*** Please answer ALL questions, especially required fields 1, 2, 4, 5, 8, 12, 25, 30, 32, 33, 34, 36, 37, and 49 ... medication list, allergies, family and your health condition. ------ You can type in "na" for Not Applicable or "NONE" ***
Note: We require current vaccine record for children's visit. Physical are morning appointment because of fasting. *** Fasting mean NO FOOD and drink after midnight. WATER IS ALLOWED. No "black" coffee. Take your medication with water. Medication which require food, take those meds after doctor's visit and labs.
Patient's Information.
(mm/dd/yyyy)
We may need to contact you regarding your medical care. Please let us know in writing which phone # you wish for us NOT to leave a general message.
Address and Apt#, City, State, Zip code<br/>If mail to PO Box then also include physical address, too.
If policy holder "insurer" is different from the patient then enter insurer's name & birthdate information. ie Patient is the child. Insurer is the dad.
ie Medicare, BCBS, UHC, Aetna, Cigna...
Primary insurance member ID / policy #.
Primary insurance Claim Billing address and provider service phone
Name of your Secondary Insurance (ins2). Enter NONE if none.
Secondary insurance Claim Billing address and provider service phone
Ethnicity (required by insurance)
Note: ie. English, Chinese, Spanish, Vietnamese, Refused, Other ...
Note: Name, relationship to patient, Cell #, Home phone #
Note: A friend, A family, hospital, newspaper, Online web, Insurance.
Note: include estimate Year, Hospital, Reason & Outcome
smoked > 100 cigarettes/lifetime... or smokes > 10 cigarettes/day or equivalent cigar or pipe smoke...
number of packs, cigarettes, cigar, pipe, etc PER DAY, number of years, Date started, Date Stopped.
Enter "NONE" if not use.
Note: REQUIRED. Dad's and Mom's health status (good, fair, bad, decease include cause) and health condition. (Arthritis , Diabetes, Gout, Heart Disease, Asthma, Strokes, Hay Fever, High Blood Pressure, Cancer, Kidney disease, Chemical Dependency, Tuberculosis, Other ____) ie dad 87 bad cancer, mom healthy good
*** DO NOT skip *** REQUIRED. Each sibling's health status (good, fair, bad, decease include cause) and health condition . (Arthritis , Diabetes, Gout, Heart Disease, Asthma, Strokes, Hay Fever, High Blood Pressure, Cancer, Kidney disease, Chemical Dependency, Tuberculosis, Other ____) ie bro 44 good, sis 32 fair, hi blood pressure
Note: *** Required field *** If not taking any medication, vitamin, including over-the-counter, type "NONE". *** It is very important for us to have a list of all medications that you are taking. *** Specify Dosage, Frequency, Reason, and Last Prescribing Doctor. ie: 1) Lisinopril 10mg once daily for BP by Dr Jones, 2) Adderall 10MG -1 tab twice a day in morning for ADHD by Dr Smith, 3) Estradiol 1mg @PM for hormone replace - Dr Mike Nguyen
Note: *** required field *** If any allergies to medication, x-ray dyes, or food. Else no allergies, then type "NONE".
Note: *** Required field *** If no health condition applied then type "Good Health". --- AIDS , Alcoholism , Anemia , Anorexia , Appendicitis , Arthritis , Asthma , Bleeding disorders , Breast lump , Bronchitis , Bulimia , Cancer , Cataracts , Chemical dependency , Chicken Pox , Diabetes , Down syndrome , Emphysema , Epilepsy , Glaucoma , Goiter , Gonorrhea , Gout , Heart disease , Hepatitis , Hernia , Herpes , High cholesterol , HIV positive , Kidney disease , Liver disease , Measles , Migraine headaches , Miscarriage , Mononucleosis , Multiple sclerosis , Mumps , Pacemaker , Pneumonia , Polio , Prostate problem , Psychiatric Care , Rheumatic fever , Stroke , Scarlet fever , Suicide attempt , Thyroid problems , Tonsillitis , Tuberculosis , Typhoid fever , Ulcers , Vaginal infections , Venereal disease, None ____
Note: ie. Abnormal Pap Smear , Bleeding between periods , Breast lump , Hot flashes , Extreme menstrual pain , Nipple discharge , Painful intercourse , Vaginal discharge , Other_____
Date Last menstrual period
Result normal/abnormal.
Result normal/abnormal.
39f. List number of children. List each child year of birth, Sex of birth and Complications if any (ie 2000 boy normal, 2004 girl c-section)
Note: ie. Breast lump, Erection difficulties, Lump in testicles, Penis discharge, Sore on penis, Other ______
MM/DD/YY, Dr Name, Tel#, and result is normal or abnormal.
MM/DD/YY, Dr Name, Tel#, and result is normal or abnormal.
MM/DD/YY and result is negative or positive.
MM/DD/YY; Result normal/abnormal. ........There are 4 types of test: annual Fecal occult blood test/Flexible Sigmoidoscopy/ Colonoscopy/Cologuard every 3yr.
41a. Specific and UP Front. ie How long have you been experiencing these symptoms? (hrs, days, or wks).
46. I understand that I may revoke this authorization in writing at any time, except to the extent that caption has been taken in alliance on it. I understand that if the recipient authorized to receive the information is not a covered entity, e.g. insurance company or non-healthcare provider; the release information may no longer be protected by federal or state privacy regulations.
47. Please call us if you are unable to make the appt to avoid the $30 NO-SHOW fee.
48. 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 may have made in the completion of this form.
**** 1) You are ultimately responsible for knowing what your plan does and does not cover and the administrative rules. (i.e. in-network / out-network; out-of-pocket balance, copayment, coinsurance, deductible , Health-Saving-Account balance; Labs/Radiology/EKG; authorizations and referrals) **** 2) As a courtesy, we will verify your insurance eligibility and benefits. However, we cannot guarantee that the information received, is accurate due to insurance policy changes and real-time/up-to-date system information. We will bill your insurance company with whom we have a contract agreement with.**** 3) Once your insurance company has processed a claim, any balance as determined by your insurance plan to be "patient's responsibility" and/or "non-covered service", will be your responsibility. ie. any copays, coinsurance, deductible, and fees. **** 4) If you disagree with the "patient responsibility" amounts due to our office per your insurance's Explanation-of-Benefits(EOB), please immediately call your insurance company and our office for further explanation. **** 5) Failure to provide current insurance information to our office and/or reply back to insurance's request for additional information may result in the entire bill being your responsibility.
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CONTROLLED SUBSTANCE POLICY
Narcotics (Norco, Hydrocodone, Fentanyl, Hydromorphone ...) -1- We are NOT a pain management clinic. -2- We will provide a short-term prescription for narcotics for acute pain, NOT for chronic pain management. -3- Urine drug screen will be checked every 3month (at your cost) with the prescription. -4- There will be intermittent blood work to monitor for any complication at least once per year. -5- We refer to pain management for chronic pain medication. -6- We will check the database for prescription of Control substances as required by regulations.
Benzodiazepines (Xanax, Ativan, Valium, Ambien, Klonopin, Librium ...) -1- We are NOT psychiatrists. -2- We will provide a short-term prescription for acute episodes of anxiety/panic attacks. -3- Urine drug screen will be checked periodically (at your cost) with the prescription to keep up with regulations. -4- We will refer to psychiatry for long-term management with benzodiazepine. -5- We will NOT write long-term benzodiazepine more than one month at a time. -6- We will require 3 months follow-up and monitoring for renewal of prescription. -7- There will be blood work to monitor for any complication at least once per year.
Amphetamines/stimulants and ADD medication (Vyvanse, Adderall, Dexedrine, Mydayis, Concerta ...) -1- We are NOT psychiatrists. -2- We will refer to psychiatry for diagnosis and evaluation to initiate ADD medication, and periodically if there is concerns about medication effectiveness -3- We will not write more than one month at a time. -4- Urine drug screen will be checked every 3month (at your cost) with the prescription. -5- Once established as our patient and confirmed diagnosis, we will manage the prescription writing one month at a time with follow-up every 3 months. -6- There will be blood work and an EKG to monitor for any complication at least once per year.
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NOTE: Once you are done, click submit *** IF YOU GET A RED messages, this is an error and you are missing some required fields. You need to correct and then click submit. You should get a green successful message. THANK YOU
