Stephanie Farrell, ND 516 SE Morrison St., Ste.207, Portland, OR 97214 Ph: (503) 239-1022 Fax: (503) 512-5850 PATIENT PREFERRED CONTACT FORM Name Last First M.I. Date of Birth Address Street City State Zip Can We Leave Confidential Messages at this Number? (Circle Yes or No) Preferred Contact? (Check One) Home Phone Yes No Work Phone Yes No Cellular Phone Yes No Other Phone Yes No Email Address Email is not a secure form of communication, please choose a phone number above that we may use to relay confidential messages. INSURANCE INFORMATION Name of Insurance Company ID Number Group Number Member Name (if different than patient) Are you interested in receiving information about Portland Natural Medicine through email? Yes No Office Use Only: Ins.Verified/Copied____ Medisoft ____ Pt.Rolodex ____ Email____ By signing below, you confirm that the information you have provided is both accurate and current to this date. Date Signature
Transcript
Stephanie Farrell, ND 516 SE Morrison St., Ste.207, Portland, OR 97214 Ph: (503) 239-1022 Fax: (503) 512-5850
PATIENT PREFERRED CONTACT FORM
Name Last First M.I. Date of Birth
Address Street City State Zip
Can We Leave Confidential Messages at this Number?
(Circle Yes or No)
Preferred Contact? (Check One)
Home Phone Yes No
Work Phone Yes No
Cellular Phone Yes No
Other Phone Yes No
Email Address
Email is not a secure form of communication, please
choose a phone number above that we may use to
relay confidential messages.
INSURANCE INFORMATION
Name of Insurance Company
ID Number Group
Number
Member Name (if different than patient)
Are you interested in receiving information about Portland Natural Medicine through email? Yes No
Office Use Only: Ins.Verified/Copied____ Medisoft ____ Pt.Rolodex ____ Email____
By signing below, you confirm that the information you have provided is both accurate and current to this date.
Date Signature
!
Appt. Date:
INSURANCE VERIFICATION FORM
Please call to verify whether or not your insurance covers your visit with Dr. Stephanie Farrell. Simply ask the questions listed on this form and fill in, and bring to your first appointment. Thank you for doing this to insure that you are fully aware of what is covered. Patient Name: Date of Birth:
Insurance Company:
ID#: Group#:
1. Does the patient have Naturopathic coverage? Yes or No
2. Does the patient need a referral from their PCP? Yes or No
3. Is Dr. Farrell In Network? Yes or No
4. Is there a co-pay or coins due per visit? Yes or No
If so how much is it?
5. What is the deductible for the year?
What portion of it has been met?
Date checked: Date policy resets:
6. Does the insurance policy cover if a naturopath orders labs or
x-rays? Cat scans or MRIs? Ultrasounds?
7. Is there a deductible for Labs and/or radiology?
If so what is it?
8. Is there a limit on CPT codes 97140 & 97124?
9. Is there a max benefit for naturopathic coverage per year?
Dollar amount or max visits?
