Dear New Patient: We would like to welcome you to our practice. Our goal is to make your experience with us as pleasant as possible. In order to help us meet this goal we have listed some helpful hints to benefit you as well as help our practice operate efficiently. Office Hours Our office hours are Monday through Friday 7:30 am to 5:30pm. Our office is closed on all major Holidays. Medications Please bring ALL medications and supplements in the bottle or a current medication list with you to all office appointments. New Patient Registration New patients must arrive 20 mins early to register unless otherwise instructed. Please bring photo ID and insurance cards. We also have a Health History packet that we ask you to complete before coming into the office. Completing and bringing these forms along with your insurance cards will save you time in the office and make your waiting time as short as possible. Billing and Insurance If your insurance plan has a co-pay please be prepared to pay at the time of service each visit. We ask that you always make our receptionists aware of changes in address, phone numbers, and insurance as you sign in. Phone Calls We want to be responsive to your needs. If you need to speak with a physician or their MA please call during office hours unless you have an emergency then you can page the physician on call. Our phone hours are Monday through Friday from 7:30am-11:30am and 1:30pm- 4:30pm. Prescription Refills Please ask your physician or nurse for all of your prescription refills at the time of your visit. This will ensure you have all of your needed medications. If you are needing a refill before your scheduled visit we ask that you contact the pharmacy and ask them to fax us a refill request to 423-643-2030. Any faxed refill request that is received by 4:30pm will be handled that same day. Lab Results and Test Results If you have lab work or test results pending, it is not necessary for you to call our office unless you have been instructed to do so by your physician. A medical assistant will call you with the results after they are reviewed by your physician. If you have any questions about any part of the registration process, or anything pertaining to your appointment, please feel free to call us. We are here to serve you. Sincerely, CHI Memorial Integrative Medicine Associates 320 E Main ST Suite 200 Chattanooga, TN 37323 *PH: 423-643-2246 *Fax: 423-643-2030
CHI Memorial Integrative Medicine Associates 1. Cancellation/ No Show Policy for Doctor Appointment We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, failing to call to cancel an appointment, may be preventing another patient from getting much needed treatment. As of July 1, 2016 if an appointment is not cancelled at least 24 hours in advance you will be charged a fifty dollar ($50) fee; this will not be covered by your insurance company. Three No-Show appointments will subject you to possible dismissal from the practice. 2. Scheduled Appointments We understand that delays can happen however we must try to keep the other patients and doctors on time. If a patient is 15 minutes past their scheduled time for a primary care visit or 10 mins for nutritional counseling and/or shows up after their appointment time without the required paperwork we will have to reschedule the appointment to a later time or date. / / Print Name Patient Signature Patient/Guardian Date
CHI MEMORIAL INTEGRATIVE MEDICINE ASSOCIATES FINANCIAL POLICY It is our objective to provide you with the highest quality healthcare in the most cost effective manner. If you have medical insurance we will be happy to file the claim form on your behalf. We do this as a courtesy to our patients to help you receive the maximum allowable benefits from your insurer. We need to be actively involved in the insurance claims process to insure accuracy and effectiveness. Commercial Insurance Patients Please remember that your insurance contract is between you and your insurer. If you insurance company pays only part of your bill or rejects your claim you are financially responsible for the balance. Commercial insurance carriers should be prepared to pay a minimum of 20% of their bill at the time of service. Patients with no insurance Patient s that do not have insurance are asked to pay for their visit at the time of service. We will be glad to set up payment arrangements if that is necessary. If you have any questions, please do not hesitate to ask us. We are here to help you. We accept payments in the form of cash, check, and most types of major credit cards. Patient Signature Date
