HIGH$ROCK$INTERNAL$MEDICINE,$PA$PATIENT$PAYMENT$POLICY!
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1 Patient HIGH$ROCK$INTERNAL$MEDICINE,$PA$PATIENT$PAYMENT$POLICY WelcometoHighRockInternalMedicine.Asapatientofours,westrivetoprovideyouwiththebest medicalcarepossibleatthelowestcost.thefollowinginformationwillhelpustodothis.ifyouhave anyquestions,pleasefeelfreetocallourbillingdepartmentat(336)224l0931. Thefollowingexplainsourpolicies: Wewillaskforyourpresentaddressandinsuranceinformationateachappointment.We willalsocopyyourinsurancecardateveryvisit.thisistokeepourrecordscurrent. Werequireacopyofavaliddriver slicense. Copaymentsaredueatcheckin.Ifyoudonothaveyourcopaymentyourappointmentmay berescheduled. Deductibles,coinsuranceandpaymentsforservicesnotcoveredbyyourinsurancearedue atcheckout. Aparentorlegalguardianwhosignsforthecareofaminorpatientisresponsiblefor paymentofthefees. Wewillfileyourinsuranceasacourtesy.Allunpaidbalancesbecomeyourresponsibility afterinsurancepays. Weprocessallcheckselectronicallyandwhenyoupaybycheckyouauthorizeustomakea one(1)timetransferoffundsfromyouraccount.fundsmaybewithdrawnassoonasthe samedayyoumakepayment. ReturnedcheckswillbereLpresentedtothebankandaservicefeeof$25willbecharged. Intheeventofavoidedcreditcardtransaction,themonieswilltake5L7businessdaystobe restoredtoaccount. PLEASE$READ$AND$SIGN$BELOW AUTHORIZATION$TO$PAY$BENEFIT$TO$PHYSICIAN:I,theundersigned,herebyauthorizepaymentdirectlytothe physicianforhis/herservices.iherebyauthorizethephysiciantoreleaseanyinformationacquiredinthecourseof myexaminationortreatmenttospecificinsurancecarriers,thirdpartypayersorothersinvolvedinprocessingor collectionofthisclaim. DATE: RESPONSIBLEPARTY: ASSIGNMENT$AND$RELEASE:I,theundersigned,certifythatI(ormydependent)haveinsurancecoverageand haveprovidedthatinformationandassigndirectlythephysicianallinsurancebenefits,ifany,otherwisepayableto meforservicesrendered.iunderstandthatiamfinanciallyresponsibleforallchargeswhetherornotpaidby insurance. DATE: RESPONSIBLEPARTY: DATE: WITNESS:
2 High Rock Internal Medicine, P.A. Patient Acknowledgement of Receipt of Notice of Privacy Practices (NPP) Version I, hereby affirm that I have received a copy of the Notice of Privacy Practices, Version , from High Rock Internal Medicine, P.A.. Under federal law , also known as HIPAA, I am entitled to receive a copy of this Notice from my healthcare provider. I understand that my signature on this Acknowledgement only signifies that I have received a copy of the Notice, and does not legally bind or obligate me in any way. I understand that I am entitled to receive a copy of the Notice of Privacy Practices from my healthcare provider, whether I sign this Acknowledgement or not. Patient : Signature of Patient or Personal Representative of Patient or Personal Representative Description of Personal Representative s Authority (if applicable) FOR OFFICE USE ONLY-Staff Complete Each of the 4 Lines Staff received by: received by staff: Patient declined Patient did not decline Time Received by staff: If declined, Staff Signature that witnessed the decline. Staff Signature of person setting Practice Advisory for 1 year renewal of NPP Form: Page 1 of 1
3 Designated Party Release High Rock Internal Medicine, P.A. 104 West Medical Park Drive (336) You may give High Rock Internal Medicine, P.A. written authorization to disclose your protected health information to anyone that you designate, such as a family member or personal representative. If you wish to authorize a person to receive your protected health information, please complete the form below. You may also use this form to give us consent to leave detailed information (results of labs, x-ray, prescription refills, etc.) on your home answering machine, voice mail at work, cell phone, or another party that you designate. Patient : of Birth: : Account # Chart #: At my request, I authorize High Rock Internal Medicine, P.A. to disclose my protected health information to: : Phone #: : Phone #: : Phone #: At my request, I also authorize High Rock Internal Medicine, P.A. to communicate my protected health information to me via the following methods: Leave detailed message on my home answering machine (phone #: ) Leave detailed message on my voice mail at work (phone #: ) Leave detailed message on my cell phone voice mail (phone #: ) Fax detailed medical information (fax #: ) Authorized Signature: : I understand that I may cancel this authorization at any time by signing this notice below. However, if I cancel this authorization, I also understand that the cancellation will not affect any action High Rock Internal Medicine, P.A. took in reliance on this authorization before receipt of written notice of cancellation. Signature Authorizing Cancellation: Authorization Cancelled: Page 1 of 1 Version
