ColumbiaDoctors. Adult New Patient Intake Form

Transcription

1 Name: DOB: ColumbiaDoctors Adult New Patient Intake Form Page 1 of 4 Patient Information Last Name: First Name: DOB: Gender: Home Phone: Mobile Phone: Preferred Phone: Home or Mobile (circle one) Emergency Contact: Re I at ions hip: Emergency Contact Phone: Patient Marital Status: cc up at ion: Em p Io ye r: Primary Care Provider (PCP): PCP Phone: Referring Provider: Referring Phone: Preferred Pharmacy: Pharm Phone: Preferred Pharmacy Address: Please list ALL active treating physicians (i.e. pulmonologist, oncologist, internist, cardiologist, etc... ) Doctor's Doctor's Name: Specialty: Doctor's Name: Specialty: Doctor's Name: Specialty: Doctor's Name: Specialty: Collection of the following information is encouraged by federal health agencies. This information is used to monitor and improve the quality of care provided to all patients. Ethnicity: Race: o Decline Response o Decline Response o Hispanic or Latino o American-Indian or Alaska Native o Not Hispanic or Latino o Asian o Black or African American o Native Hawaiian or Pacific Islander D White D Other Preferred Language: o Decline Response Patient Financial Obligation Agreement I understand that all applicable copayments and deductibles are due at the time of service. I agree to be financially responsible an,d make full payment for all charges not covered by my insurance company. I authorize my insurance benefits be paid directly to Columbia Doctors for services rendered. I authorize representatives of ColumbiaDoctors to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim. Notice of Privacy Practices: Acknowledgement of Receipt I acknowledge that I was provided with a copy of the Columbia Doctors Notice of Privacy Practices (NOPP). o Received o N/A (only if you received the notice from ColumbiaDoctors previously) Information Disclosure and Consent Columbia Doctors will provide you with the health plans that your provider(s) accepts*. If you decide to be treated by a provider who does not accept your health plan, you will be asked to sign a consent form agreeing that you accept treatment from that provider. I read and agree to all of the above (Financial Agreement, Notice of Privacy, Insurance Information). Patient or Legal Guardian Name (Print): Patient or Legal Guardian Signature: Date: *Please refer to our website: columbiadoctors.org, for a list of insurances accepted by your provider. Version 1.9 Updated: 2/2/2018

2 Name: DOB: ColumbiaDoctors Page 2 of 4 Reason for today's visit: General Medical Questionnaire Have you EVER had any of the following? Asthma/Breathing Problems... o Y o N Arthritis... o Y o N Bleeding/Clotting Disorder... o Y o N Blood Pressure Disorder... o Y o N Blood Transfusion... o Y o N Bowel/Stomach Problems... o Y o N Cancer... o Y o N Cholesterol Disorder... o Y o N Diabetes... o Y o N Eye Disorder (i.e. Glaucoma, cataract)... o Y o N Women Only: Gynecological Issues... o Y o N Heart Disease/Disorder... o Y o N Lung Disorder... o Y o N Liver Disease... o Y o N Neurological Disorder/Chronic Headaches.. o Y o N Psychiatric Disorder/Illness... o Y o N Pulmonary Embolism/DVT... o Y o N Stroke... o Y o N Seizure or Epilepsy... o Y o N Thyroid Disorder... o Y o N Urinary/Kidney Disorder... o Y o N Please list any other medical illnesses or problems and provide details for any of the above conditions: Please list all past surgeries and hospitalizations and the approximate date. Procedure/ Hospitalization Date Complications Please indicate any major conditions/illnesses that your immediate family members have had: Relative Condition and description Living? If deceased, at what age? Mother oy on Father oy on Sibling oy on Other: oy on Do you currently smoke? o Y o N If no, previously? o Y o N Years smoked --- Packs/day --- Do you use other tobacco products? o Y o N Consume alcohol? o Y o N If yes, drinks/week: --- Women Only: Any past pregnancies? o Yo N How many? -- How many deliveries? --- Version 1.9 Updated: 2/2/2018

3 ColumbiaDoctors Page 3 of 4 Please list ALL of your current medications, including over the counter medications, supplements, and herbs: Medication Name Dose Medication Name Dose Review of Systems Please indicate ALL that you have experienced within the past 6-12 months. Constitutional DYDN Fever DYDN Fatigue DYDN Weight Gain(_ Lbs) DYDN Sleep Disturbances DYDN Chills DYDN Feeling Poorly DYDN Weight Loss(_ Lbs) DYDN Sweats Head, Eyes, Ears, Nose, and Throat DYDN Unexp. Weight Change DYDN Vision Problem DYDN Red Eye s DYDN Congestion DYDN Hoarseness DYDN Decreased Hearing DYDN Eye Pain DYDN Snoring DYDN Ringing in Ears DYDN Double Vision oyon Runny Nose DYDN Dry Mouth oyon Vertigo DYDN Light Sensitivity DYDN Neck Stiffness DYDN Flu-Like Symptoms OYDN Earache DYDN Itchy Eyes DYDN Nosebleed DYDN Sore Throat DYDN Other: Cardiovascular DYDN Chest Pain DYDN Cold Extremities DYDN Irregular Heart Rhythm DYDN Palpitations DYDN Cold Hands or Feet DYDN Other: DYDN Leg Swelling DYDN Leg Pain w/ Walking Respiratory DYDN Shortness of Breath DYDN Wheezing DYDN Coughing Up Blood D DYDN Cough DYDN Shortness of Breath DYDN Coughing Up Sputum DYDN Rapid Breathing DYDN Chest Congestion o Other: Gastro i ntesti na 1 DYDN Abdominal Pain DYDN Blood in Stool DYDN Vomiting DYDN Nausea oyon Diarrhea oyon Change in Bowels oyon Painful Swallowing DYDN Black/Ta1rry Stools DYDN Vomiting Blood o Other: DYDN Decreased Appetite DYDN Bowel Incontinence DYDN Yellow Skin DYDN Rectal Pain Version 1.9 Updated: 2/2/2018

4 Name: DYDN Constipation Neurological DYDN Headache DYDN Dizziness DYDN Decreased Strength DYDN Poor Coordination Musculoskeletal DYDN Joint Pain DYDN Neck Pain DYDN Back Pain DOB: ColumbiaDoctors Page 4 of 4 DYDN Trouble Swallowing DYDN Unsteady DYDN Disorientation OYDN Confusion OYDN Burning Sensation DYDN Limb Pain DYDN Joint Swelling OYDN Muscle Cramps DYDN Heartburn DYDN Numbness DYDN Tingling OYDN Seizures DYDN Fainting (Syncope) DYDN Muscle Pain oyon Muscle Weakness OYDN Leg Swelling DYDN Tremor DYDN Memory Lapses/Loss Genitourinary DYDN Frequent Urination DYDN Pelvic Pain DYDN Painful Intercourse DYDN Heavy Period Bleeding DYDN Incontinence DYDN Nocturia DYDN Discharge- Vaginal DYDN Urinary Urgency DYDN Painful Urination DYDN Itching- Genital DYDN Change in Libido DYDN Vaginal Bleeding DYDN lrreg. Monthly Cycles lntegumentary DYDN Rash DYDN Dry Skin DYDN Skin Wound DYDN Change in A Mole DYDN Unusual Growth DYDN Itching DYDN Skin Cancer Psychiatric OYDN Depression DYDN Anxiety oother: Hematologic/Lymphatic DYDN Easy Bruising DYDN Easy Bleeding DYDN Swollen Lymph Nodes Endocrine DYDN Excessive Thirst OYDN Heat Intolerance DYDN Changes- Skin DYDN Cold Intolerance DYDN Changes- Hair o Other: OFFICE USE ONLY: Provider Signature: Date: Version 1.9 Updated: 2/2/2018

5 Additional Ophthalmology Information Chief Complaint: What is the main or primary problem with your eye(s), and when did you first notice symptoms or were you told of diagnosis? Past History: Do you have or have you had any of the following problems or conditions? Pleas.e answer ALL questions-indicate YES or NO. If the answer is YES, please provide a brief explanation. Glaucoma DYES ono Cataract DYES ono Droopy Eyelids o YES ono Double Vision o YES ono Dry Eye o YES ono Tearing DYES ono Lazy Eye (Amblyopia) o YES ono Crossed Eyes (Strabismus) o YES ono Macular Degeneration DYES ono Retinal Detachment o YES ono Eye Injury o YES ono Eye Inflammation o YES ono Thyroid eye disease/ Graves' disease o YES ono Laser Surgery o YES D NO Other o YES o NO o Previous eye surgery? What kind(s) o Previous face, brow, eyelid, tear duct, or orbital surgery? What kind(s) D Previous cosmetic facial procedures? (Botox, fillers, peels, LASER, etc.) EXPLANATION Sensitive to soaps? o YES ono Do you ever take Aspirin, Plavix, Coumadin, Lovenox? Tapes? o YES o YES ono ono History of slow or poor wound healing o YES o NO History of Keloids History of cold sores, herpes, shingles o YES ono History of skin cancer o YES o NO Type: History of other cancer(s) o YES ono Type: DYES D NO Hepatitis Positive HIV Test o YES o NO When? 0 YES o NO When? Type: A B C Problems tolerating anesthesia: To local anesthetic o YES o NO To general aesthetic o YES o NO Family History: Glaucoma o YES o NO Macular Degeneration o YES o NO Thyroid Disease o YES o NO Other eye conditions Version 1.9 Updated: 2/2/2018

