Initial New Patient Forms

MrMsDr

Gender MaleFemaleAge

Date of Birth:

Race —Please choose an option—WhiteBlack or African AmericanAmerican IndianAlaska NativeNative HawaiianOther Pacific IslanderAsianOther

Address

Phone

Preferred Content Method (appointment reminders, biopsy results, etc.)
HomeWorkCell

—Please choose an option—StudentPart-TimeRetiredFull-Time

Are you:
—Please choose an option—Insured


(If yes, please provide copy of your insurance cards)

I consent to treatment necessary or desirable to the care of me (or my minor), including but not limited to, medicine, performance of procedures and ordering of laboratory or other studies that may be used by the physician or his qualified surrogate.


Date:

I authorize Partners in Health Management, LLC to release information concerning my (or my minor’s) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits or to the Social Security Administration and Health Care Financing Administration. I permit a copy of this authorization to be used in place of the original and assign directly to Partners in Health Management, LLC all insurance benefits, if any, otherwise payable to me for the services rendered. I understand that I am responsible for all final charges whether or not they are paid by insurance. Regulations pertaining to Medicare assignment of benefits apply. I authorize Partners in Health Management, LLC to communicate my medical diagnoses and treatment plan as necessary to secure payment of benefits and to other physicians involved in my care.

Date:

I acknowledge that I have been provided a copy of the privacy practices of Partners in Health Management, LLC and that I have read (or had the opportunity to read if I so chose) and understand the Notice. This acknowledgement is requested per federal law/HIPAA requirement.

Date:

I authorize Partners in Health Management, LLC to discuss or release my health information to the person or persons listed below. Examples include (but are not limited to) someone calling on your behalf regarding prescription refills, biopsy results, etc., or our office leaving a message (biopsy results, appointment reminders, etc.) with someone over the phone when you are not available or in case of an emergency. I understand that it is my responsibility to notify Partners in Health Management, LLC in writing should my desires change.

—Please choose an option—Decline
(Infromation will not be shared with ANYONE execpt as permitted/required by law; leave above fields blank and sign below)


Date:

1. Payment is expected in full by cash at the time services are rendered.
2. Any patient 18 years or older will be the responsible party for his/her account. The parent or guardian accompanying a minor child is responsible for any payment due at the time of service. Partners in Health Management, LLC does not mediate divorce or custody agreements.
3. Please understand that as health care providers, our relationship is with you. Your insurance policy is a contract between you and your insurance company; we are not a party in that contract. We accept many insurance plans, but please check with our office for specifics. You are ultimately responsible for checking with your insurance company regarding coverage.
4. In order to correctly file your visit with your insurance company, you may be asked to present your current insurance card at each visit. Without the necessary information, we will be unable to bill your insurance company on your behalf. You are responsible for any and all charges we are unable to bill to your insurance.
5. Costs not covered by your insurance (including deductibles, co-pays, and co-insurance) are payable at the time services are rendered. Any overpayment will be reimbursed to you.
6. Some insurance policies require a primary care referral to see a specialist. While we make every effort to inform you if one is required, it is ultimately your responsibility to ensure a proper referral is obtained prior to your visit.
7. Please be aware that some diagnoses may not be medically necessary by your insurance carrier. Costs associated with these conditions may not be covered by your policy. It is your responsibility to know your plan.
8. Accounts over 120 days past due are subject to a referral to an outside collection agency. In addition to account balances, the responsible party will be billed for all associated collection and/or attorney’s fees.
9. To ensure prompt and efficient patient care, we require 24-hour notice to reschedule or cancel appointments. A reactivation fee up to $25.00 may be assessed for each missed appointment in order to reschedule if you “no-show” or fail to give 24-hour notice. Patients arriving more than 15 minutes after their appointment time may be asked to reschedule. Habitual no-shows or last-minute appointment changes may result in dismissal from the practice.
10. Unless stated otherwise, specimens biopsied/removed will be sent for pathologic examination. This will incur a pathology fee unrelated to Partners in Health Management, LLC.
I have read and understand the Office and Financial Policies and agree to abide by its contents.