4 Patient Registration Form of Appointment: Patient Information Patient s First Middle Last (as it appears on insurance card or ID) Sex Marital Status of Birth (Age) Social Security Number Patient s Address Home Phone Mobile Phone Address Referred by Primary Care Physician Primary Care Physician Phone Pharmacy Pharmacy Phone Pharmacy Address Patient Employer/School Information Employer/School Occupation Employer/School Phone Employer/School Address Emergency Contact Information Emergency Contact Emergency Contact Phone Relation to Patient Billing and Insurance Primary Health Insurance Insurance Company Plan Plan Number Group Number Insured s Employer/School Insured s (as it appears on insurance card or ID) Relation to Patient Insured s Phone Number Insured s Address Insured s Social Security Number Insured s Birthdate Secondary Health Insurance Insurance Company Plan Plan Number Group Number Insured s Employer/School Insured s Social Security Number Insured s (as it appears on insurance card or ID) Relation to Patient Insured s Phone Number Responsible Party Billing (if other than patient) Phone Relation to Patient Address Signature of Patient or Authorized Guardian Check-In by
5 Gender Age of Appointment: Reason for Visit Excellent Good Fair Poor Current Medications Dosage Frequency Dosage Frequency Allergies Adhesive Tape Antibiotics Latex Barbiturates (Sleeping Pills) Aspirin Iodine Codeine Sulfa Local Anesthetics Dosage Dosage Frequency Frequency Reaction Reaction Past Medical History Alcoholism Allergies Back Problems Bleeding Disorder Ear Problems Eating Disorder Hepatitis - A, B, or C High Blood Pressure Measles Migraines Skin Disorder Stomach Ulcer Anemia Blood Disease Epilepsy High Cholesterol Osteoporosis Substance Abuse Anxiety Disorder Blood Transfusion Glaucoma Joint Disorder Pneumonia Thyroid Disorder Arthritis Cancer Gout Kidney Disorder Polio Tuberculosis Asthma Diabetes Heart Disease Liver Disorder Rheumatic Fever Venereal Disease AIDS / HIV Depression Heart Problems Lung Disease Stroke Hospitalizations & Surgeries Women Only: Reason # of Pregnancies # of Miscarraiges # of Abortions # of Living Reason Last Pap Smear Last Mammogram Birth Control Method Family History Lifestyle Factors Alcoholism Cancer Joint Disorder Allergies Depression Kidney Disease Alzheimer s Diabetes Liver Disorder Anemia Epilepsy Lung Disease Anxiety Genetic Disorder Migraines Arthritis Glaucoma Psychiatric Disorders Asthma Heart Disease Osteoporosis AIDS/HIV Hepatitis Stroke Bleeding Disorder High Cholesterol Substance Abuse Blood Disorder High Blood Pressure Thyroid Disorder Details: Yes No # of partners in past year Yes No Yes No Yes No # of years # packs/day Yes No # packs/day Yes No # times/week # drinks/week # drinks/day # times/week Check-In by
6 Medical Review of Systems Click next to any symptom you have experienced recently, or for which you have concerns. Click again if you wish to remove the checkmark. Please print this form out after its complete and bring it with you to your appointment. If you don't understand something, write a question-mark by it on your print out.. Your doctor will discuss any positive responses with you. : : General Pulmonary Musculoskeletal Endocrine Recent unexpected weight loss Chronic Fatigue Anemia Lack of regular exercise Overweight Eyes Failing Vision Eye pain Double Vision Blurred vision Frequent eye infections Glaucoma Cataracts Ears, Nose, Mouth Decreased hearing Ringing in ear Frequent ear infections Frequent nose bleeds Sinus trouble Frequent sore throats Prolonged hoarseness Tooth or jaw pain Pneumonia / pleurisy Bronchitis/chronic cough Asthma/wheezing Gastrointestinal Recent loss of appetite Difficulty swallowing Heartburn/gastritis Persistent nausea/ vomiting Chronic abdominal pain Gall bladder trouble Jaundice (yellow skin) Change in appearance of stool Diarrhea Constipation Bloody or very black stools Hemorrhoids Hernia Genito-Urinary Frequent urine infections Blood in urine Pain in joints Pain in muscles Recurrent back pains Past injury to bones, spine, or joints Gout attacks in the past Concerned about osteoporosis Integumentary Skin rashes Hives Skin moles-black or changing Breast mass Nipple discharge Neurologic Frequent headaches Tremor/hands shaking Muscle weakness Numbness/tingling Seizures/convulsions Difficulty sleeping Excessive daytime sleeping Memory loss Excessive thirst and urination Feet and hands numbness/pain Low blood sugar problems Intolerance to heat or cold Hematologic / Lymphatic Excessive bruising or bleeding Swollen glands-neck, armpit or groin Unexplained fever, chills, night sweats Allergic / Immunologic Hay fever/allergies Getting lots of infections Desire HIV discussion Substance/Chemical Use More than 6 drinks/week Use of tobacco products Caffeine use Over-the-counter medicine / vitamins Anything else you want your doctor to be aware of? Cardiovascular Chest pain Dizzy spells Fainting spells High blood pressure Swollen ankles Kidney Stones Painful urination Loss of control of urine Decrease in flow Urination more than 2 times per night Psychological Feeling depressed Nervous or anxious feeling Excessive moodiness Difficulty concentrating Women Only Periods Irregular Excessive flow/pain Irregular pulse Shortness of breath Any venereal disease in the past? (Herpes, Chlamydia, gonorrhea) Phobias/unexplained fears No pleasure in life anymore Hot flashes/night sweats Abnormal PAP smear
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