Acknowledgement of receipt of notice of privacy practices

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1 Acknowledgement of receipt of notice of privacy practices NOTICE OF PRIVACY PRACTICES I acknowledge that I have received a Notice of Privacy Practices from Kettering Physician Network (dba Kettering Cancer Care) Yes No Signature of patient, parent/legal guardian LIVING WILL I have a Living Will: Yes No I have a Durable Power of Attorney: Yes No Signature of patient AUTHORIZATIONS You have my permission to discuss my medical record information and account with the following family members: Name Relationship Name Relationship Name Relationship I hereby authorize Kettering Physician Network (dba Kettering Cancer Care) to apply for benefits on my behalf for covered services rendered by the physicians or their orders, realizing that I am responsible to pay for my medical services, any collection agency fees or attorney fees. I request that payment from my insurance company be made directly to the physician. I hereby authorize the release of any pertinent medical information to insurance carriers from Kettering Physician Network (dba Kettering Cancer Care) or consulting physicians. I hereby authorize Kettering Physician Network (dba Kettering Cancer Care) to release pertinent medical information to consulting physicians. I certify that the information I have reported with regard to my insurance company is correct. Either my insurance company or I may revoke this authorization at any time in writing. I permit a copy of any of these authorizations to be used in place of the original. Signature of patient, parent/legal guardian Note: Children under 14 years of age are not permitted in the infusion room. The Infusion Center is a service of Grandview Medical Center. Initial 18ON1599 KCC Patient Guide inserts.indd 1 6/18/18 2:31 PM

2 Authorization for disclosure of protected health information Patient Name of Birth Patient Telephone Number SSN I authorize: Name Street Address City State ZIP Phone Fax to use or disclose the above named individual s health information as described below. The type of information to be used or disclosed is as follows (check the appropriate boxes and include other information where indicated): Complete medical records Progress notes History & physical Patient demographics Laboratory Imaging/EKG of Treatment I understand that the information in my medical records may include information relating to sexually transmitted disease (STD), acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse. The information identified above may be used by or disclosed to the following: This information for which I am authorizing disclosure will be used for the following purpose: My personal records Other (please describe) Sharing with other health care providers as needed I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to Kettering Cancer Care. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. This authorization will expire: 60 DAYS or I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations I understand authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to ensure healthcare treatment. SIGNATURE OF PATIENT OR LEGAL REPRESENTATIVE If signed by legal representative, relationship to patient 18ON1599 KCC Patient Guide inserts.indd 2 6/18/18 2:31 PM

3 Patient history Patient s name of birth Age of consult Referring physician Primary physician Others Pharmacy name Pharmacy phone number Do you have a living will? Yes No Is there a copy in your chart? Yes No Reason for consultation History of present illness Medical history Surgical history Current medications (name & dosage) Allergies Marital status: Single Married Widowed Place of birth Military experience Yes No Occupation Level of education completed Alcohol use: Yes No Tobacco use: Yes No Street drug use: Yes No Number of pregnancies Number of miscarriages Ancestry: Western/Northern Europe Near East/Mid East Native American Asian Ashkenazi Latin American/Caribbean Africa Other Biological family history: Blood problems: Yes No Cancers: Yes No Mother: Living Age Deceased Cause of death & age Father: Living Age Deceased Cause of death & age Siblings: Living Age Deceased Cause of death & age Mother s side diseases Father s side diseases 17ON Kettering Health Network

4 Please answer the following questions in relation to the past few months only. HEMATOLOGIC PAIN CARDIAC/RESPIRATORY BREAST THROAT MOUTH VISION GENERAL Significant weight change? Yes No Night sweats? Yes No Recurrent fever? Yes No Trouble seeing? Yes No Double vision? Yes No History of glaucoma? Yes No Cataracts? Yes No Sore gums? Yes No Lump in mouth or on tongue? Yes No Ulcer in mouth or on tongue? Yes No Persistent white patches in mouth? Yes No Hoarseness? Yes No Persistent sore throat? Yes No History of thyroid disorder? Yes No Lumps? Yes No Discharge or bleeding? Yes No Pain? Yes No Dimpling or nipple inversion? Yes No of last mammogram Results Shortness of breath? Yes No Swelling of ankles? Yes No Chest pain? Yes No Cough? Yes No Coughing blood? Yes No High blood pressure? Yes No Location of pain Is the pain sharp? Yes No Is the pain related to movement? Yes No Is the pain a dull ache? Yes No Is the pain crampy? Yes No Severity of pain on a 0 to 10 scale Excessive bleeding in any area? Yes No Excessive bruising of the skin? Yes No History of anemia (low red count)? Yes No History of known blood disorder? Yes No Unusually frequent infections? Yes No Swollen lymph glands? Yes No Prior blood transfusions? Yes No Blood donor? Yes No NEUROLOGIC GYNECOLOGIC ENDOCRINE GENITOURINARY DIGESTIVE Change in appetite? Yes No Difficulty swallowing? Yes No Abdominal distress? Yes No Vomiting? Yes No Vomiting blood? Yes No Diarrhea? Yes No Constipation? Yes No Rectal bleeding? Yes No Black, tarry stools? Yes No Hemoccult stools? Yes No GI evaluation? Physician Yes No EGD? Results Yes No Colonoscopy? Results Yes No Painful urination? Yes No Frequent urination? Yes No Slow stream? Yes No Blood in urine? Yes No Kidney/flank pain? Yes No Urgency or control difficulties? Yes No Lump, ulcer, or pain in genital area? Yes No Diabetes? Yes No Excessive thirst or urination? Yes No Other glandular problems? Yes No of last pelvic exam Age at onset of menses of last menses Irregular vaginal bleeding? Yes No Pelvic pain? Yes No Did you breast feed? Yes No Have you taken hormones? Yes No Have you used birth control pills? Yes No Headaches? Yes No Convulsions? Yes No Dizziness? Yes No Numbness or tingling? Yes No Weakness? Yes No Loss of consciousness? Yes No Depression Yes No Difficulty with memory? Yes No Difficulty with concentration? Yes No Problems with balance? Yes No Problems with coordination? Yes No

5 Patient information Patient Name of birth SS# Male Female Marital status: Single Married Widowed Other Street Address City State Zip Home phone Is this your billing address as well? Yes No If no, please provide billing address Employer Work street address Address Occupation City State Zip Work phone INSURANCE Please present your insurance card and driver s license for us to make copies. Primary Insurance Address ID # Group # Plan # Subscriber s Name Subscriber s SS# Relationship to Patient Effective Amount of Copay $ Secondary Insurance Address ID # Group # Plan # Subscriber s Name Subscriber s SS# Relationship to Patient Effective Amount of Copay $ CONTACT Preferred phone number for contracting you about appointment or results A message may be left at my home: Yes No A message may be left at my place of employment: Yes No A message may be left on my voice mail: Yes No Kettering Physician Network (dba Kettering Cancer Care) may be identified as the caller: Yes No Emergency contact Phone Relationship MINOR/GUARDIAN If patient is a minor, parent/legal guardian s name Address Home phone Guardianship authorization: I give my permission to evaluate and treat my child, Work phone of Birth of Birth State of birth, my permission to bring my child, to Kettering Physician Network (dba Kettering Cancer Care) for medical treatment. (signature of parent/legal guardian), I give Kettering Physician Network (dba Kettering Cancer Care) Signature of parent/legal guardian in my absence. 17ON Kettering Health Network

6 Office policy & procedure Form Completion and Copying of Medical Records The medical office has numerous requests for the completion of forms at any time. Although we do not required to a fee for forms completion, we do require appropriate time for completion of at least 3 business days. Patients requesting copies of their medical records may be charged according to the hospital fee schedule. There is no charge for the forwarding of medical records to other physicians providing you care. Account Balances We will require that patients with balances make payment arrangements on their account balances. For your assistance, we have a Financial Navigator available to discuss programs for which you may be eligible. Please call and ask to speak to the Financial Navigator if you have any concerns regarding your account. Attestation I have received a copy of these policies. I have been given the opportunity to ask questions regarding the above information. I understand that my signature below represents agreement with them. PRINT PATIENT NAME PATIENT SIGNATURE DATE / / PATIENT S GUARDIAN SIGNATURE DATE / / USE ONLY PATIENT ACCOUNT # 17ON Kettering Health Network

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