Staying Healthy Assessment

Similar documents
Thank you, in advance, for being a partner in your care.

PATIENT REGISTRATION FORM PARENTAL MEDICAL CONSENT FORM FOR A MINOR CHILD

Adult Health History

NAME SS# ADDRESS CITY STATE ZIP. TELEPHONE (home) (business) Cell SEX M F BIRTH DATE PLACE OFBIRTH RACE ETHNICITY LANGUAGE

PEDIATRIC CENTER FOR WELLNESS, P.C. CRYSTAL B. HOOD, M.D KLONDIKE RD SW SUITE 205 CONYERS, GA TELEPHONE FAX

Responsible Party Information (Information used for patient balance statements) Responsible Party Another Patient Guarantor Self

Welcome Letter- Orchard School Clinic

12 King Philip Rd. Sudbury, MA (585)

W e l c o m e t o B i l l e r i c a C h i r o p r a c t i c

12086 Ft. Caroline Road, Suite #401, Jacksonville, FL Phone: (904) Fax: (904) Patient Full Legal Name Date

NEW PATIENT PACKET. Address: City: State: Zip: Home Phone: Cell Phone: Primary Contact: Home Phone Cell Phone. Address: Driver s License #:

Patient Registration Form Pediatrics

REGISTRATION FORM (Minors)

Pediatric Patient History

Additionally, the parent or legal guardian must provide the following documents upon registration of a new student:

Anchor Academy Registration Form. Last Name: Middle Name: First Name: Name Used: Address: City: State: Zip Code:

2201 Murphy Avenue, Suite 307 Nashville, TN Phone Fax Date. Patient s Full Name

IMPORTANT PAPERS FOR PRE-ADMISSION

Signature (Patient or Legal Guardian): Date:

Dear Kaniksu Patient,

New Patient Information

Thank you for choosing Oakland Medical Center as your Patient-Centered Medical Home

PATIENT INFORMATION RESPONSIBLE PARTY INFORMATION NAME: DOB: SEX: M / F SOCIAL SECURITY # RELATIONSHIP TO PATIENT: PHONE #: CELL#: EMPLOYER:

PATIENT REGISTRATION FORM (ecw)

Date: PATIENT REGISTRATION Chart # PLEASE PRINT FILL OUT ALL AREAS PATIENT INFORMATION CHILD S NAME BIRTHDATE SSN SEX CELL PHONE# (14 YRS & OLDER)

Initial Child & Adolescent Questionnaire

Sage Medical Center New Patient Forms

Family Care Health Centers

St. Vincent Apartments 1521 Las Vegas Blvd. North Las Vegas, NV 89101

Citrus County Tax Collector s Office Application for Employment

Fax: Do not mail the forms!

Patient: Gender: Male Female. Mailing Address: Ethnicity: Not Hispanic or Latin Hispanic/Latin Home Phone #:

The Children's Clinic Patient Information Form

We want to thank you for your interest in the Orion Weight Loss Program. We are looking forward to helping you reach your weight loss goal.

Amarillo Endoscopy Center Srinivas Pathapati, MD., PA 6833 Plum Creek Drive Amarillo, TX (806)

James B. Duke, MD PA Orthopedic Surgery 2300 SE 17 th Street, Suite 500 Ocala, FL

CITY OF PLANT CITY 302 W. REYNOLDS STREET P. O. BOX C PLANT CITY, FLORIDA PHONE (813)

Re-Vita -Life. Sub-dermal Bio-identical Pellets

SPRING BRANCH COMMUNITY HEALTH CENTER

Dear New Patient: Sincerely, The Scheduling Staff

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

Date: PATIENT REGISTRATION Chart # PLEASE PRINT FILL OUT ALL AREAS PATIENT INFORMATION CHILD S NAME BIRTHDATE SSN SEX CELL PHONE# (14 YRS & OLDER)

Stop, if you are under the age of 21 and living with your parents, an office visit is required.

Client Registration Form

CORAZON PANES SANCHEZ., M.D., L.L.C.

Developmental Pediatrics of Central Jersey

Allergy Consultants, P.A. Visit Date: Specialist in Pediatric and Adult Allergy, Asthma, and Sinus Disease

Pediatric New Patient Intake Form

NORTH COUNTY PHYSICAL THERAPY, INC. DBA MISSION PHYSICAL THERAPY GROUP

Welcome Baby Postpartum: 2 Month Call. Visit Information

PATIENT INFORMATION Please Print

Fulcrum Orthopaedics Patient Registration Packet

New Substitute Paraprofessional or Secretary Fingerprint-Based Criminal Background Check Procedures

- Cardiac Catherization - Cardiac Angioplasty - Cardiac Bypass - MUGA - CT Scan

WHITMAN COUNTY CIVIL SERVICE COMMISSION

PATIENT S NAME: LAST NAME: FIRST NAME: MI: DOB: MARRIED: SINGLE: SOCIAL SECURITY: HOME ADDRESS: APT# CITY: STATE: ZIP: CELLULAR PHONE:

Please Note: Please send all documentation related to the credentialing portion of this documentation to:

New Patient Packet. Shawnee Health Care (618) Welcome to.