6 Name of Beneficiary: AUTHORIZATION OF BENEFITS Health Insurance Claim#: 1 request that payment of authorized health insurance benefits, including Medicare and Medigap, be made either to me or on my behalf to Dr. for services furnished to me by this provider. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents, any information needed to determine these benefits payable for related services. Signature of Responsible Party: Date: Commercial Insurance I hereby authorize direct payment of surgical/medical benefits to Dr. for services rendered by him/her in person or under his/her supervision. I understand that I am financially responsible for any balance not covered by my insurance, including co-pays, deductibles, refractions, and differences between surgeon's charges and allowable. I hereby authorize Dr. to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefits. Signature of Responsible Party: Date: Advance notice regarding Insurance Reimbursement and Beneficiary Agreement I have been informed that refraction ( the measurement of one's eyeglass prescription and the determination of the best visual sharpness ) is usually not considered by insurance companies, health maintenance organizations, and Medicare to be medically reasonable of necessary. Knowing this, I have instructed the doctor to proceed with the services. If insurance decides to reduce or even deny the fee or services, I agree to pay the doctor's fee in full. Signature of Responsible Party: Date:

7 Eye Glass and Contact Lens Prescription Policy ColumbiaDoctors Ophthalmology does not accept vision insurance. You are responsible for fees of any services not covered by your medical insurance. *A 25% fitting fee reduction if contact lens brand and prescription are not changed. I. Refraction A. What is a refraction? Refraction is a test done to determine the refractive error of your eyes, or the need for corrective glasses and/or contact lenses. B. When do I have to pay for a refraction? Refraction (CPT code 92015) is a non-covered service by Medicare. As a result, your healthcare provider is required by CMS (the department to the federal government that controls Medicare) to charge for this service. Most insurance plans follow Medicare's rules. All these plans consider refraction a "vision" service, and not a "medical" service. C. How much do I have to pay? You will only be charged a refraction fee if you receive a prescription for glasses or contact lenses. Our office fee for refraction is $80. This is collected at the time of service in addition to any co-payment your plan may require. Should your plan pay us for the refraction, we will refund you accordingly.

8 D. Suggestions When Filling Your Prescription Since refraction is an inexact art in which errors may arise at any step, including from the patient, the doctor, and the optician making the eyeglasses, we suggest the following: 1. Fill your prescription at an establishment that will give you a warranty. At the very least, choose an optical that agrees to make at least one adjustment at no charge to you. if you are uncomfortable with the new prescription for whatever reason, this will enable us to make changes as necessary at no cost to you. 2. Start with purchasing only one pair of new glasses with the new prescription to ensure you are happy with your vision before purchasing new pairs. 3. Please address any legibility issues regarding the written prescription with the prescribing doctor prior to filling the prescription. 4. Change as few parameters like lens size and shape, lens company/brand (especially with progressive add spectacles), as possible, with your new glasses to minimize the risk of being uncomfortable with newly prescribed glasses. II. Non-Medically Necessary Contact Lens Fitting Please be aware that most medical insurance do not cover the portion of the eye examination to evaluate you for elective contact lenses. This part of the examination requires a separate evaluation in addition to the medical examination. Contact lenses are medical or cosmetic devices placed on a vital organ in your body. An improper fit may cause a host of problems including infection, permanent scarring, new growth of blood vessels, contact lens rejection and ultimately decreased vision. Based on FDA regulation, contact lens prescriptions are only valid for 1 YEAR. An annual contact lens evaluation is required. If you are also being seen for an ocular complaint that requires a medical examination, your insurance will be billed for the medical portion. III. What if my glasses or contact lenses don't fit well? Our physician will re-evaluate you at no charge within 60 days of your initial refraction to change your prescription if necessary. However, our office does not pay for revision of glasses in which good faith efforts were made in measuring and writing the prescription. I understand that refraction and contact lens examination are not included in my eye exam and there will be an additional fee. Refraction and contact lens fitting fees are non-refundable. Any changes that need to be made to your prescription must be made within 60 days of your examination. I have been fully informed and accept full responsibility to pay. Patient Name Patient Signature Date

9 Pharmacy Information Update Form As of Mairch 27, 2016, NYS Public Health Law requires your doctor t,o electronically prescribe (eprescribe) all your prescription medications directly to your pharmacy. Prescriptions will no longer be handwritten or called in to your pharmacy, except in limited circumstances. Please use this form to tell your doctor where you want your prescriptions filled. Your Name Date of Birth Cell Phone Home Phone Pharmacy Name D Retail Pharmacy Telephone D Mail Order Pharmacy Address City State -- D Please make this my default pharmacy 2. Pharmacy Name D Retail Pharmacy Telephone D Mail Order Pharmacy Address City State NABP # (if known) D Please make this my default pharmacy Page 1 of 1