Individual Notice of Privacy Practices Acknowledgement I acknowledge that I received a copy of CHI/Memorial Health Partners Foundation Notice of Privacy Practices (v03/2016) for (print patient s name). Signature of Patient Patient s DOB OR Signature of Patient Representative or Parent/Legal Guardian if Under 18 Individual (or patient representative/parent/legal guardian) did not sign the acknowledgement for the following reason (check below): Individual refused Individual refused, stating that he/she has already signed an acknowledgement There was not a personal representative of the individual available to sign Other (please explain): Signature of Witness Date Personal Representative of Patient As a patient you may designate one or more personal representatives. A personal representative may receive protected health information (PHI) about you. PHI includes medical conditions and diagnosis, treatment and prognosis, and billing and payments. You can remove or add personal representatives at any time. I (Patient) do not wish to designate a personal representative. I (Patient) designate the following personal representative(s): Name of Personal Representative Relationship Phone Name of Personal Representative Relationship Phone Consent for Telephone Communication I consent to receive telephone calls from Memorial Health Partners Foundation (MHPF) or a designated third party relating to my healthcare and other services. I agree to receive telephone calls at either my home telephone or my cellular telephone. I agree to allow MHPF to call my home or cellular telephone for purposes related to my care, to provide information about service offerings provided by MHPF, or for quality related surveys or communications related to my care. I understand that calls may be either live in-person calls or automated prerecorded communications. I understand that cellular service charges may apply. I understand that my consent to receive telephone calls is not a condition of my treatment. Home Phone Mobile Phone Signature of Witness Date
Bio-identical HRT Treatment Consent Form I have been advised by my physician that he/she recommends I have Bioidentical hormone supplementation. The reason for this recommendation has been explained to me to my satisfaction. I understand: That Bio-identical hormonal supplementation may be outside the parameters of conventional medicine in the U.S. That this treatment is recommended and administered with utmost care in conjunction with attention to hormone blood levels, lifestyle, and diet. Possible side-effects have been explained to me may include: o Allergy to a component of the prescribed agent/carrier o Weight Change o Headache and/nausea o Breast tenderness o Dizziness or lightheadedness o Breakthrough bleeding o Rarely liver inflammation, blood clotting disorders, migraines or hypertension That this treatment is not covered by Medicare and may not be covered by private health insurance funds. That this treatment may not be regulated by the Federal Drug Administration and that my physician deems that this treatment is in my best interest. I have been provided sufficient information to make an informed decision. I have informed my health care provider if I have suffered from heart disease, hypertension, chronic liver disease, chronic kidney disease, or strokes before beginning recommended therapy. Breast cancer risk is unclear and studies available are based on synthetic hormones. I am agreeing to this treatment of my own free will and consent and exercise my right to discuss and choose any treatment(s) made available to me with my physician s approval. Print Patient Signature Date of Birth _Date
Date: FEMALE Bio-Identical Hormone Therapy - History Form Patient Name: Date of Birth: Address: Age: Ht: Phone: Last Menstrual Period (month/day): or age of Menopause: Sexually Active? Yes / No CHECK IF YOU HAVE HAD THE FOLLOWING AND LIST DATES IF APPLICABLE: Hysterectomy & Date: Bone Density Scan: Pap Smear: Physician: Was it normal: Mammogram: Was it normal: Tubal: Cramps: Severe / Moderate / Mild: Breast problems: Cancer History (you or family): Abnormal Bleeding: PMS: Severe / Moderate Describe: Hormone Replacement Therapy - Current: Previous: Problems associated with your previous HRT? (describe): Wt gain Wt loss Significant Stress in your life: CHECK WHICH SYMPTOMS YOU ARE EXPERIENCING Energy (Good / Fair / Poor) Appetite (Good / Fair / Poor) Sleep (Good / Fair / Poor) Libido (sex drive) Decreased / Increased Joint Complaints Night Sweats Hot Flashes Mood Changes / Depression / Anxiety / Irritability Bloating Constipation / Irritable Bowel Bleeding: Frequency Cravings Breast Tenderness Vaginal Dryness Painful Intercourse Fibrocystic Breasts Headaches / Fuzzy Thinking Hair Loss Bladder Infections Urinary Incontinence Yeast Infections Weight loss Weight gain
CONDITIONS - Check (3) conditions you have or have had in the past. AIDS Alcoholism Anemia Anorexia Arthritis Asthma Blood Clots Bronchitis Bulimia Cancer Cataracts Chemical Dependency Emphysema Epilepsy Glaucoma Goiter Gout Heart Disease Hepatitis Hernia Herpes HIV Positive Kidney Disease Liver Disease Migraines Miscarriage Mononucleosis Pacemaker Pneumonia Osteopenia Osteoporosis Psychiatric Care Rheumatic Fever Stroke Tonsilitis Tuberculosis Ulcers Venereal Disease PAST MEDICAL HISTORY: List illnesses & conditions you have had and the year. 1. 4. 2. 5. 3. 6. MEDICATIONS: List medications you are currently taking, including OTC & Supplements. ALLERGIES: To medications or substances 1. 9. 2. 10. 3. 11. 4. 12. 5. 13. 6. 14. 7. 15. 8. 16. SURGICAL HISTORY: Type of Surgery Year Complications if any SOCIAL HISTORY: Check (X) the substances you use and describe how much you use. Caffeine Tobacco Alcohol Exercise FAMILY HISTORY: List any illnesses that run in your family: 1. 5. 2. 6. 3. 7. 4. 8. I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I have made in the completion of this form. Signature Date Physician s Signature