APPLICATION FOR EMPLOYMENT

CALIFORNIA MEDICAID / MEDI-CAL EDI CONTRACT INSTRUCTIONS (SKCA0)

Crandall Fire Department

PATIENT NOTICE. If you are already taking any of the above medications, your provider may want to talk to you about alternative treatments.

Friendswood Counseling Center, LLC Phone: (479) E. FM 528 Rd, Suite 200 Fax: (281) Client Registration

2018 State Funded Youth Employment Program

GENERAL APPLICATION FOR EMPLOYMENT Human Resources City of New Smyrna Beach 210 Sams Avenue New Smyrna Beach, Florida 32168

Directions to our office are included in this mailing.

Pediatric New Patient Form

NEW PATIENT INFORMATION: ADULT

PATIENT INSTRUCTIONS FOR PAPERWORK

MAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE

PATIENT REGISTRATION

Inland Empire Region phone fax. CAIR v 3.30 Data Entry Guide Rev 4/09

DELTA STATE UNIVERSITY ROBERT E. SMITH SCHOOL OF NURSING RN TO BSN COMPLETION PROGRAM APPLICATION

MEDI-CAL (MC051) EDI ENROLLMENT INSTRUCTIONS

PATIENT'S NAME DATE OF BIRTH SOCIAL SECURITY # HOME PHONE # CELL PHONE # WORK PHONE #

HARBOR CARE HEALTH & WELLNESS CENTER Patient Intake Form Please print clearly. Please ask for assistance in completing this form if needed.

COUNTY OF SACRAMENTO Probation Department

Dr. Albert F. Bravo Gastroenterology / Internal Medicine

WHY THIS FORM IS IMPORTANT

BONITA UNIFIED SCHOOL DISTRICT

School-Based Health Center Wilmington Charter/Cab Calloway High Schools 100 N. Dupont Road Wilmington, DE Phone: Fax:

Welcome to University Family Healthcare, PA.

Welcome to Church Lane Surgery / Dymchurch Surgery

Forms to be completed by the parent

MAIN STREET RADIOLOGY

ACKNOWLEDGEMENT OF HIPAA PRIVACY INFORMATION CONSENT TO USE OR DISCLOSE MEDICAL INFORMATION

PLASTIC SURGERY ASSOCIATES OF LEHIGH VALLEY MEDICAL HISTORY QUESTIONNAIRE (MR: )

School Based Health Consent for Services Grace Community Health Center, Inc.

Patient Information. Address: City: State: Zip: Spouse/Guardian s Last 4 Digits S.S. #: Phone: ( ) Cell Phone: ( ) Emergency Contact Information

(Please Print) PATIENT INFORMATION. Sex: Male Female Home phone no: ( ) City: State: Zip: Cell phone no: ( ) Occupation: Employer: Work phone no: ( )

Affordable Concierge New Patient Registration

Welcome Baby Prenatal Intake

COLON & RECTAL SURGERY, INC.

Name: Last First Middle. Date of Birth: / / Place of Birth: Current Address: Street City State Zip # of years

Change Healthcare CLAIMS Provider Information Form *This form is to ensure accuracy in updating the appropriate account

Other submitted/received documentation (check all that apply): Current Immunizations Student Records Photo ID

Written Financial Policy

RESPITE CARE VOUCHER PROGRAM

Olivieri Chiropractic Inc. AUTO ACCIDENT INFORMATION FORM IF YOU NEED MORE SPACE, WRITE ON THE BACK OF THIS PAGE

Delta Sigma Theta Sorority, Inc. Cincinnati Alumnae Chapter

Transcription:

State of California Health and Human Services Agency Department of Health Care Services Staying Healthy Assessment 0 6 Months Child s Name (first & last) Date of Birth Female Male Today s Date In Child/Day Care? Yes No Person Completing Form Parent Relative Friend Guardian Other (Specify) Please answer all the questions on this form as best you can. Circle Skip if you do not know an answer or do not wish to answer. Be sure to talk to the doctor if you have questions about anything on this form. Your answers will be protected as part of your medical record. 1 Do you breastfeed your baby? Need Help with Form? Yes No Need Interpreter? Yes No Clinic Use Only: N u t r i t i o n 2 Are you concerned about your baby s weight? No Yes Skip P h y s i c a l A c t i v i t y 3 Does your baby watch any TV? No Yes Skip 4 Does your home have a working smoke detector? S a f e t y 5 Have you turned your water temperature down to low-warm (less than 120 degrees)? 6 If your home has more than one floor, do you have safety guards on the windows and gates for the stairs? 7 Does your home have cleaning supplies, medicines, and matches locked away? 8 Does your home have the phone number of the Poison Control Center (800-222-1222) posted by your phone? 9 Do you always put your baby to sleep on her/his back? 10 Do you always stay with your baby when she/he is in the bathtub? DHCS 7098 A (Rev 06/13) SHA (0 6 Months) Page 1 of 2

