Patient Name: 1831 N. Belcher RD Suite C3 Clearwater, FL Phone: Fax: Authorization to Release Protected Information Da

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Transcription:

Patient Name: 1831 N. Belcher RD Suite C3 Clearwater, FL 33765 Phone: 727-754-4959 Fax: 727-754-5910 Authorization to Release Protected Information Date of Birth: Instructions: Following section to be completed by office. Last section is to be completed by Patient or Guardian. Release Information From Release Information To Total Family Wellness 1831 N. Belcher RD Suite C3 Clearwater, FL 33765 Total Family Wellness 1831 N. Belcher RD Suite C3 Clearwater, FL 33765 Other (Specify facility/individual & address below, including phone/fax if known). Other (Specify facility/individual & address below, including phone/fax if known). Purpose of Release Treatment/Continued care Personal Legal purposes Application for insurance Disability determination Payment of insurance claim Other Information To Be Released (Required - check all that apply) Clinic notes Hospital discharge summary Laboratory reports Radiology reports History and physical EKG s Operative reports Radiology images Hospital notes Immunization records Pathology reports Billing information Other (specify information to be released in the space below) Service dates (optional) From To Information needed by (optional) I understand the information to be released may include records related to behavior and/or mental health care, alcohol and drug abuse treatment, HIV/AIDS, and genetics. This authorization may be revoked at any time except to the extent that action has been taken in reliance upon it. Revocation must be made in writing to the provider/facility releasing the information. The provider/facility will not condition treatment on whether I sign the authorization. I may be charged for copies in accordance with state law. Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal law. ATTENTION: This is a legal document. Please read carefully. By signing, you agree that you understand and accept the terms on this form. If the patient is 18 years of age or older, the patient must sign and date the form. If the patient is 18 years of age or older and is incapable of signing, a legally authorized substitute may sign and date the form. Please indicate your legal authority and include documentation of your relationship: Legal Guardian or Conservator Health Care Agent (Health Care Power of Attorney) If the patient is 17 years of age or younger, the patient s parent or legal guardian must sign and date the form, unless an exception exists under state or federal law. Please indicate your relationship: Parent Legal Guardian Signature (Required) Date Signed (Required) (Month DD, YYYY) Printed Name of Person Signing (If Not Patient) Mailing Address of Patient - Street City State ZIP Code Phone

Total Family Wellness Pediatric intake form Name: Parents' Names Today's Date Concerns regarding your child today please bring immunization records to your first appointment!! Date of birth Current age birth weight birth length APGAR score (if known) last known weight date performed / / last known height/length date performed / / Problems during mother's pregnancy or labor? Medical Problems 1 2 3 Medications 1 2 3 Allergies Surgeries 1 2 3 Social history Household members mom dad siblings grandparent(s) Do any of the above persons smoke? no yes Any pets at home? no yes type of pet? Is the child safe at home? yes no Are helmets worn for bike riding and skating? yes no Are lower cabinets in the home free of poisons or locked? yes no do you know the phone number for Poison Control? yes no Is the child always in a car seat or seat belt when in the car? yes no School or Daycare child attends Grade Behavioral or School problems? no yes Developmental History Age at first word Age s/he walked Age s/he entered school Females: Age at first menstrual period N/A Last Menstrual period? / / on contraceptives? yes no (turn over)

Family History Adopted or Unknown Asthma Arthritis Bleeding disorder Breast cancer Colon Cancer Ovarian cancer Endometrial (uterine) cancer Prostate cancer Lung cancer Lymphoma or Leukemia Liver/pancreatic cancer Alzheimer s disease Parkinson s disease Depression or Anxiety Bipolar disorder Other mental disorders Emphysema/Lung disease Epilepsy/seizures Diabetes Heart attack or Heart failure High cholesterol Stroke Thyroid disease Tuberculosis Kidney Disease Genetic Disorder Blood clotting disorder Deafness Birth Defect/Other Family member (s) affected Review date (turn over)

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