Dr. Stephanie Farrell, N.D. 516 SE Morrison St., Ste.207, Portland, OR 97214
p: 503-239-1022 f: 503-512-5850
Pediatric Intake
10 Years of Age to 17 Years of Age Name (First, Middle, Last)_________________________________________ Date_________________ Age __________ Date of Birth _____________________________ Sex: M F Mother or Guardian _________________________ Father or Guardian _________________________ Address ___________________________________________ City ____________________________ State _________ Zip ___________ Telephone (Home) ________________________ Education ____________________ Hours per week ________ Hours of homework per week _______ Are you: Next of kin or other to reach in an emergency _______________________________________ Relationship _________________ Address ________________________________________ Telephone (Home) ______________________ Telephone (Work) ______________________ How did you hear about the clinic? ______________________________________________________
Health History Questionnaire
Holistic health care and preventative medicine are only possible when the physician has complete understanding of the patient physically, mentally, and emotionally. Please complete this questionnaire as thoroughly as possible. Print all information and mark anything you don’t understand with a question mark. When and where did you last receive medical or health care? ___________________________________________________________________________ What was the reason? _________________________________________________________ What are your most important health problems? List as many as you can in order of importance. 1. ________________________________________________________________________ 2. ________________________________________________________________________ 3. ________________________________________________________________________ 4. ________________________________________________________________________ 5. ________________________________________________________________________ 6. ________________________________________________________________________
Family History Check those applicable Father Mother Brothers Sisters Spouse Children Age (if living) _______ _______ _______ _______ _______ _______ Health G= good P= poor _______ _______ _______ _______ _______ _______ Cancer _______ _______ _______ _______ _______ _______ Diabetes _______ _______ _______ _______ _______ _______ Heart Disease _______ _______ _______ _______ _______ _______
Term: full ___ premature ___ late ___ weight at birth ______________ length of labor ________________ complications __________________________________________ As a baby, did your child have any of the following problems? ___ jaundice ___ diarrhea ___ birth defects ___ rashes ___ colic ___ fever ___ cerebral palsy ___ allergies ___ blue baby ___ seizures ___ birth injuries ___ other ___________________ Feeding: breast fed ___ how long? ___ formula ___ milk/soy ___ Age the child began: solid foods _____ sitting _____ crawling _____ walking _____ first words ___________________________________ Child's sleep patterns during the first year _________________________________________________ ___________________________________________________________________________________
now past now past now past aspirin ___ ___ antibiotics ___ ___ decongestant ___ ___ Tylenol ___ ___ anti-histamine___ ___ ibuprofen ___ ___ inhalers ___ ___ asthma meds ___ ___ topical steroids ___ ___ __________ ___ ___ __________ ___ ___ ___________ ___ ___ others Do you take or use? Laxatives Y N Pain relievers Y N Antacids Y N Cortisone Y N Appetite suppressants Y N Sleeping pills Y N Tranquilizers Y N Thyroid medication Y N
Allergies to medicines_________________________________________________________________
X-Rays and Special Studies
when where results electroencephalogram ________________________________________________________________ psychological evaluation ______________________________________________________________ hearing ____________________________________________________________________________ speech/language _____________________________________________________________________
Please circle: Y = a condition your child has now. N = never had. P = has had in the past. General Weight _________ Weight 1 year ago______ Max weight When Height _________ Fatigue Y P N ___________ __________
Skin Rashes Y P N Eczema, Hives Y P N Itching Y P N Acne Y P N Color change Y P N Lumps Y P N Night sweats Y P N
Head Headache Y P N Head injury Y P N Eyes Impaired vision Y P N Glasses or contacts Y P N Eye Pain Y P N Tearing or dryness Y P N Double vision Y P N Glaucoma Y P N Cataracts Y P N
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Ears Impaired hearing Y P N Ringing Y P N Earache Y P N Dizziness Y P N Nose and Sinuses Frequent colds Y P N Nose bleeds Y P N Stuffiness Y P N Hay fever Y P N Sinus problems Y P N Mouth and Throat Frequent sore throat Y P N Sore tongue Y P N Gum problems Y P N Hoarseness Y P N Dental cavities Y P N Neck Lumps Y P N Swollen glands Y P N Goiter Y P N Pain or stiffness Y P N Respiratory Cough Y P N Spitting up blood Y P N Sputum Y P N Wheezing Y P N Asthma Y P N Bronchitis Y P N Pneumonia Y P N Emphysema Y P N Pleurisy Y P N Difficulty breathing Y P N Pain on breathing Y P N Tuberculosis Y P N Shortness of breath Y P N Short/breath lying down Y P N Short/breath at night Y P N Cardiovascular Heart disease Y P N Angina Y P N High blood pressure Y P N Murmurs Y P N Palpitations, fluttering Y P N Rheumatic fever Y P N Swelling in ankles Y P N Chest pain Y P N Gastrointestinal Trouble swallowing Y P N Heartburn Y P N Change in thirst Y P N Change in appetite Y P N Nausea Y P N Vomiting Y P N Vomiting blood Y P N Bowel movements How often? ______________ Is this a change? Y N Blood in stool Y P N Belching, passing gas Y P N Jaundice (yellow skin) Y P N Liver disease Y P N Gall bladder disease Y P N Ulcer Y P N Hemorrhoids Y P N Urinary Pain on urination Y P N Increased frequency Y P N
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Frequency at night Y P N Inability to hold urine Y P N Frequent infections Y P N Kidney stones Y P N Female Reproductive Average number of days _______ Length of cycle _______ Regular cycles Y P N Bleeding between periods Y P N Pain during intercourse Y P N Painful menses Y P N Excessive flow Y P N Breasts Do you do self exam? Y P N Lumps Y P N Pain or tenderness Y P N Nipple discharge Y P N Male Reproductive Hernias Y P N Discharge or sores Y P N Testicular pain Y P N Muscoskeletal Joint or pain stiffness Y P N Arthritis Y P N Broken bones Y P N Weakness Y P N Muscle spasms / cramps Y P N Peripheral Vascular Deep leg pain Y P N Cold hands or feet Y P N Varicose veins Y P N Thrombophlebitis Y P N Neurologic Fainting Y P N Seizure Y P N Paralysis Y P N Muscle weakness Y P N Loss of memory Y P N Numbness Y P N Emotional Depression Y P N Anxiety or nervousness Y P N Mood swings Y P N Tension Y P N Endocrine Hypothyroid Y P N Heat or cold intolerance Y P N Excessive thirst Y P N Excessive hunger Y P N Blood Anemia Y P N Easy bleeding Y P N
Any other condition not mentioned? ____________________________________________________ __________________________________________________________________________________ Habits What are you main interests and hobbies? ______________________________________________ __________________________________________________________________________ Do you exercise? Y N What forms? ______________________________________ How often? __________________________________________________________ Do you eat three meals daily Y N Awaken rested Y N Average 6-8 hours sleep Y N Sleep well Y N Enjoy school Y N Spend time outside Y N
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Watch television Y N How many hours/day (TV) ____ Read Y N How many hours/day (Read) ____ Take vacations Y N Use recreational drugs Y N Been treated for drug dependence Y N Use alcoholic beverages Y N Been treated for alcoholism Y N Use tobacco Y N
516 SE Morrison St., Ste.207, Portland, OR 97214 Telephone (503) 239-1022 • Fax (503) 512-5850
Patient Consent Form I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: � Conduct, plan and direct my treatment and follow-up among the multiple health care providers who may be
involved in that treatment directly and indirectly. � Obtain payment from third party payers. � Conduct normal health care operations such as quality assessments and physician certifications.
I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you agree than you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. All HIPPA Policies are effective April 14th, 2003 Please direct any questions, concerns or complaints regarding HIPPA policies and procedures to o r o i e at (503)239-1022.
Consent for Treatment Naturopathic Medical Consent: I consent to services rendered and treatment provided by Dr. Stephanie Farrell. I recognize that Dr. Farrell is a licensed Naturopathic Physician. I have the right to refuse any treatment suggested that I am uncomfortable with. I have the right to ask questions to my satisfaction. Dr. Farrell has the right to treat me within the scope of her practice. Dr. Farrell has the right to refuse rendering of treatment or to make referrals to outside physicians if they feel that they can not be of service to my case. Patient Name: __________________________________________________________________ Patient/ Guardian Signature:_______________________________________________________ Relationship to Patient: __________________________________________________________ Date: ___________________________
Stephanie K Farrell, N.D. LLC
Stephanie K Farrell N.D. LLC 516 SE Morrison St, Ste 207, Portland, OR 97214
This Notice Describes How Medical Information about you may be used and disclosed and how you get access to this information. Please review it carefully.
The Health Insurance Portability & Accountability Act of 1996 (“HIPPA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally , are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPPA” provides penalties for covered entities that misuse personal health information. As required by “HIPPA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose you medical records only for each of the following purposes: treatment, payment, and health care operations.
• Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination.
• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
• Health Care Operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.
We may also create and distribute de-identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or informational bout treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the privacy officer:
• The right to request restriction on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
• The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
• The right to inspect and copy your protected health information. • The right to amend your protected health information. • The right to obtain a paper copy of this notice from us upon request.
Stephanie Farrell N.D LLC 516 SE Morrison St, Ste 207, Portland, OR 97214
We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. We are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice of the policies and procedures of our office. We will not retaliate against you for filing a complaint. Please contact us for more information For more information about HIPPA or to file a complaint: The U.S. Department of Health & Human Services Office of Civil Rights 200 Independence Ave, S.W. Washington D.C. 20201 (202) 619-0257 Toll Free 1-877-696-6775
Please sign and date to say that you have read, understood, and agree to the above privacy practices. Patient's or Authorized Person's Signature Date
Stephanie K Farrell N.D. LLC 516 SE Morrison St, Ste. 207, Portland, OR 97214
Please initial to show that you have read and understood each section. • Missed Appointments/ Cancellations __________
o If for any reason you are unable to make your appointment, Please give us 48 hours notice. For any missed appointments or for less than 48 hours notice for cancellation your account will be charged $120. (Exceptions will be made for genuine emergences.)
o If you are late for your appointment, your visit may be shortened and you will also be charged for the reserved time on the schedule.
• Supplements __________
o All orthopedic supplies, medicinary and supplement items are to be paid in full at the time of purchase. We will only accept a return if the safety seal has not been broken or unwrapped.
o We ask that you please call in advance when you need a refill on your supplements to ensure we have it on hand or if needed to be ordered. If available you can pick up supplements during office hours. As a courtesy for patients who are unable to pick up these items, we can mail them to you via priority mail. For this service, the total must exceed $50.00, and there is a $20.00 processing fee. You will be responsible for the postage. If mail order is over $75, insurance will be required to ship package.
• Insurance __________
o If you have insurance, you are required to fill out the insurance verification form to confirm naturopathic coverage.
o Once you have verified your insurance, you will be responsible for any co-pays, deductibles, and amounts not covered by the insurance at the time of service.
o In the case of a Motor Vehicle Accident (MVA) or Personal Injury Protection (PIP) claim, you are responsible for any balance that is incurred after the claim has been closed. If the claim goes to litigation, you must pay the balance before litigation starts.
• Payments __________
o For cash paying patients, a Time of Service discount will be given to you of 25%. We accept cash, checks, and credit cards. A payment plan can be arranged if needed (Discuss this with Dr. Farrell). We have the right to agree, or not, to any payment plans.
o Supplemental telephone calls and emails exceeding 5 minutes are billed at $40 per 15 minute increments.
o Dishonored checks will be charged a $25 fee. o Any balances due on your account will be billed to you every 30 days. Balances that are
90 days past due may be submitted to collections if there is no communication. Please sign and date to say that you have read, understood, and agree to the above policies. Patient's or Authorized Person's Signature Date
Due to a number of patients not showing up for their scheduled appointments , or cancelling the day
of their appointment, it has become necessary to implement a cancellation policy .
In an effort to better serve you, our providers at Portland Natural Medicine do not over-schedule their days.
We believe you deserve our undivided attention when you are seeking our care. We also have a
number of patients on a waiting list waiting to see a practitioner when an appointment becomes available. Thus we appreciate the courtesy of at least 48 hour notice for cancelling an appointment so we can call patients that are on the waiting list and in need of care.
A credit card will be kept on file in the secure Electronic Health Record for each patient. If you do not show up for an appointment or fail to cancel by giving us a minimum of 48 hours' notice, your card
will automatically be charged $125.
If you have missed your appointment due to an emergency, please contact your provider directly to discuss any fees.
I read and understand and am in agreement with the above policy.
__________________________________ ___________________ Patient or Authorized Person’s Signature Date _____________________________________ Printed Name of Patient or Authorized Person