State of California Health and Human Services Agency Department of Health Care Services 11 Do you always place your baby in a rear facing car seat in the back seat? 12 Is the car seat you use the right one for the age and size of your baby? 13 Does your baby spend time in a home where a gun is kept? No Yes Skip 14 Do you give your baby a bottle with anything except formula, milk, or water? No Yes Skip D e n t a l H e a l t h 15 Does your baby spend time with anyone who smokes? No Yes Skip T o b a c c o E x p o s u r e 16 Do you have any other questions or concerns about your baby s health, development or behavior? No Yes Skip If yes, please describe: Clinic Use Only Counseled Referred Anticipatory Guidance Follow-up Ordered Comments: Nutrition Physical Activity Safety Dental Health Tobacco Exposure Patient Declined the SHA PCP s Signature: Print Name: Date: DHCS 7098 A (Rev 06/13) SHA (0 6 Months) Page 2 of 2

Riverwalk Pediatric Clinic, Inc. HASMUKH C. AM IN, M.D. MARIA C. RUERAS, M.D. MARISSA Q. DeLEON, M.D. VALERIE J. CAYABYAB-GARCIA, M.D. MARILOU D. VELOSO, M.D. JENNIFER HENNICK, FNP JESSICA PRATHER, FNP 9508 STOCKDALE HWY., SUITE 150- BAKERSFIELD, CA 93311 PHONE: (661) 663-7500- FAX: (661) 663-3063 /~ Black Ink Only r'c-' Primary Language Spoken 0 English 0 Spanish 0 Other DATE CHART NO.------- 0 American Indian 0 Asian 0 Black 0 Flipino 0 Mex. Amer/Hisp OWhite 0 Other 0 Pacific Islander ADDRESS FATHER'S NAME MOTHER'S NAME DATE OF BIRTH SOC. SEC. NO. DATE OF BIRTH SOC. SEC. NO. ADDRESS ADDRESS PHONE PHONE CELL CELL EMAIL EMAIL EMPLOYER'S NAME EMPLOYER'S NAME PRIMARY INSURANCE SECONDARY INSURANCE SUBSCRIBER'S NAME NAME I.D.# GROUP# I.D.# # RESPONSIBLE PARTY REFERRED BY IN CASE OF EMERGENCY CONTACT (Other than Parent) NUMBER AND STREET CITY. STATE ZIP PHONE CELL ASSIGNMENT OF INSURANCE BENEFITS I hereby authorize Riverwalk Pediatric Clinic, Inc. to furnish information concerning this illness and I hereby assign to them all payments for medical services rendered. A copy of this authorization is valid as the original. I understand that I am financially responsible for the charges not covered by this authorization. SIGNED (INSURED PERSON) DATE------------ Reorder KVP 32 7-1 772

Medical Record: Riverwalk Pediatric Clinic, Inc. 9508 Stockdale Hwy # 150, Bakersfield ca. 93311, 661 663-7500 t1~1 R Calilornia lmm.unizotion ~ Reg1stry Immunization Registry Notice to Patients and Parents Immunizations or 'shots' prevent serious diseases. Keeping track of shots you have received can be hard. It's especially hard if more than one doctor gave them. Today, doctors use a secure computer system called an immunization registry to keep track of shots. If you change doctors, your new doctor can use the registry to see the shot record. It's your right to choose if you want shot records shared in the California Immunization Registry. How Does a Registry Help You? Keeps track of all shots, so you don't miss any or get too many Sends reminders when you or your child need shots Gives you a copy of the shot record from the doctor Can show proof about shots needed to start child care. school, or a new job How Does a Registry Help Your Health Care Team? Doctors, nurses, health plans, and public health agencies use the registry to: See which shots are needed Prevent disease in your community Remind you about shots needed Help with record-keeping Can Schools or Other Programs See the Registry? Yes, but this is limited. Schools, child care, and other agencies allowed under California law may: See which shots children in their programs need Make sure children have all shots needed to start child care or school What Information Can Be Shared in a Registry? patient's name, sex, and birth place parents' or guardians' names limited information to identify patients details about a patient's shots What's entered in the registry is treated like other private medical information. Misuse of the registry can be punished by law. Under California law, only your doctor's office, health plan, or public health department may see your address and phone number. Patient and Parent Rights It's your legal right to ask: not to share your (or your child's) registry shot records with others besides your doctor" not to get shot appointment reminders from your doctor's office to look at a copy of your or your child's shot records who has seen the records or to have the doctor change any mistakes If you DO want your or your child's records in the registry, do nothing. You're all done. If you DO NOT want your doctor's office to share vour immunization information in the registry: Please request an "Immunization Registry Refusal Form" from your doctor's office. For more information about your rights, call (800) 578 7889 Patient Name:------------- 0.0.8.. *By law, public healih officials can also look at the registry in the case of a public health emergency. rev 1108

