Phone: Fax PATIENT REGISTRATION FORM

Transcription

1 East Side Office & Mailing address West Side Office at Tanasbourne Providence Professional Plaza Office Wilsonville Office 9300 SE 91st Ave, Suite NW 188th Ave, Suite NE Hoyt St, Suite SW Miley Road, Suite 202 Portland, OR Hillsboro, OR Portland, OR Wilsonville, OR Phone: Fax Primary Care Provider: PATIENT REGISTRATION FORM Date: Is treatment related to a work comp injury? YES NO If yes, Attending Physician: PATIENT INFORMATION Legal Name: (Last, First, Middle) Preferred Name: Marital Status: Single Married Divorced Widowed Referred By: Age: Date of Birth: Gender: Male Female Street Address: State: City/Zip Code: Social Security #: Cell Phone: Address: Home Phone: Work Phone: Employer: RESPONSIBLE PARTY Legal Name: (Last, First, Middle) (Check if Same as Patient) Date of Birth: Gender: Male Female Street Address: State: City/Zip Code: Relationship to Patient: Social Security #: Cell Phone: Address: Home Phone: Work Phone: Employer: Primary Insurance: INSURANCE COVERAGE Phone: Billing Address: State: City/Zip Code: Subscriber Legal Name: (Last, First, Middle) (Check if Same as Patient) Date of Birth: Gender: Male Female ID & Group #: Employer: Work Phone: Relationship to Patient: Secondary Insurance: Phone: Billing Address: State: City/Zip Code: Subscriber Legal Name: (Last, First, Middle) (Check if Same as Patient) Date of Birth: Gender: Male Female ID & Group #: Employer: Work Phone: Relationship to Patient: Accident Insurance: Auto Worker s Compensation Other Name of Accident Insurance Company: Billing Address: State: City/Zip Code: Claim #: Date of Injury: Phone: Adjuster/Case Manager: Name of Local friend/relative: EMERGENCY CONTACT INFORMATION Phone: The above information is true to the best of my knowledge. I understand I am financially responsible for any balance not covered by my insurance carrier. MEDICARE I request that the payment of authorized medical benefits be made on my behalf to Joseph P Stapleton MD PC, for any services related to me. I hearby authorize Joseph P Stapleton MD PC to release to the health care administrator and its agents any medical information needed to determine these benefits payable for related services under Title XVIII of Social Security Act. COMMERCIAL I hearby authorize the release of information necessary to file a claim with my insurance company and assign benefits otherwise payable to me to Joseph P Stapleton MD PC. Patient/Guardian Signature: Date:

2 HIPAA Consent Form THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We are required by law to maintain the privacy of your protected health information, to notify you of our legal duties and privacy practices with respect to your health information, and to notify affected individuals following a breach of unsecured health information. This Notice summarizes our duties and your rights concerning your information. Our duties and your rights are set forth more fully in 45 CFR Part 164. We are required to abide by the terms of our Notice that is currently in effect. 1. Uses And Disclosures We May Make Without Written Authorization. We may use or disclose your health information for certain purposes without your written authorization, including the following: Treatment: We may use or disclose your information for purposes of treating you. For example, we may disclose your information to another health care provider so they may treat you; to provide appointment reminders; or to provide information about treatment alternatives or services we offer. Payment: We may use or disclose your information to obtain payment for services provided to you. For example, we may disclose information to your health insurance company or other payer to obtain payment for treatment. Healthcare Operations: We may use or disclose your information for certain activities that are necessary to operate our practice and ensure that our patients receive quality care. For example, we may use information to train or review the performance of our staff or make decisions affecting the practice. Other Uses or Disclosures: We may also use or disclose your information for certain other purposes allowed by 45 CFR or other applicable laws and regulations, including the following: To avoid a serious threat to your health or safety or the health or safety of others. As required by state or federal law such as reporting abuse, neglect or certain other events. As allowed by workers compensation laws for use in workers compensation proceedings. For certain public health activities such as reporting certain diseases. For certain public health oversight activities such as audits, investigations, or licensure actions. In response to a court order, warrant or subpoena in judicial or administrative proceedings. For certain specialized government functions such as the military or correctional institutions. For research purposes if certain conditions are satisfied. In response to certain requests by law enforcement to locate a fugitive, victim or witness, or to report deaths or certain crimes. To coroners, funeral directors, or organ procurement organizations as necessary to allow them to carry out their duties. 2. Disclosures We May Make Unless You Object. Unless you instruct us otherwise, we may disclose your information as described below. We may disclose health information about you to your family members or friends if we obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection. We will limit the disclosure to the information relevant to that person s involvement in your healthcare or payment.

3 3. Uses and Disclosures With Your Written Authorization. Other uses and disclosures not described in this Notice will be made only with your written authorization, including most uses or disclosures of psychotherapy notes; for most marketing purposes. You may revoke your authorization by submitting a written notice to the Privacy Contact identified below. The revocation will not be effective to the extent we have already taken action in reliance on the authorization. 4. Your Rights Concerning Your Protected Health Information. You have the following rights concerning your health information. To exercise any of these rights, you must submit a written request to the Privacy Officer identified below: You may request additional restrictions on the use or disclosure of information for treatment, payment or healthcare operations. We are not required to agree to the requested restriction except in the limited situation in which you or someone on your behalf pays for an item or service, and you request that information concerning such item or service not be disclosed to a health insurer. We normally contact you by telephone, mail at your home address and possibly by if you have given your address. You may request that we contact you by alternative means or at alternative locations. We will accommodate reasonable requests. You may inspect and obtain a copy of records that are used to make decisions about your care or payment for your care, including an electronic copy. We may charge you a reasonable cost-based fee for providing the records. We may deny your request under limited circumstances, e.g., if we determine that disclosure may result in harm to you or others. You may request that your protected health information be amended. We may deny your request for certain reasons, e.g., if we did not create the record of if we determine that the record is accurate and complete. You may receive an accounting of certain disclosures we have made of your protected health information. You may receive the first accounting within a 12-month period free of charge. We may charge a reasonable cost-based fee for all subsequent requests during that 12-month period. You may obtain a paper copy of this Notice upon request. You have this right even if you have agreed to receive the Notice electronically. 5. Changes To This Notice. We reserve the right to change the terms of this Notice at any time, and to make the new Notice effective for all protected health information that we maintain. If we materially change our privacy practices, we will post a copy of the current Notice in our reception area and on our website. You may obtain a copy of the operative Notice from our receptionist or Privacy Officer. 6. Complaints. You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint with us by notifying our Privacy Officer. All complaints must be in writing. We will not retaliate against you for filing a complaint. 7. Contact Information. If you have any questions about this Notice, or if you want to object to or complain about any use or disclosure or exercise any right as explained above, please contact: Ask for the Privacy Officer Phone: Address: 9300 SE 91 st Ave. Suite 400 Portland, OR Patient Name: Signature Date Patient Name: Print *Effective Date. This Notice is effective April 9, 2014.

4 Please fill this form out before your appointment and bring it with you. New Patient Intake Form Patient Information Name: Date: Referring Physician: Primary Care Provider: Height: Weight: Current Medications/Allergies: Medications: Currently not taking any medications (Please include dosage and how often you take your medication). Do you currently take any blood thinning medication (Aspirin, Coumadin, Warfarin, Plavix, Lovonox)? Yes No If yes, when was your last dose? Allergies: I have No Known Drug Allergies Pain History Chief Compliant: (Reason for your visit today) Use diagram to indicate the area of your pain. Mark location(s) with an 'X' Pain Intensity (0 being no pain, 10 being worst pain) Circle number that best describes your pain. *Please circle only one number Average Pain With Activity Worse Pain With Meds Current Pain Without Meds

5 Pain History Continued... Activities that make pain worse: Activities that make pain better: Qualities of your pain: NONE NONE NONE Bending forward Bending forward Aching Exertion/Exercise Injections Burning Getting out of chair Lying down Dull Lifting Medications Sharp Lying down Moving Shooting Moderate physical activity Position change Stabbing Nonspecific activity Physical activity Throbbing Position change Procedures Pressure Reaching Rest Crushing Significant physical activity Sitting Cramping Sitting Standing Spasmodic Standing Pulling Turning the head Tender Twisting Tight Walking Knife like Hot Duration of your pain *Please check only one Sore No pain Constant pain Intermittent pain History - Personal HEAD/EARS/EYES/NOSE/THROAT GASTROINTESTINAL INFECTIONS CANCER Headaches Gallstones Hepatitis Bladder cancer 0Migraines GERD HIV Breast cancer Seasonal allergies GI bleed Shingles Colon cancer Sinusitis Hiatal hernia NEUROLOGICAL Lung cancer CARDIOVASCULAR Irritable bowel syndrome Stroke Melanoma Angina Pancreatitis Parkinson's disease Prostate cancer Arrhythmia Ulcers Peripheral neuropathy Coronary artery disease GENITOURINARY Seizure disorder MUSCULOSKELETAL Deep venous thrombosis Enlarged prostate TIA Back pain High blood pressure Frequent bladder infections PSYCHOLOGICAL Connective tissue disorder High cholesterol Kidney stones ADD Fibromyalgia Past heart attack Renal failure Anxiety Kyphoscoliosis Mitral valve prolapse Renal insufficiency Bi-Polar disorder Osteoarthritis Heart murmur ENDOCRINE Dementia Osteoporosis Pace maker Diabetes Depression Rheumatoid arthritis Peripheral vascular disease Obesity Schizophrenia Scoliosis RESPIRATORY Asthma COPD Obstructive sleep apnea Thyroid disorder Anemia BLOOD Bleeding disorder Blood transfusion History - Prior Procedures (Example: Epidural Steroid Injections, Trigger Point Injections)

6 List all past procedures for pain & approximate dates History - Surgery List all past surgeries & approximate dates. History - Prior Treatments Treatment Helpful Not Helpful Treatment Helpful Not Helpful Acupuncture Massage Biofeedback relaxation therapy Minimally invasive procedures Botox injections Occupational therapy Chiropractic Physical therapy Heat Surgery Home exercise TENS Ice History - Prior Medications Medication Helpful Not Helpful Medication Helpful Not Helpful NSAIDS Percocet Oxycodone Celebrex Celecoxib Duragesic Diclofenac Methadone Flector Patch Morphine Motrin Ibuprofen Oxycontin Mobic Meloxicam Oxymorphone Opana Relafen Nabumetone Cymbalta Duloxetine Naproxen Lyrica Pregablin Voltaren Gel Neurontin Gabapentin Flexeril Cyclobenzaprine Savella Skelaxin Metaxalone Topamax Soma Trileptal Zanaflex Tizanidine Lidoderm Patch Actiq Tramadol Ultracet Hydrocodone Vicodin Tylenol Acetaminophen Hydromorphone Dilaudid Blood Thinners History - Social History

7 Single Currently smoke every day I never exercise Married Currently smoke some days I exercise 1-2 times per week Domestic partner Former smoker I exercise 3-5 times per week Widowed Never smoker I exercise 6-7 times per week Separated Cigarettes packs per day Aerobics Divorced Pipe times per day Biking Chew cans per day Running Children, How Many Total years Hiking Swimming Retired No alcohol use Climbing Disabled Rarely use alcohol Treadmill/Elliptical Unemployed Socially use alcohol Walking Self-employed Daily use alcohol Weight lifting Employed part-time Details: Employed full-time Current occupation I do not use recreational drugs Previous occupation I use marijuana I use cocaine Elementary school I use heroin Some high school I use morphine High school I use methamphetamines GED I use LSD Some college I use mushrooms College degree I use ecstasy Master's degree I use Doctorate degree History - Family History Reviewed and non-contributory Unknown, adopted Unknown Condition Father Mother Brother Sister Other Arthritis Asthma Bleeding disorder Coronary artery disease Cancer Congestive heart failure COPD Diabetes High blood pressure Irritable bowel syndrome Kidney disease Heart attack (MI) Peripheral artery disease Stroke Thyroid disease History - Psychological

8 Check box if you have been diagnosed with the any of the following: Depression Describe: Anxiety Describe: Psychosis Describe: Check which applies I am currently not in treatment I am currently seeing a psychiatrist I am currently seeing a psychologist Check which applies I have had thoughts of suicide I have not had thoughts of suicide Check which applies I am coping with my chronic pain I am frustrated with my chronic pain Review of Systems Fever Shortness of breath Joint pain Sexual problems Chills Wheezing Joint swelling Problems urinating Fatigue Cough Stiffness Poor appetite Weakness Headache Poor sleep Chest pain Dizziness Weight gain Irregular heart beat Abdominal pain Loss of consciousness Weight loss Swelling in legs Nausea Weakness Vomiting Numbness Hearing loss Rash Diarrhea Tingling Sore throat Itching Loss of bowel/bladder Blurred vision Lesions Heartburn Depression Decreased vision Bruise easily Constipation Anxiety