Date:

All minors must have a parent or legal guardian present at their initial visit. Minors 15 years of age or younger MUST have an authorized adult present for each office visit. Patients 16 or 17 years of age may be seen at follow up visits without an adult if prior consent has been given by the parent/guardian (below).
I, am the parent/legal guardian of . I authorize health care professionals at Partners in Health Management, LLC to provide medical care to my minor child, including, but not limited to, diagnostic examinations and medical necessary treatment (including minor surgical procedures) when they arrive unaccompanied at the office and/or with an authorized adult.
Please list authorized adults below:

Date:

Allergies:(medications, foods or plants)

Select "Yes" if you HAD or HAVE at present:

Heart problems or chest pain —Please choose an option—Yes
Fever/Chills —Please choose an option—Yes
Heart murmur —Please choose an option—Yes
Rheumatic fever —Please choose an option—Yes
High blood pressure —Please choose an option—Yes
Heart pacemaker —Please choose an option—Yes
Artificial heart valve —Please choose an option—Yes
Sleep on more than 2 pillows or sleep problems —Please choose an option—Yes
Thyroid disease —Please choose an option—Yes
Stroke —Please choose an option—Yes
Hepatitis/Liver disease —Please choose an option—Yes
Artificial joint —Please choose an option—Yes
Anemia —Please choose an option—Yes
Diabetes —Please choose an option—Yes
Kidney trouble —Please choose an option—Yes
Problems with urination —Please choose an option—Yes
Ulcers —Please choose an option—Yes
Emphysema —Please choose an option—Yes
Cancer or tumor —Please choose an option—Yes
Limited movement —Please choose an option—Yes
Ankles swell —Please choose an option—Yes

Shortness of breath —Please choose an option—Yes
Chronic cough —Please choose an option—Yes
Tuberculosis —Please choose an option—Yes
Asthma —Please choose an option—Yes
Hay fever —Please choose an option—Yes
Sinus trouble —Please choose an option—Yes
Use tobacco products —Please choose an option—Yes
Lung disease or frequent respiratory infections —Please choose an option—Yes
Smoker in the house —Please choose an option—Yes
Vision problems —Please choose an option—Yes
Hearing problems/Ear aches —Please choose an option—Yes
Flu shot, Pneumonia shot or Zoster shot —Please choose an option—Yes
Lead poisoning —Please choose an option—Yes
Chemotherapy/Radiation —Please choose an option—Yes
Arthritis —Please choose an option—Yes
Cortisone medicine —Please choose an option—Yes
Glaucoma —Please choose an option—Yes
HIV/AIDS —Please choose an option—Yes
White or blue patches in mouth —Please choose an option—Yes
Fainting or dizzy spells —Please choose an option—Yes

Sickle cell disease —Please choose an option—Yes
Yellow jaundice —Please choose an option—Yes
Blood transfusion —Please choose an option—Yes
Drug addiction —Please choose an option—Yes
More than 5 drinks per day [select 5-drinks include_blank "Yes"]
Hemophilia —Please choose an option—Yes
Stomach pain —Please choose an option—Yes
Gained or lost more than 10 pounds in the past year —Please choose an option—Yes
Epilepsy or seizures —Please choose an option—Yes
Nervousness/Anxiety —Please choose an option—Yes
Domestic Violence —Please choose an option—Yes
Excessive Bleeding —Please choose an option—Yes
Special diet —Please choose an option—Yes
Persistent diarrhea/constipation —Please choose an option—Yes
Nausea or Vomiting —Please choose an option—Yes
Genital sores —Please choose an option—Yes
Sexually transmitted disease —Please choose an option—Yes
Bad breath —Please choose an option—Yes
Enlarged glands or lymph nodes —Please choose an option—Yes
Tire easily —Please choose an option—Yes

Menarche —Please choose an option—Yes
Birth control —Please choose an option—Yes
Last Menstrual Period:
Anticipate becoming pregnant? —Please choose an option—Yes
Pregnant Now? —Please choose an option—Yes
Number of children:
Menstruation problems? —Please choose an option—Yes
Menopause —Please choose an option—Yes
Age:
Last Mammogram:
Last PAP:

Do you smoke? How long? How many?
Do you drink? How often?


Please state your last colonoscopy if over 50:



List all Health Professionals you have visited outside of our clinic within the past 2 years and for what reason.



Have you had any surgeries?
NoYes


If yes, please explain type of surgery and at what hospital or surgery center.



Please list all your medications (include non-prescription)


To the best of my knowledge all the answers are true and correct. If I ever have any change in my health I will inform my doctor.


Date:


Date:

I hereby certify that I have read and understood the NOTICE OF PRIVACY PRACTICES as Required by Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Updated HIPAA Omnibus Rule Published January 25, 2013, which describes how health information about me may be used and disclosed, and how I can get access to your personal health information.

Date: