The Lymph Clinic: Client History DEMOGRAPHICS Name: Date of Birth: Age: Home Phone: Cell Phone: Email: Best way to contact: Home Cell Email PHYSICIAN INFORMATION Referring Physician: Physician s Specialty: Referring Physician Phone #: Referring Physician Fax #: Please list all medical providers involved in your health care: Name of Medical Provider Specialty Phone Number SWELLING HISTORY Currently I am experiencing (please circle) Swelling Weakness Open sores that will not heal Pain Rash Shortness of breath Impaired motion Numbness/Tingling Heaviness/Tightness/Fullness Other: Skin Changes: dry, discolored, weeping, hard Which body part is affected? Date of initial onset of symptoms: Does anyone in your immediate family have a history of swelling? 1
MEDICAL HISTORY IN AREAS WITH A *, PLEASE EXPLAIN AND LIST DATES High Blood Pressure Asthma Congestive Heart Failure Diabetes Arrhythmia Arterial Disease Renal (Kidney Disease) Neuropathy Thyroid Problems Fractures Scoliosis Vertigo Breathing Problems Heart Problems Circulation Problems Deep Vein Thrombosis (Blood Clot) Other: Latex Allergy * Paralysis GERD (reflux) Crohn s Disease Cancer Heart Problems Medications: (name, dose, freuency) (include herbal supplements, vitamins, over-the-counter-medication) Medication allergies: Surgical History: N/A Left Right Both Reconstruction Reconstruction: (date/type) Lumpectomy Axillary node dissection Modified/radical mastectomy Simple/total mastectomy Abdominal surgery (Please list dates) N/A Gall bladder Hysterectomy N/A Breast surgery Prostate surgery Date: Hernia Repair Plastic Surgery Other: 2
SOCIAL HISTORY Do you live in a: o House o Apartment/Condo o One Level o Two Level Do you live alone? Yes o No o Do you sleep in a o Bed o Chair o Other: Do you have help to participate in lymphedema therapy? o Yes o No Do you reuire assistance for walking or getting in/out of bed or chair? o Yes o No Do you reuire assistance for bathing/dressing/home management tasks? o Yes o No Are you currently working? o Yes o No o Retired Occupation: What recreational activities do you do on a regular basis (i.e., walking, swimming, weightlifting, hiking, crafts)? How many days a week are you physically active? o 0 o 1-2 o 3-5 o 6-7 Please list 2 important activities you are unable to do or have difficulty doing as a result of your swelling? 1. 2. Please list 2 important goals that you would like The Lymph Clinic to help you achieve? 1. 2. THERAPY HISTORY Have you received ANY outpatient Physical, Speech or occupational Therapy Services this year? Yes o No o Are you currently being seen for outpatient Physical, Speech or Occupational Therapy Services? Yes o No o Are you currently receiving home health services including nursing, Physical, Speech, Occupational Therapy Services or home health aide? Have you had lymphedema therapy before? Yes o No o If yes, where and when? What treatments have you received? Manual Lymphatic Drainage Compression Bandaging Diuretics Antibiotics Kinesio Taping Self Drainage Other: 3
PAIN SCALE On a scale from 0 (no pain) to 10 (the works pain you could imagine), what is your pain: Worst: 0 1 2 3 4 5 6 7 8 9 10 Current: 0 1 2 3 4 5 6 7 8 9 10 Best: 0 1 2 3 4 5 6 7 8 9 10 Where is your pain centered? Please describe your pain : What increases your pain : What decreases your pain : Is there anything else you would like us to know regarding your pain: LEARNING STYLE How do you best learn? o Visual o Auditory o Demonstration o Video I have filled out this form to the best of my knowledge and understand that it is important to relay any health-related changes to my therapist at my next visit. Even little changes such as prescription doses or new medications can have an impact on my body s response to therapy. Client signature: Date: Therapist signature: Date: 4
HEALTH TEAM AGREEMENT Lymphedema is a chronic condition that occurs when the lymphatic system has been damaged or impaired. In order to treat this condition, and reduce swelling, there must be a team approach. Body of Health is a part of your health team to help you achieve a better uality of life through lymphatic therapies. We have set up a program that works. Our lead therapist has combined many years of experience in this field to come up with a program that effectively reduces swelling and improves function. This program consists of: 1. 2. 3. 4. 5. Daily/weekly visits for evaluation, treatment, and measurements by the therapist. Meticulous skin care routine. Massage/manual lymph drainage, which may include the chest and groin. Bandaging of the limb 20-23 hours a day. Self-bandaging on weekends. (You and your caregiver will be instructed in self-massage and self-bandaging.) 6. Therapeutic exercises to accelerate lymph flow. 7. Instruction in a home maintenance program. While this routine seems demanding, it is not forever. Once the limb or area is under control, you can move to compression garments and a maintenance routine. Body of Health is a comprehensive Lymphedema facility. We offer garments as well as helpful hints to make home care simple and doable. Your commitment to the treatment program will lead to uicker recovery and better uality of life. Please note that if you choose not to fully participate in the above outlined program this may lead to poor results. Are you prepared to follow this program? Yes No This agreement form has been explained to me and I certify that I fully understand its contents. Date Witness Date Client Signature 5
FINANCIAL POLICY PLEASE READ THIS VERY CAREFULLY 1. Your insurance plan is an agreement between you, your employer (if applicable) and your insurance carrier. The Lymph Clinic LLC is not a partner in this arrangement. Therefore, any CO-PAYMENTS, CO-INSURANCE and DEDUCTIBLES are due before the insurance claim will be filed. 2. It is your responsibility to determine if The Lymph Clinic LLC or any other providers to which you may be referred are in your network for Preferred Provider. If your insurance denies payment for treatment because you did not 3. notify our staff of a Preferred Provider, that will be between you and your insurance company. st As of January 1 2017, statements will be sent to you monthly from this office. Payment for a balance is expected in full. If payment in full is not received by the THIRD statement, you may be dismissed as a client from this practice. Balances not paid within 90 days are subject to client dismissal and/or submission to our Collection agency. 4. If you receive a statement and find you cannot pay the balance in full, please contact our office to make payment arrangements. 5. It is your responsibility to provide our office with your correct contact information (name, address & phone number) for which to send statements or call you if necessary. 6. Please be advised that should this account be referred to a collections agency or attorney for the purposes of collecting outstanding balances you will be responsible for covering the costs. 7. Please be advised that if you do not come to a scheduled appointment you will be charged a No Show fee. The fee is 50% of the visit cost under your insurance negotiated price or cash pay rate. A same day cancellation will also result in a 50% cancellation fee unless you have a doctor s excuse. 8. Please be advised that you will be billed and are expected to pay all outstanding balances as determined by the insurance company. Should you believe you are not responsible for the balance, you will need to provide out office with documentation or you will need to file an appeal with your insurance company. 9. Photocopies of all Business Office forms that I sign are also considered as valid as the original. *****I have read and understand all of the above and have agreed to these statements. Client Signature: If the patient is under the age of 18, parent or guardian signature: Date: 6
ADVANCED DIRECTIVE Advance directive sometimes called a living will is a document expressing a person's wishes about critical care when he is unable to decide for himself. An advance directive is a living will documenting one s wishes for end-of-life medical treatment. The document instructs whether dialysis, breathing machines or tube feeding are desired, whether to resuscitate, and whether to donate organs and tissue at the end of one's life. Planning ahead provides the medical care a person desires and avoids unnecessary suffering, disagreements and decision-making burdens during times of crisis. Two physicians must certify the person is terminally ill, seriously injured, in a coma, in the late stages of dementia, or permanently unconscious and unable to make medical decisions before the living will is enacted. An advance directive becomes legally valid in the United States after signing in front of a witness. However, emergency medical technicians cannot honor a living will; they must do everything in their power to stabilize a person for transfer to a hospital. Once a physician fully examines the person s condition, advance directives can be implemented. Completing a new living will invalidates the old one. An advance directive should be updated periodically to stay current with a person s changing end-of-care desires. Advance directives aren't just for older adults. Unexpected end-of-life situations can happen at any age, so it's important for all adults to prepare these documents. YES I do have an Advanced Directive and will provide you with a copy. NO I do not have an Advanced Directive. I would like more information. Print Name Signature Links to state-specific forms can be found on the websites of various organizations such as the American Bar Association and the National Hospice and Palliative Care Organization. 7