State of California-Health and Human Services Agency c~~ ( ~~ Department of Health Services Children's Medical Services Branch California Child Health and Disability Prevention Program CONSENT FORM I hereby give my consent for (Name of patient) to receive the health screening tests and immunizations recommended by the CHOP Program from ---------::-:--...---,-.--,---------:-. (Name of provider) 1 hereby authorize release of information concerning the results of these screening tests to CHOP Program personnel. I also authorize release of the information to the locations checked below. 1 understand that information provided to CHOP Program personnel will be strictly confidential and will be used only to rna~e the provision of health services easier and to permit statistical reporting on the results of screening. D School Name Address (number, street) lcny I state I ZIP code D Health care provider Name Address (number, street) ~c~ I State I ZIP code D Other Name Address (number, street) ~c~ 1- r,~. Name of parent, guardian, or emancipated minor Signature of parent, guardian, or emancipated minor Date Screening Provider: This form, signed by parent, guardian, or emancipated minor, must be retained in patient's file. PM 211 (Bilingual) (3/03)

~ FORM 15-1 NOTICE OF PRIVACY PRACTICES: Acknowledgement of Receipt HASMUKH AM IN, M.D. ACKNOWLEDGEMENT OF RECEIPT Patient Name: Date ofbirth: -------------------------- ------------- By signing this form. you acknowledge receipt ofthenotice of Privacy Practices of Dr. Amin's office. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full. Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by coming by the office at 9508 Stockdale Hwy., Suite 150 Bakersfield, CA93311. If you have any questions about our Notice of Privacy Practices, please contact: Tina Lujan, Privacy Officer at: 661-663-7500 D'lnBrownat: 661-663-7500 I acknowledge receipt of the Notice of Privacy Practices of Dr. Amin's office. Patient/Parent Name: ------------------------------- Signature: (patient/parent/conservator/guardian) Date: ---------------- INABILITY TO OBTAIN ACKNOWLEDGEMENT Complete only if no signature is obtained. If it is not possible to obtain the individual's acknowledgement, describe the good faith efforts made to obtain the individual's acknowledgement, and the reasons why the acknowledgement was not obtained. Patient's Name: ----------------------------------------------- Reasons why the acknowledgment was not obtained: 0 Patient refused to sign this acknowledgement even though the patient was asked to do so and the patient was given the Notice of Privacy Practices 0 Other: ----------------------------------------- Signature of provider representative: Date: --------- (5/12)KVP

~ ~ Chart# Riverwalk Pediatric Clinic, Inc. 9508 Stockdale Hwy, Suite 150 Bakersfield, CA 93311 Patient Name: ---------------------------------- D.O.B ------ IMPORTANT INFORMATION REGARDING YOUR FINANCIAL RESPONSIBILITY Riverwalk Pediatric Clinic, Inc. is contracted with most major health plans. Insurance coverage is an agreement between you and your insurance company. We will be happy to bill your insurance compat.iy directly for medical services rendered. It is your responsibility to contact the insurance company to verify coverage when being treated at Riverwalk Pediatric Clinic, Inc. If problems arise regarding coverage issues, we will attempt to work with you and your insurance company to resolve them. It is your responsibility to keep your insurance and personal information current in our files. We ask that you present your insurance card at every visit. Copayments and coinsurance are due at time of service. If you do not have medical insurance at time of service, you must pay in full before services are provided. We accept cash, personal checks, and Visa, Master Card, Discover, and American Express. If your financial situation is such that you are unable to pay in full, please contact our billing office to discuss possible payment options. Cash Patients: As a courtesy, we are able to provide information, which may assist you in obtaining specific medical services at a minimal/or no cost..riverwalk Pediatric Clinic, Inc. is committed to providing quality service. Thank you in advance for your cooperation and patience Patient/Parent/or Guardian Name Date Patient/Parent/or Guardian Signature

2024 © careersdocbox.com Privacy Policy | Terms of Service | Feedback