Patient Registration Form - PDF Free Download

Patient Registration Form Patient Information Last Name: First Name: M.I.: Previous Name (if applicable) Mailing Address: Apt # Patient Information City/State/Zip: Home Phone: Cell Phone: Work Phone: Email Address: Preferred Method of Contact for Reminder Calls and Other Electronically Generated Messages: (Please Select Only One Option) Voice Text Patient Portal Marital Status: Social Security #: Date of Birth: Emergency Contact Name: If Voice, Please Select Preferred Number: Home Cell Work Sex: q Male q Female Emergency Contact Phone #: Relationship to Patient: Responsible Party- If the patient is a minor (under the age of 18), the parent or guardian bringing the patient in will be listed as the guarantor Additional Information and Responsible Party Last Name: Date of Birth: Address of Person Responsible: City/State/Zip: How did you hear about us? Race (please select): Relationship to Patient: Ethnicity (please select one): o White o American Indian or Alaska Native o Asian o Hispanic or Latino o Hispanic o Black or African American o Native Hawaiian or Pacific Islander o Not Hispanic or Latino o Decline o Other o Other Preferred Language (please select one): o English o Chinese o Indian (including Hindi & Tamil) Preferred Pharmacy Name & Location: Social Security #: Friends Family Co-worker Insurance Website ER/Urgent Care Internet: Specialist Newspaper Magazine Other First Name: o Filipino/Tagalog o Spanish o Russian o Other Phone: When you are unavailable to answer the phone, may we leave detailed voicemails about your medical treatments, care plan, test results, referrals, and prescriptions? o Yes o No If yes, on which phone numbers? Home Cell Work Primary Medical Insurance Secondary Medical Insurance Insurance Information Ins. Co. Name Ins. Co. Name Policy Holder Name: Policy Holder Name: Policy Holder's Date of Birth: Policy Holder's Date of Birth: Policy Holder's Social Security #: Policy Holder's Social Security #: Patient Relationship to Policy Holder: Patient Relationship to Policy Holder: Our office uses our online Patient Portal extensively to communicate with our patients. Patients can view lab results, book appointments, request refills, update key information, pay balances, and many other functions via Patient Portal. Be sure you sign up for it.

Name Date of Birth Main reason for today s visit: Please list all healthcare providers you see regularly: Comprehensive New Patient Health History Questionnaire PERSONAL MEDICAL HISTORY: Have you ever had any of the following conditions? Check box if you have no history of significant medical illnesses. Condition Now Past Condition Now Past Alcohol / Drug abuse Gynecological Conditions (Endometriosis) Allergy (Hay Fever) ( ) Gynecological Conditions (Fibroids) Anemia Gynecological Conditions (Other) Anxiety Hepatitis Type A B C Arthritis (Rheumatoid) Herpes (cold sore or genital) Arthritis (Osteoarthritis) High Blood Pressure Asthma High Cholesterol Bladder / Kidney Problems Inflammatory Bowel Disease Blood Clot ( ) Irritable Bowel Syndrome Cancer ( ) Kidney Disease / Failure Cataracts Kidney Stones Chronic Pain ( ) Liver Disease Colon Polyp Migraine Headaches Coronary Artery Disease Osteoporosis Depression Prostate (enlargement) Diabetes (adult onset) Seizure / Epilepsy Diabetes (childhood onset) Sleep Apnea Diverticulosis Stomach Ulcer Emphysema (COPD) Stroke Fractures (broken bones) Thyroid (Nodule) Gallbladder Disease Thyroid High (Overactive) / Hyperthyroidism Gastroesophageal Reflux (Heartburn/GERD) Thyroid Low (Underactive) / Hypothyroidism Glaucoma Other ( ) Gout Other ( ) SURGICAL & PROCEDURE HISTORY Please enter the year of any procedures or surgeries below. Check box if you have never had any medical procedures or surgeries. Surgical Procedure Year Surgical Procedure Year Abdominal surgery ( ) Hysterectomy (partial, ovaries left) Appendectomy (appendix removal) Hysterectomy (total, including ovaries) Back surgery Joint Arthroscopy ( ) Biopsy ( ) LEEP (Cervix surgery) Breast Biopsy Neck Surgery Breast surgery Ovary Removal Cataract surgery Sinus Surgery Coronary Bypass Tonsillectomy Coronary Stent Tubal ligation C-Section Urological Surgery Gallbladder Removal Vascular Surgery ( ) Heart Surgery( ) Vasectomy Hip Surgery ( ) Other ( ) Please go to next page Page 1 of 3

FAMILY HISTORY Adopted? No Yes. If adopted, and you do not know your family history, skip the Family History section. Indicate which relative has had the following diseases (parents, brothers & sisters are the most important). Write in number of siblings in appropriate boxes.* If some siblings are alive and some are deceased use the space to the right to explain further. Mother Father * Sister(s) * Brother(s) Mom s Mom Mom s Dad Dad s Mom Dad s Dad Alive Deceased Age currently or at death Diseases & Conditions No significant history known Hypertension high blood pressure Hyperlipidemia high cholesterol Heart Attack, Angina (Coronary Artery) Diabetes Type I (childhood onset) Diabetes Type II (adult onset) Osteoporosis Depression Alcoholism / Drug abuse Alzheimers Asthma Autoimmune Disease Bleeding or Clotting Disorder Cancer ( ) Colon Polyp Emphysema (COPD) Genetic Disorder (explain) Heart Disease (CHF) Hepatitis B or C Hypothyroidism / Thyroid Disease Kidney Disease Stroke Sudden Cardiac Death Other ( ) Other ( ) Mother Father Sister(s) Brother(s) Mom s Mom Mom s Dad Dad s Mom Dad s Dad Other blood relatives (list relationship to you) MEDICATIONS: Please list (or show us your own printed record) all prescription and non-prescription medications. This includes vitamins, herbs, supplements, home remedies, birth control pills, inhalers, over the counter pain pills (Advil, Aleve, Tylenol, etc). Check box if you do not take any prescription or over the counter medications. Check box if you brought a list of your medications (give it to my assistant and don t write in medications below). ALLERGIES or intolerance to medications? (If yes, to what & what reaction?) No known drug allergies Medication Dose (e.g. mg/pill) How often? Medication Dose (e.g. mg/pill) How often? Please go to next page Page 2 of 3

IMMUNIZATIONS: Voluntarily declined all vaccines Vaccine Date Vaccine Date Vaccine Date Hepatitis A Pneumovax (Pneumonia) Whooping Cough (DTaP) Hepatitis B Prevnar 13 (Pneumonia) Zostavax (shingles) HPV Tetanus (Td) Influenza (flu shot) Varicella (Chicken Pox) HEALTH MAINTENANCE SCREENING TESTS: Test Date Result Test Date Result Screening Labs Normal Abnormal Sigmoidoscopy Normal Abnormal Physical Exam Normal Abnormal Colonoscopy Normal Abnormal Endoscopy Normal Abnormal Stress Test Normal Abnormal Women Only Mammogram Normal Abnormal Bone Density Test (DEXA) Normal Abnormal Pap Smear Normal Abnormal HEALTH ISSUES: Tobacco Use Exposure to second hand smoke? Yes No Alcohol Use Do you drink alcohol? No Yes Smoke / smoked Cigarettes E-Cigarettes Pipe Cigar None # of drinks/week: Beer Wine Liquor Never Smoked How many times in a year have you had >3 drinks (for women) or >4 drinks (for men) in a day? Current smoker: Packs/day: # of years: Are you ready to quit? No Yes Former smoker: Quit date: Approximately how many packs/day did you smoke? How many years did you smoke? SOCIAL HISTORY: Drug Use Have you ever used recreational drugs? No Yes If yes, which ones? Quit which ones? All Any used currently? Marital status: single partner married divorced widowed Spouse/partner s name: Number of children: Age and sex of your children: # of grandchildren: # of great grandchildren: Education: high school or GED trade school college graduate school other Occupation: Employer: If you are not working, you are: retired unemployed on a leave of absence disabled homemaker other Country of birth: WOMEN S HEALTH HISTORY: Total number of pregnancies: Number of births: Number of miscarriages: Number of abortions: Thank you for taking the time to complete this form Page 3 of 3