The Lymph Clinic, LLC HIPAA Acknowledgment and Consent Form Patient Name: Date of Birth: Notice of Privacy Practices (Patient/Representative initials) I acknowledge that I have received the practice s Notice of Privacy Practices, which describes the ways in which the practice may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the Privacy Officer designated on the notice if I have a uestion or complaint. I understand that this information may be disclosed electronically by the Provider and/or the Provider s business associates. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice s Notice of Privacy Practices. Release of Information (Patient/Representative initials) I hereby permit practice and the physicians or other health professionals involved in the inpatient or outpatient care to release healthcare information for purposes of treatment, payment, or healthcare operations. If I am covered by Medicare or Medicaid, I authorize the release of healthcare information to the Social Security Administration or its intermediaries or carriers for payment of a Medicare claim or to the appropriate state agency for payment of a Medicaid claim. This information may include, without limitation, history and physical, emergency records, laboratory reports, operative reports, physician progress notes, nurse s notes, consultations, psychological and/or psychiatric reports, drug and alcohol treatment and discharge summary. Federal and state laws may permit this facility to participate in organizations with other healthcare providers, insurers, and/or other health care industry participants and their subcontractors in order for these individuals and entities to share my health information with one another to accomplish goals that may include but not be limited to: improving the accuracy and increasing the availability of my health records; decreasing the time needed to access my information; aggregating and comparing my information for uality improvement purposes; and such other purposes as may be permitted by law. I understand that this facility may be a member of one or more such organizations. This consent specifically includes information concerning psychological conditions, psychiatric conditions, intellectual disability conditions, genetic information, chemical dependency conditions and/or infectious diseases including, but not limited to, blood borne diseases, such as HIV and AIDS. 8
The Lymph Clinic, LLC HIPAA Acknowledgment and Consent Form Continued Disclosures to Friends and/or Family Members DO YOU WANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM THE PROVIDER MAY DISCUSS YOUR MEDICAL CONDITION? IF YES, WHOM? I give permission for my Protected Health Information to be disclosed for purposes of communicating results, findings and care decisions to the family members and others listed below: Name Relationship Contact Number Patient/Representative may revoke or modify this specific authorization and that revocation or modification must be in writing. Note: This clinic uses an Electronic Health Record that will update all your demographics to the information that you just provided. Please note this information will also be updated for your convenience to all our affiliated clinics that share an electronic health record in which you have a relationship. Consent for Photographing or Other Recording for Security and/or Health Care Operations (Patient/Representative Initials) I consent to photographs, digital or audio recordings, and/or images of me being recorded for security purposes and/or the practice s health care operations purposes (e.g., uality improvement activities). I understand that the facility retains the ownership rights to the images and/or recordings. I will be allowed to reuest access to or copies of the images and/or recordings when technologically feasible unless otherwise prohibited by law. I understand that these images and/or recordings will be securely stored and protected. Images and/or recordings in which I am identified will not be released and/or used without a specific written authorization from me or my legal representative unless it is for treatment, payment or health care operations purposes or otherwise permitted or reuired by law. 9
The Lymph Clinic, LLC HIPAA Acknowledgment and Consent Form Continued (Patient/Representative Initials) I do not consent to photographs, digital or audio recordings, and/or images of me being recorded for security purposes and/or the practice s health care operations purposes (e.g., uality improvement activities). Consent to Email or Text Usage for Appointment Reminders and Other Healthcare Communications We want to stay connected with our patients. Patients in our practice may be contacted via email and/or text messaging to confirm an appointment, to obtain feedback on your experience with our healthcare team, and to be provided general health reminders/information. If at any time, you provide an email address or text number below, you understand that you may get these communications from the Practice. You may opt out of these communications at any time. The practice does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan (contact your carrier for pricing plans and details). The cell phone number that I authorize to receive text messages for appointment reminders, feedback, and general health reminders/information is. The email that I authorize to receive email messages for appointment reminders and general health reminders/feedback/information is. OR (Patient/ Representative Initials) I decline to receive communication via text. (Patient/ Representative Initials) I decline to receive communication via email. 10
If you have previously consented to receive communication via text/email and wish to remove the consent longer for the above-mentioned communications. Patient/Parent/Guardian/Patient Representative Signature Date: Patient/Parent/Guardian/Patient Representative Name (Printed) 11