PATIENT DEMOGRAPHIC INFORMATION PATIENT INFORMATION Today’s Date: MRN: Account Number: Patient Name: Nickname: Mailing Address: Email Address: Home Phone: Cell Phone: Work Phone: Can we leave a message? □ Y □ N □ Y □ N □ Y □ N DOB: Sex: Marital Status: EMERGENCY CONTACT INFORMATION Emergency Contact Name: Phone Number: RESPONSIBLE PARTY Guarantor Name: DOB: Address: INSURANCE INFORMATION Primary Insurance: Secondary Insurance: Address: Address: Phone Number: Phone Number: Subscriber Name: Subscriber Name: DOB: DOB: Subscriber ID: Subscriber ID: Group Number: Group Number: EMPLOYER INFORMATION Patient Employer: Patient Occupation: ADVANCED DIRECTIVE Please provide our office with a copy and check the box if you have any of the following in place: □ POA □ Living Will □DNR □None ETHNICITY/RACE/LANGUAGE Which category best describes your race? Please select all that apply □ African American □ Asian □ Caucasian □ Other __________ □ Decline to answer Are you of Hispanic or Latino descent? □ No □ Yes □ Decline to answer What is your preferred language? □ English □ Spanish □ French □ Other______________
Transcript
PATIENT DEMOGRAPHIC INFORMATION
PATIENT INFORMATION
Today’s Date: MRN: Account Number:
Patient Name: Nickname:
Mailing Address:
Email Address:
Home Phone: Cell Phone: Work Phone: Can we leave
a message? □ Y □ N □ Y □ N □ Y □ N
DOB: Sex: Marital Status:
EMERGENCY CONTACT INFORMATION
Emergency Contact Name: Phone Number:
RESPONSIBLE PARTY
Guarantor Name: DOB:
Address:
INSURANCE INFORMATION
Primary Insurance: Secondary Insurance:
Address: Address:
Phone Number: Phone Number:
Subscriber Name: Subscriber Name:
DOB: DOB:
Subscriber ID: Subscriber ID:
Group Number: Group Number:
EMPLOYER INFORMATION
Patient Employer: Patient Occupation:
ADVANCED DIRECTIVE
Please provide our office with a copy and check the box if you have any of the following in place:
□ POA □ Living Will □DNR □None
ETHNICITY/RACE/LANGUAGE
Which category best describes your race? Please select all that apply
□ African American □ Asian □ Caucasian □ Other__________ □ Decline to answer
Are you of Hispanic or Latino descent? □ No □ Yes □ Decline to answer
What is your preferred language?
□ English □ Spanish □ French □ Other______________
HIPAA: (May Discuss Information With) Primary Contact: Relationship: Phone:
Secondary Contact: Relationship: Phone:
PATIENT APPOINTMENT AND NO SHOW POLICY At Medical Hills we value our relationships with our patients and understand your time is valuable. With that in mind,
we work to maintain the most efficient schedule and make every attempt to get patients an appointment within a
reasonable timeframe. We appreciate your understanding of and adherence to our policy.
Medical Hills utilizes scheduled patient appointments and does not accept walk-in visits. We also understand that
schedules sometimes change. Our office sends automated voice message reminders for provider appointments. In the
event you do not receive this message, you are still responsible for no show fees in regards to missed appointments. If
you are unable to keep a scheduled appointment, we ask that you call us at least 24 hours in advance to reschedule.
This allows us to reschedule your cancelled appointments in a timely manner and allows other patients with urgent
needs to quickly access our providers. If you do not call to cancel or reschedule before your scheduled appointment
time, it is documented as a NO SHOW. You will be notified via our automated messaging system of the no show. You
will need to call our office to schedule another appointment.
The following outlines our policy for NO SHOWS:
1. First Occurrence: Notified via automated message and assessed a $25 NO SHOW FEE.
2. Second Occurrence: Notified via automated message and assessed an additional $25 NO SHOW FEE. No
more patient appointments will be scheduled until the NO SHOW FEES are paid in full. We will provide one
30-day medication refill to allow time to reschedule the missed appointment and pay the no show fee.
3. Third Occurrence within a 24 month period: If you no show 3 appointments within a 24 month timeframe,
you will be dismissed from the practice and be assessed an additional $25 NO SHOW FEE.
NO SHOW fees will be billed directly to you, the patient. This fee is not covered by insurance, and must be paid prior
to your next appointment.
Because it is important to keep our appointments on time and not make patients wait longer than necessary, patients
arriving more than 10 minutes late for a scheduled appointment may be rescheduled for another day.
Thank you for your understanding and cooperation as we strive to best serve the needs of all of our patients.
My signature below constitutes acknowledgement and acceptance of this policy. _________________________________________ _________________________ Patient or Guarantor Signature Date
Patient Name: «FirstName» «LastName» Date of Birth: «DOB» MRN: «MRNNo»
CONSENT FOR TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS
PATIENT PORTAL CONSENT TO ACCESS
I grant consent for Medical Hills Internists, LLC to activate my account on the patient portal. The portal offers a secure way for our patients to view limited data, clinical summaries, and communicate with our staff through secure messaging. Access to this secure web portal is an optional service, and Medical Hills Internists may suspend or terminate your access at any time and for any reason. If we do suspend or terminate this service we will notify you as promptly as possible. I agree not to hold Medical Hills Internists or any of its staff liable for network infractions beyond its control. I understand and will comply with the terms of use regarding the patient portal.
Please initial if you consent to the Patient Portal:_________
MEDICATION HISTORY CONSENT
I give permission to Medical Hills Internists, LLC to access my pharmacy benefits data electronically through Sure Scripts. This consent will enable Medical Hills Internists to send my prescription electronically, determine if a patient's health plan allows electronic prescribing to Mail Order pharmacies, e-prescribe to the pharmacy if possible, and download a historic list of all medications prescribed for a patient by any provider. I also allow Medical Hills Internists permission to obtain formulary information, and information about other prescriptions prescribed by other providers using Sure Scripts.
Please initial if you consent to Rx History:_________
I-CARE CONSENT
I give my consent for Medical Hills Internists, LLC to release my immunization(s) and identifying information to the Illinois Comprehensive Automated Immunization Registry Exchange (I-CARE). I understand the purpose of the I-CARE is to assist in my medical care and to record the immunizations that I have received. My immunization information may potentially be used by the Department of Health for quality improvement purposes, epidemiologic research, and disease control purposes. Any Information used for these purposes will have my personal identifying information removed. The immunization information in the I-CARE may be released to the following: myself, my health insurance organization, the state and local health departments, the school that I am registered to attend, and authorized medical providers that deliver my medical care. I understand that there will be no effect on my treatment, payment, or enrollment for benefits if I choose to participate. This consent may be withdrawn at any time by using the form provided.
Please initial if you consent to I-CARE :________
eHX CONSENT
I give my consent for Medical Hills Internist, LLC to partake in the eHX summary program. This program electronically shares important parts of patient medical information with authorized healthcare professionals, their agents, and others whose job it is to secure, monitor, and evaluate the operation of the information system and quality of care. The eHX summary will allows the provider to access health information more quickly and accurately with billing and financial management, administrative management, clinical care, reports to public health agencies, reports to protect security of your medical information, reports to evaluate the use of the eHX summary, and reports to track and evaluate the quality of your healthcare services.
Please initial if you consent to eHx:_________
If at any point you wish to withdraw permission, please notify our office to complete a new form.
CONSENT TO TREAT (required for all patients) I am seeking medical care and treatment at Medical Hills Internists, LLC. I consent to the rendering of such medical care and treatment deemed necessary by my provider, other members of the clinical staff, and by Medical Hills Internists, LLC and its employees.
NOTICE OF PRIVACY PRACTICE By signing this document, I acknowledge that a copy of the Medical Hills Internists, LLC Notice of Privacy Practice has been made available to me. I understand that I can request a copy of the notice at any time. The privacy notice can also be located on the Medical Hills Internists LLC website at www.medicalhills.org.
This notice is effective September 23, 2013.
FINANCIAL POLICY AND CONSENT FOR PAYMENT Medical Hills Internists, LLC will submit fees for services to insurance. Payment of service is due according to the date listed on your statement. Returned checks, unpaid balances older than 60 days, and failure to pay account balances timely as promised may subject your account to external collection fees and possible termination from the practice. Your insurance is a contract between you, your employer and the insurance company. Please make sure we are in network with your insurance plan before having services to avoid any unexpected expenses or denied services. It is your responsibility to understand your insurance policy, and all coverage and benefits, including pre-certification, in/out of network benefits, and referral and authorization requirements. Medical Hills does not bill for motor vehicle accident claims or become involved in third party litigation.
I hereby authorize payment of medical benefits billed to my insurance by Medical Hills Internists, LLC. I have listed all health insurance plans from which I may receive benefits. I accept responsibility for payment for any service(s) provided to me that is not covered by my insurance. I agree to pay all copayments, coinsurance and deductibles at the time services are rendered. I also accept responsibility for fees that exceed the payment made by my insurance, if Medical Hills Internists does not participate with my insurance. I authorize Medical Hills Internists to use and/or disclose my health information, which specifically identifies me or which can reasonably be used to identify me, to carry out my treatment, payment and healthcare operations. I understand that while this consent is voluntary, if I refuse to sign this consent, the Medical Hills Physicians can refuse to treat me. I understand this authorization can only be revoked in writing.
PATIENT AGREEMENT On the sections previously initialed, I grant permission for Medical Hills Internists to activate my account on the patient portal and share secured information via ICARE, RX History, and eHX registries. I have read this Consent for Treatment, Payment and Health Care Operations form or have had it read to me, and all information has been explained to my satisfaction. By signing this document, I confirm that I accept the terms of this document and confirm that any questions have been addressed. I further certify that I am the patient or his/her authorized representative or legal guardian, and I am signing voluntarily. Print Name: _________________________________________________ Relationship:_____________ Date:_____________ Patient or Legal Guardian or Patient Representative Signature: __________________________________________________ Relationship:_____________ Date:______________ Patient or Legal Guardian or Patient Representative
How many times in the last year have you used a street drug?
o None o A few times o Several times o Most days
How often do you use prescription drugs for non-medical reasons
o Not at all o Some days o Several times
Most days
Tobacco Which of the following tobacco products have you used in the last year?
o Smoke cigarettes or cigars o Smoke e-cigarettes o Dip o Chewing tobacco o Water pipes o Hookahs
Have often do you smoke/use tobacco? o Not at all o Some days o Most days o Every day
Do you need support to quit? o Yes o No
Have you tried to quit tobacco within the last year?
o Yes o No o If yes, how did it go?
Preventative Care History
Colonoscopy
Date of Last:
☐ Never
Results:
☐Abnormal ☐Normal ☐Unknown
Mammogram
Date of Last:
☐ Never
Results:
☐Abnormal ☐Normal ☐Unknown
Pap Smear
Date of Last:
☐ Never
Results:
☐Abnormal ☐Normal ☐Unknown
PSA (Screening for Prostate Cancer)
Date of Last:
☐ Never
Results:
☐Abnormal ☐Normal ☐Unknown
Skin Exam by dermatologist Date of Last:
☐ Never
Results:
☐Abnormal ☐Normal ☐Unknown
Flu Shot/Influenza Vaccine Date of Last: ☐ Never
Gardasil (HPV) Vaccine Date of Last: ☐ Never
Pneumonia Vaccine Date of Last: ☐ Never
Tetanus Vaccine Date of Last: ☐ Never
Shingles Vaccine Date of Last: ☐ Never
Hepatitis A Vaccine (2 shot series)
Date of Last: ☐ Never
Hepatitis B Vaccine (3 shot series)
Date of Last: ☐ Never
Review of Systems
Please place an X by any symptoms that you are experiencing today: Constitutional o Weight change o Fatigue o Weakness
Respiratory o Shortness of breath o Difficulty breathing at night o Cough
Gastrointestinal o Nausea o Abdominal pain o Vomiting
Musculoskeletal o Morning stiffness o Muscle spasms o Joint pain
o Fever
Ears/Nose/Throat o Pain o Redness o Double or blurred vision o Eye dryness o Ringing in ears o Hearing loss o Nosebleeds o Loss of smell o Sores in mouth o Dry mouth o Hoarseness o Difficulty swallowing
Cardiovascular o Pain in chest o Irregular heart beat o Sudden changes in heart
beat o High blood pressure o Low blood pressure o Heart murmur
o Coughing up blood o Wheezing o Swollen legs or feet
Neurological o Headaches o Dizziness o Sensitivity in hands/feet o Memory loss o Night sweats
Psychiatric o Excessive worries o Anxiety o Easily loses temper o Depression o Agitation o Difficulty sleeping o Difficulty concentrating
Endocrine o Excessive thirst o Cold intolerance o Heat intolerance
o Stomach pain relieved by food/milk
o Constipation o Persistent Diarrhea o Blood in stools o Black stools o Heartburn o Excessive gas o Change in appetite
Genitourinary o Difficulty urinating o Pain/burning when
urinating o Frequent urination o Blood in urine o Discolored urine o Discharge from
penis/vagina o Rash/ulcers o Sexual difficulties o Change in periods
o Muscle tenderness o Joint swelling
Allergic/Immunologic o Frequent sneezing o Frequent infections Skin/Breast o Easy bruising o Rash/hives o New lesions o Change in mole o Hair loss o Color changes of hands/feet
when cold o Breast lump o Nipple discharge
Hematologic/Lymphatic o Swollen glands o Tender glands o Anemia o Bleeds easily o Blood transfusion
When?___________
Advanced Directives
Which of the following have you completed?
Power of Attorney for Healthcare Living Will Do-Not-Resuscitate (DNR) Order
What questions do you have for your doctor today? What is your MAIN medical concern?
