social Security Number I voluntarily give UNCPN the last four digits of my social security number, if needed, to identify me and file bills with my insurance company. UNCPN will follow any federal and state laws about the use and protection of my social security number. Personal Items UNCPN is not responsible for taking care of my personal items. This includes items such as jewelry, eyeglasses, hearing aids, dentures, clothing, and cell phones. I know that I must take care of my personal items. Notice of Privacy Practices The Notice of Privacy Practices tells me my rights as a patient of UNCPN. This includes how my medical records are protected at all doctors offices. I have been given a copy of UNCPN s Notice of Privacy Practices. UNC Physicians Network Consent to Treatment 3.2012
I prove with my signature below that: Patient Acknowledgement the above facts that I have given to UNCPN are correct, I have read and understand all of the facts stated above, I have had the chance to ask questions about the facts in this form, and all of my questions have been answered. I know that I will be asked to sign this form again if I am still a UNCPN patient in one year. I know that I may withdraw this form by writing to UNCPN. This may change actions that UNCPN is taking or may have taken. I consent to treatment as a patient of UNCPN. Signature of Patient or Responsible Party Relationship (if not Patient) Witness Date and Time Printed Name (if not Patient) Date and Time UNC Physicians Network Consent to Treatment 3.2012
I authorize: (Check One) UNC Physicians Network: Name of Person or Facility: Address, City, State, ZIP: AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION **Important-Please mail records if over 10 pages** Phone: Fax: Email: To use or disclose to: Name of Person or Facility: Address, City, State, ZIP: Phone: Fax: Email: The MEDICAL RECORD (Protected Health Information) OF: Patient Name: Address, City, State, ZIP: Date of Birth: Phone: Medical Record #: SSN (last four): Treatment Dates From: Put a CHECKMARK next to the specific documents that apply to your request: to Clinic Notes Radiology Reports Nurses Notes Emergency Room Progress Notes Lab Reports Urgent Care Doctor Consults History & Physical Pathology Reports Operative Reports Other Discharge Summary Physician Orders EKG, EEG, EMG Place your initials in the applicable boxes below to authorize the release of SENSITIVE information pertaining to: Mental Health Drugs & Alcohol Put a CHECKMARK next to the purpose of the request: HIV/AIDS/ other infectious diseases Genetic Testing Not Applicable: None of these apply Continued Patient Care Social Service / Disability Insurance Other: Personal Attorney / Legal Worker s Compensation Put a CHECKMARK next to how you would like to receive your request: Mail to address above. Verbal release Fax to # listed above (Urgent or Prioritized) Pick up at Practice I UNDERSTAND THAT: I may revoke this Authorization at any time: o the revocation will not apply to information that has already been released in response to this Authorization o I must revoke this Authorization in writing. The procedure for revoking this Authorization is to present my written revocation to the UNC Physicians Network Compliance Manager. I may refuse to sign this Authorization: o My treatment, payment, enrollment in a health plan, or eligibility for benefits cannot be conditioned upon my authorization of this disclosure. o A fee may be charged for copying the protected health information. Please contact Compliance Manager to obtain fee and rate information @ 919-804-5064. I have been informed and understand that information disclosed pursuant to this Authorization may be subject to re-disclosure by a recipient of such information. It is possible that once disclosed, the privacy of the information may no longer be protected under federal medical privacy law. Unless otherwise revoked, this authorization will expire on the following date, event, or condition:. If I fail to specify an expiration date or event or condition, this authorization will expire automatically in ninety (90) days from the date of signature. I have read and understand the information in this Authorization form. Signature of Patient: Printed Name: Signature of Authorized Representative: Printed Name: Please explain Representative s authority to act on the behalf of the Patient: Processed Date: Processed By: OFFICE USE ONLY Stamps / Additional Notes: Date: Date: