EMERGENCY SCREENING PLEASE PROVIDE US THE REASON FOR YOUR VISIT TODAY. Date of Birth: Is today s visit related to work place injury?

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1 EMERGENCY SCREENING Welcome to MedStar PromptCare. In order to provide the very best care for you and also protect your privacy, we ask that you complete this form immediately upon presentation to the practice and provide it to the Patient Services Coordinator at the front reception desk. Your health is of the utmost importance to us and we are committed to serving you. PLEASE PROVIDE US THE REASON FOR YOUR VISIT TODAY Date of Birth: Is today s visit related to work place injury? Yes No Is today s visit related to an auto accident? Yes No ARE YOU (OR THE PATIENT) EXPERIENCING ANY OF THE FOLLOWING AT THIS TIME? 1. Chest pain (not associated with coughing or flu symptoms), pressure or heaviness in the chest, chest pain that radiates into the shoulder, arm, back or jaw, heart attack 2. Difficulty breathing, shortness of breath, asthma attack 3. Severe or uncontrolled bleeding 4. Loss of consciousness, fainting or seizure 5. Foreign object in the eye or chemicals splashed in the eye 6. Medication overdose or ingestion of a chemical 7. Sudden onset of one-sided extremity or facial weakness, difficulty speaking, blurred vision, dizziness, headache, confusion, disorientation or other symptoms of a stroke 8. Possible contagious rash (such as chickenpox, scabies, measles) 9. Fall or motor vehicle crash with neck pain, numbness, weakness or tingling in the extremities 10. Severe abdominal pain CHECK ONE: NO YES (if yes, please circle the symptom-event above) Signature Patient Name Date Name of Patient Representative Signing for Patient (required if the patient is a minor or an adult who is unable to sign this form) Relationship of Patient Representative to Patient

2 AUTOMOBILE OR WORK INJURY Please complete this form if the reason for today s care is an automobile accident or an injury at work and this is the first time you are being seen by MedStar PromptCare for this particular injury. PATIENT - ACCIDENT INFORMATION Patient Name: Social Security Number: Today s Date: Date of Accident: State Where Accident Occurred: INSURANCE INFORMATION Insurance Company Name: Claim Number: Phone Number: Billing Address: I hereby authorize MedStar PromptCare to furnish the insurance carriers listed above my medical information. I hereby assign MedStar PromptCare all payments for medical services rendered to myself or my dependents until revoked in writing. I understand that I am responsible for any amount not covered by insurance at the time of service. I also understand that I am responsible for collection and legal costs should my account be turned over to a collection agency. Date:

3 PATIENT REGISTRATION, PAGE 1 Please complete Patient Registration, Page 1 and Page 2, if the patient is new to MedStar Health, has not received care from MedStar in the past three years, or if the patient has had a significant change in information (demographic, insurance, medical history). PATIENT INFORMATION Patient s Name (Last) (First) (MI) Gender Date of Birth Age Race Language Address City State Zip Marital Status Social Security # Evening Phone Daytime Phone Employed (Y/N) Employer/School Relationship to Guarantor PERSON TO NOTIFY IN CASE OF EMERGENCY Name Relationship to Patient Address City State Zip Phone # PRIMARY INSURANCE Name of Insurance Address Effective Date Group Number Insured s Date of Birth Insured s ID # Insured s Social Security # Copay Insured s Party Name SECONDARY INSURANCE Name of Insurance Address Effective Date Group Number Insured s Date of Birth Insured s ID # Insured s Social Security # Copay Insured s Party Name PRIMARY CARE PHYSICIAN Primary Care Physician Name Practice Phone Practice Name and Address Completed by: Patient Parent/Guardian/Other

4 PATIENT REGISTRATION, PAGE 2 Patient s Full Name: Gender: Female Male Date of Birth: PHARMACY: Would you like your prescriptions electronically transferred to a pharmacy? Yes No Pharmacy Name: Phone No.: Fax No: Pharmacy Address: Medication-Drug Allergies: MEDICAL, FAMILY, SOCIAL HISTORY Current Medications: Have you been diagnosed with any of the following: Abnormal Heart Rhythm Anxiety Arteriosclerosis Arthritis Asthma Blood Clots Cancer Cholesterol - Triglyceride Disorder COPD - Pulmonary Disease Congestive Heart Failure (CHF) Depression Diabetes Gallbladder Disease Glaucoma Headaches Hiatal Hernia Hypertension - High Blood Pressure Kidney Disease - Uremia Kidney Stones Hypotension - Low Blood Pressure Lung Disease Muscle Disease Pulmonary Hypertension Renal Disease Seizure Disorder Sleep Disorders Stomach - GI Disorders Stroke Thyroid Disorders Tremor Ulcer Disease Urinary Infections Children, Ages 10 and under Premature - Complications at Birth Ear Infections Febrile Seizure Surgeries Procedures Appendix Removal Blood Transfusions CABG (Heart Surgery) Gallbladder Removal Hernia Repair Hysterectomy (circle: Total-Partial) Pacemaker Tonsils Removal Tubal Ligation TURP Stomach Surgery Thyroid Surgery Spleen Surgery Other Medical History: Vision and Hearing Hearing Problems Wear Hearing Aid Wear Contact Glasses Wear Glasses for Reading Only Last Menstrual Period: Birth Control Yes No Type: Biological Mother: Alive Deceased at age from: Biological Father: Alive Deceased at age from: Tobacco: No Yes Recently Traveled Abroad: No Yes, Location: Alcohol: Never Rarely Occasional Heavy Dates: Other Relevant Medical History: Completed by: Patient Parent/Guardian/Other

5 REVIEW OF SYSTEMS Today s Date: Completed by: Patient Parent/Guardian/Other: Patient s Full Name: Gender: Female Male Date of Birth: As part of your current illness-injury, please indicate which of the following you are experiencing: CONSTITUTIONAL Yes No - Fever Yes No - Chills/Sweats Yes No - Fatigue CHILDREN BABIES Yes No - Decreased Activity Yes No - Inconsolable/Fussy Yes No - Crying More Yes No - Drinking/Eating Less Yes No - Attends Daycare/School Yes No - Pulling at Ears Yes No - Diaper Rash EYES Yes No - Eye Pain Yes No - Sensitivity to Light Yes No - Redness Yes No - Vision Changes EARS NOSE THROAT MOUTH Yes No - Sore Throat Yes No - Nasal Congestion Yes No - Runny Nose Yes No - Ear Pain/Ache Yes No - Nasal Foreign Body Yes No - Tooth Pain RESPIRATORY Yes No - Cough w/sputum w/blood Yes No - Shortness of Breath Yes No - Wheezing Yes No - Pain with Coughing or Breathing CARDIOVASCULAR Yes No - Chest Pain Yes No - Heart Racing/Palpitations Yes No - Leg Swelling Yes No - Difficulty Breathing SKIN HAIR NAILS Yes No - Rash Yes No - Skin redness Yes No - Insect Bite/Sting Yes No - Itching Yes No - Cuts, Bumps, Scrapes, Bruises Yes No - Finger Toe Nail Problem GENITOURINARY Yes No - Urination Pain/Discomfort/Pressure Yes No - Blood in Urine Yes No - Kidney Pain Yes No Vaginal or Penile Discharge Yes No - Genital Pain or Lesions Yes No - Pregnant Yes No - Breast Feeding Yes No - Using Birth Control Pills GASTROINTESTINAL Yes No - Abdominal Pain Yes No - Indigestion/Reflux Yes No - Nausea Yes No - Vomiting Yes No - Diarrhea Yes No - Constipation Yes No - Black or Bloody Stool Yes No - Hemorrhoid Yes No - Rectal Problem MUSCULOSKELETAL Yes No - Back Pain Yes No - Neck Pain Yes No - Muscle Aches Yes No - Bone Pain Yes No - Joint Pain Yes No - Joint Swelling Yes No - Extremity Swelling NEUROLOGICAL Yes No - Headache Yes No - Dizziness Yes No - Loss of Consciousness Yes No - Numbness/Tingling Yes No Seizure HEMATOLOGY ENDOCRINE Yes No - Easy Bruising Yes No - Prolonged Bleeding Yes No - Swollen Glands Yes No - Excessive Thirst Yes No - Excessive Hunger Physician Review Date and Time: FORM: ROSGEN

6 Privacy and Billing Procedures Authorization and Acknowledgement These authorizations/acknowledgements cover all services rendered to me, or the patient I am signing for, today and all future dates of service. I understand I may revoke this authorization by informing MedStar in writing but if I do revoke this authorization, it will not affect anything prior to the date the revocation is received by MedStar. Acknowledgement of Receipt of Notice of Privacy Practices Authorization to Release Information to Family/Friends or Others I have received a copy of MedStar s Notice of Privacy Practices. I authorize MedStar to release any information regarding my treatment including lab results, x-rays and medical records, to the following individuals (MedStar may not release information or records to the named individuals unless you identify them here): Name: Name: Name: Relationship to Patient: Relationship to Patient: Relationship to Patient: MedStar will use my home phone number and/or mobile phone and my primary address supplied during registration to contact me, including leaving messages, regarding my treatment including lab results, x-rays and medical records. I will ensure this information is up-to-date at every visit. Authorization to Treat and Bill I consent to be treated by MedStar. If I am not the patient being treated today I am authorized to consent to treatment and billing for the patient identified below. I authorize MedStar to bill my medical insurance for the care I receive today and to release any information the insurance carrier requires to process this bill. I authorize payment of medical benefits to MedStar, or to outside labs as described below, for all services performed and billed by MedStar. I understand that I am responsible for all charges for the treatment I receive at MedStar today. As a courtesy, MedStar will bill my medical insurance. If I do not provide complete and accurate insurance information to MedStar, I understand MedStar may not receive payment from my carrier and I will be entirely responsible for my bill. Even after my medical insurance company pays MedStar s bill, I may owe MedStar payment for services not covered by my insurance and I agree to pay these promptly to MedStar. I understand that MedStar may send lab specimens to an outside laboratory. I authorize any lab performing services for me to bill my medical insurance for their services. I understand that my medical insurance may not pay for all services provided by the lab and I agree to pay any remaining balance promptly to any outside lab providing services to me. I understand that MedStar is not responsible for payment to outside labs for tests provided to me. To protect my privacy and prevent fraud, I understand that if I cannot provide acceptable photo identification at the time of service that MedStar may choose not to bill insurance and may decline credit/debit cards and checks as a form of payment. I understand that if I fail to pay MedStar for services provided to me, the balance owed may be sent to collections and I may incur collection costs of up to 25% in addition to the amount owed for treatment. I understand that I may contact MedStar to work out payment arrangements that may prevent this additional cost. Patient Name: Date: Patient DOB: Name of Patient Representative Signing for Patient Relationship of Patient Representative to Patient (required if the patient is a minor or an adult who is unable to sign this form)