Patient name: How did you hear about us? Lives (circle one): in assisted living with a relative alone Current address (include name of assisted living or independent living facility if applicable): Current phone (assisted living if applicable): Date of birth: SS# - - Gender: Male Female Medicare D #: Primary insurance: D # Group # Claims address (from back of insurance card): Telephone number: Secondary insurance: D # Group # Claims address (from back of insurance card): Telephone number: Correspondence address (where bills and other documents are to be sent): Phone: Home - Cell - Work -
Patient name: Chief medical complaint/history of present illness: Medications (please list name, strength and dose; include additional pages if necessary): Name Dosage How often do you take it? Allergies/Reaction: No known drug allergies: Pharmacy: Telephone: Rx D: Support (include name of agency): Home Health: Hospice: Patient
Emergency Contact 1: Phone: Home- Cell- Work- Emergency contact 2 (if different from above): Phone: Home- Cell- Work- _ Social (please describe the following): Diet: Tobacco use: Alcohol use: Does patient drive a car? Adaptive equipment (circle all that apply): wheelchair / walker / cane / eyeglasses / hearing aid Race (optional) Hispanic Caucasian Asian African American Other: Marital status: Single Married Widowed Divorced Domestic Partnership Primary language if other than English: Person supplying information on this form (if other than patient): Relationship to patient:
Authorization to Bill and Treat PLEASE SGN AND RETURN We are a Medicare Participating Provider My signature and date below authorizes/acknowledges each of the following: 1. Direct billing to Medicare, Medicaid, Medicare Supplemental or other insurer(s) on my behalf, including billing of Chronic Care Management services (CCM) as outlined in the Practice Policies document which have received. 2. hereby authorize medical services as indicated by the medical provider of House Calls Primary Care for myself and/or my family member 3. Release of my medical information to my insurance providers and their agents. 4. House Calls Primary Care and/or any of their corporate affiliates to obtain medical or other information necessary in order to process claim(s), including determining eligibility and seeking reimbursement for medical supplies and/or medication(s) provided. 5. acknowledge that have received a copy of House Calls Primary Care Notice of Privacy Practices. 6. There are certain services House Calls Primary Care provides which are not covered by Medicare and most other insurances. These charges must be paid by the patient or their representative at the time of service. The following charges may apply: Missed Visit Fee $75 Formal Letter Requests $40 Records (free to MD office) $35 Care Plan Oversight (other than Medicare) $40 Long Term Care Form $40 SGN, DATE AND RETURN THS PAGE MMEDATELY! n order for us to bill Medicare and/or other insurance for your medical supplies and/or medications, this page must be completed, signed, dated and returned immediately. Name of patient/legal representative: Relationship to patient: SGNATURE: X Date:
Patient City/State/Zip: Date of Birth: / / Authorization to Release Protected Health nformation Patient information - please fill out completely Phone Number hereby authorize the following provider to disclose the above-named individual s health information. understand that the information in my health record may include information relating to communicable disease, Acquired mmunodeficiency Syndrome (ADS), or Human mmunodeficiency Virus (HV), genetic testing or screening, behavioral or mental health, alcohol/drug (substance) abuse or any such related information. Name of Facility Releasing nformation: Provider to whom information will be released: House Calls Primary Care 22820 E. Appleway Ave. Suite A Liberty Lake, WA 99019 Please FAX requested information to (509)279-0286 or mail to the above address Purpose of disclosure: TREATMENT nformation to be used/disclosed: Progress notes Laboratory reports Consultations Radiology/maging reports Most recent history and physical Radiology films mmunization record Two-way verbal exchange of communication Other: Entire medical record Date Range of nformation Disclosed Start Date / / End date / / By signing this authorization, agree to the following: X understand if authorize my information to be released to persons or organizations not subject to federal privacy laws, the information may be re-disclosed by the recipient and the information will no longer be protected. understand that authorizing the use and disclosure of this health information is voluntary and that can refuse to sign this authorization. do not need to sign this form in order to receive treatment. understand that may inspect a copy of the information to be used or disclosed. understand that can revoke this authorization at any time by contacting my provider, but any revocation will not apply to the extent that my provider has acted in reliance of this authorization. authorize the use and disclosure of my health information as described above. This authorization expires one year from the date on which it was signed, unless otherwise specified. (Otherwise specified date, event, or condition: ) Signature of Patient or Personal Representative Date f not signed by Patient, list Personal Representative s authority We accept patients for care regardless of age, race, color, national origin, religion, sex, disability, being a qualifed disabled veteran, being a qualifed disabled veteran of the Vietnam era, or any other category protected by law, or decisions regarding advance directives. 2017 Kindred at Home CSR 190291-01, EOE