Healthy Living Primary Care PPO Auto-Pay Policy Please choose one of the options below: For your convenience, we created two forms of payment to assist with balances until your deductible is met. I choose to keep my HSA/Credit Card on file for any balance due after billing my insurance. I understand you will mail a statement and allow 3 weeks for me to contact the office with any concerns. If I have no concerns, my balance will be paid with the credit card on file. I will receive an email through Patient Portal once the payment has been processed. I choose to pay $100 upon check-in that will go toward any patient portion of my office visit until my deductible is met. If there is a credit remaining on my account it will be used toward future balances. This amount will only be charged to me if there is no credit already remaining on my account. Authorization for Credit Card Use Patients Name: Name on Card: Billing Address: Credit Card Type: Visa MasterCard Discover AmEx Credit Card Number: Expiration Date: Card Identification Number: (3 digit code on the back of the credit card) I understand I have up to 3 weeks from the date my billing statement was mailed out, to pay my balance in full. If I have not paid my balance in full after the 3 weeks, I authorize this office to charge up to $150 to the credit card above to settle up to $150 of the balance on my account. I further understand that if there is a balance remaining after charging $150 to the credit card above, that I will make payment in full immediately to avoid any late fees. Cardholder Signature: Date: Print Name: If there are any questions about your statement please contact our biller, Annie through Patient Portal or call her at (510) 679-7222 upon receipt of the statement. This agreement will remain in place until the expiration of your credit card on file. If you would like to cancel the authorization, please provide us with a written request would.

Healthy Living Primary Care Dr. Joy Liu, D.O. Dr. Kevin Moynihan, M.D. Dr. Jayferson Golepang, M.D. Diane Asmuth, P.A.-C Loran Killar, PhD, P.A.-C Noelle Menesini, P.A.-C Nisha Nijjar, F.N.P.-C 2545 E. Bidwell Street, Suite 110, Folsom, CA 95630 11634 Fair Oaks Blvd, Fair Oaks, CA 95628 Phone: (916) 983-8868 Fax: (916) 983-8891 Office Policies WELCOME TO OUR PRACTICE: We are glad you have selected our office for your healthcare needs. Our care team include three physicians, four mid-levels, and many supporting staffs. We work as a team to provide quality care to people of all ages. We offer personalized care through the use of the latest in medical information and diagnostic technology. Developing a strong and long-lasting relationship between the patient and physician is important to us. KNOW YOUR INSURANCE PLAN: Under the dynamic changes of the insurance world, it is critical for patients to understand their own insurance benefits and restrictions. Until your deductible is met, office visits, blood work and imaging tests are the patient s responsibility. Preventive lab tests are only limited to cholesterol panel, complete metabolic panel, complete blood count, thyroid test, and prostate enzyme. Any other tests is subject to potential out-of-pocket payments, depending on your plan. Preventive visits only cover screening for high blood pressure, cholesterol, breast exam, Pap smear, vaccinations and physical exam. Discussion of any medical condition during your preventive visit is subject to an additional charge for a sick visit. APPOINTMENTS: One of the goals of this office is to respect our patients time by having you in the exam room at the time of the scheduled appointment as opposed to being in the waiting room. In the event that you are inadvertently delayed in your arrival for your appointment, every effort will be made to fit you into the existing schedule. However, there may be times that we will request that you re-schedule your appointment if we cannot accommodate you. CANCELLATIONS: If you find that you need to cancel your appointment, please provide the office with 24- hours notice to avoid a $25.00 no-show/same-day cancellation fee via Patient Portal, phone call or voicemail. We will be glad to reschedule you to a more convenient time. CHRONIC DISEASE MANAGEMENT PROGRAM (if you qualify): If you have at least two chronic diseases, you qualify for our Chronic Disease Management Program at no charge to you. This program s goal is to make sure that your health is well managed. Our designated CCM specialist will review your chart monthly for such things as preventative care, medication reconciliation, RX refills, and medical management by other specialists. Patient understands that only the primary care physician can administer this program and that patient can opt out of the program anytime. I understand and agree to all the above policies. Patient s Name: Parent s/conservator s Name: Patient s/parent s/conservator s Signature: Date:

LABS: Healthy Living Primary Care Office Procedures Lab orders are sent to Quest electronically for your convenience. You can go to any Quest without a printed order. If you would like to go to LabCorp, we will print you the lab order. If you are given a paper slip at check out, it is important to bring that lab slip with you to the lab. You can make appointments online at www.questdiagnostics.com to cut down wait time. If you have a PPO, most lab tests count toward your deductible. For most insurances, preventive lab tests are limited to cholesterol panel, comprehensive metabolic panel, complete blood count, thyroid test, and prostate enzyme. Please call your insurance if you have questions about cost and coverage. IMAGING TESTS: Call Sutter Imaging to schedule the test and bring in the printed order. However, any patient with Covered California and Connected Care needs to go to Mercy Imaging If prior authorization is required by your insurance, we will obtain the authorization and you will be contacted through our Patient Portal once this is complete. Depending on the urgency of your exam, prior authorization can take up to 7-10 business days to process. REFERRALS: Please allow up to 7-10 business days to process your referral unless it is medically urgent. You will be notified through our Patient Portal when your referral is done. Please make an appointment with the specialist within 30 days because many offices will disregard the referral after 30 days. There is a $25 fee for any repeat referrals. All pertinent medical information will be sent with the referral to the specialist. You also have access to your medical record through our Patient Portal if anything additional is needed by the specialist. We will do our best to refer you to a specialist within your insurance network. However, it is your responsibility to confirm that the specialist is in your network before receiving services with that office. TEST RESULT: We will always notify you of all test result. If you do not hear from us after 2 weeks, contact us via Patient Portal. For routine or preventative lab/test, our providers will send you the interpretation of the test results through our Patient Portal. Afterward, you will also be able to view your results on Patient Portal. If the test result is abnormal and requires an in-depth discussion, we will contact you via Patient Portal to schedule a follow-up appointment. For follow-up tests, our provider will discuss the test results with you in detail at your next follow-up appointment. If any test result is urgent, you will be contacted by phone. KNOW YOUR INSURANCE PLAN: Under the dynamic changes of the insurance world, it is critical for patients to understand their own insurance benefits and restrictions. Until your deductible is met, office visits and tests are the patient s responsibility. URGENT CARE/AFTERHOUR CARE: We have multiple providers here daily to take care of your urgent medical needs. You should be able to get an appointment with someone on our care team on the same day if you call early in the day. If you need care after office hours, on-call doctors are available for consultation 24/7. Directions to local urgent care centers are outlined in our voicemail message. Keep in mind that for life threatening emergencies you should call 911. RX REFILLS: Please check for any refills you might need prior to each visit. If you need a prescription refill between visits, please contact your pharmacy and they will send an electronic request to our office. You can also request for medication refill on Patient Portal. Please allow 24 to 48 hours for your prescription to be approved by the physician and processed by our office. However, we are not able to refill narcotic medication without a visit. I understand and agree to all the above office procedures. Patient s Name: Parent s/conservator s Name: Patient s/parent s/conservator s Signature: Date:

Healthy Living Primary Care NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US. We are required by applicable federal and state law, including the Health Insurance Portability & Accountability Act of 1996 (HIPAA), to maintain the privacy of your medical information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your medical information. You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice. We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all medical information that we maintain, including medical information we created or received before we made the changes. We may use and disclose medical information about you for the following purposes: Treatment, Payment and Health Care Operations: Treatment: We may use your medical information to treat you or disclose your medical information to a physician or other health care provider providing treatment to you. Payment: We may use and disclose your medical information to obtain payment for services we provide you. Health Care Operations: We may use and disclose your medical information in connection with the normal course of operating our practice. Health care operations may also include quality assessment activities, performance evaluations, conducting training programs, accreditation, and certification, licensing or credentialing activities. We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you. Any other uses and disclosures of your medical information will only be made with your written authorization or in response to legal requirements such as disaster relief, court orders, suspected abuse, neglect, or domestic violence, or in certain instances affecting national security. You have the following rights with respect to your protected health information which you may exercise by written request using the contact information at the end of this notice: The right to request additional restrictions on the use or disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement which must be in writing. The right to inspect and copy your protected health information. The right to request amendments to your protected health information. The right to receive an accounting of disclosures of your personal health information for other than treatment, payment, health care operations or pursuant to other authorized disclosures as stated above. The right to obtain a copy of this notice If you are concerned that we may have violated your privacy rights, or you disagree with a decision we have made to amend or restrict the use or disclosure of your medical information or to have us communicate with you by alternative means or at alternative locations, you may contact us using the contact information listed at the end of this notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint upon request. We support your right to the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us or with the U. S. Department of Health and Human Services. Contact Office: Healthy Living Primary Care Phone: 916-983-8868 Fax: 916-983-8891 Address: 2545 E. Bidwell St, Suite 110, Folsom, CA 95630 Patient s Name Patient s Signature Date