new!patient!information!packet! - dearment endo patient packet.pdf · 2017-03-03 · list any...

NewPatientInformationPacket

ThankyouforchoosingDeArmentEndocrinology

Beforeyouvisitourofficeforthefirsttimethereareseveralformsthatweaskyoutocompletetohelpmakeyourfirstvisit

moreenjoyableandtohelpusserveyoubetter

PleasecompletetheattachedformsasfullyasyouareableNoteveryquestionwillbeapplicabletoeverypatientandwerealizethatWesimplyaskthatyouanswerthequestionsascompletelyasyoucanandbringtheformswithyoutoyour

firstappointmentatouroffice

Ifyouhaveanyquestionsyoumayeithercallourofficebeforeyourappointment(717J303J3588)orjustwaituntilyourappointmenttoaskaboutanyitemsaboutwhichyoumaybe

unsure

Welookforwardtoseeingyousoon

2800 Market Street Camp Hill Pennsylvania 17011

Tel (717) 303-3588 Fax (717) 303 3589

Patient Information Sheet Date _____________________ New Updated

Patient Name ________________________________________ _____ ________________________________________________ First Name MI Last Name

SS _________ - ______ - ______________ Date of Birth _______________ Age ________ Gender Male Female

Address ________________________________________________________ City __________________________________ State _______ ZIP _____________

Telephone (Home) (_______) ________ - ______________ (Work) (_______) ________ - ______________ Ext _________

(Cell) (_______) ________ - ______________ (email) _________________________________________________

Employer Name ____________________________________________________ Telephone (_______) ________ - ____________

Address _____________________________________________________ City ____________________________ State ______ ZIP ___________

Marital Status Single Married Divorced Widowed Separated

If Married Spousersquos Name _________________________________________ ___________ ___________________________________________________ First Name MI Last Name

Telephone (Cell) (_______) ________ - ______________ (Work) (_______) ________ - ______________ Ext ________

Emergency Contact _____________________________________________________ Relationship _____________________________________________

Telephone (Home) (_______) ________ - ______________ (Work) (_______) ________ - ______________ Ext ________

(Cell) (_______) ________ - ______________

May we leave a message regarding your medical care at your home Yes No on your work voicemail Yes No on your cell phone voicemail Yes No

Minor Patient Information ndash If Patient is a minor (under 18 years of age) please complete the following

Motherrsquos Name _______________________________________________ ___________ _________________________________________________________ First Name MI Last Name


(Cell) (_______) ________ - ______________

Fatherrsquos Name _______________________________________________ ___________ ___________________________________________________________ First Name MI Last Name

Telephone (Home) (_______) ________ - ____________ (Work) (_______) ________ - ______________ Ext _________

(Cell) (_______) ________ - ______________

Who has legal custody of the patient Both parents Mother Father Guardian (if Guardian complete the following)

Guardianrsquos Name ____________________________________________ ___________ ___________________________________________________________ (First Name) MI (Last Name) Address _____________________________________________________ City ____________________________ State ______ ZIP ______ ______


(Cell) (_______) ________ - ______________

Referral Information Referred by __________________________________________________________________________________________________ (Referring Physicianrsquos Name)

Have you had information from another DrFacility forwarded to this office Yes No -If yes from whom _______________________________

AUTHORIZATION

bull I hereby authorize DeArment Endocrinology LLC to furnish information to any insurance carriers concerning my medical condition and I hereby irrevocably assign DeArment Endocrinology LLC any payment for services rendered

bull I understand that I am responsible for all charges whether or not covered by insurance bull I certify that this information is accurate and current as of this date

SIGNATURE ________________________________________________________________________________ DATE __________________________________________________

Date

HEALTH HISTORY QUESTIONNAIRE DeARMENT ENDOCRINOLOGY LLC

All questions contained in this questionnaire are strictly confidential and will become part of your medical record

Name (Last First MI) M F DOB

Marital status Single Partnered Married Separated Divorced Widowed

Previous or referring doctor Reason for Visit

PERSONAL HEALTH HISTORY

List any medical problems that other doctors have diagnosed

Year Problem Specialist Name (if any)

Surgeries

Year Reason Hospital

Other hospitalizations


List your prescribed drugs and over-the-counter drugs such as vitamins and inhalers

Name the Drug Strength Frequency Taken

Allergies to medications

Name the Drug Reaction You Had

HEALTH HABITS AND PERSONAL SAFETY

Exercise Sedentary (No exercise)

Mild exercise (ie climb stairs walk 3 blocks golf)

Occasional vigorous exercise (ie work or recreation less than 4xweek for 30 min)

Regular vigorous exercise (ie work or recreation 4xweek for 30 minutes)

Alcohol Do you drink alcohol Yes No

If yes what kind

How many drinks per week

Tobacco Do you use tobacco Yes No

Cigarettes ndash pksday Chew - day Pipe - day Cigars - day

of years Or year quit

Yes No

FAMILY HEALTH HISTORY

AGE SIGNIFICANT HEALTH PROBLEMS AGE SIGNIFICANT HEALTH PROBLEMS

Father Children M F

Mother M F

Sibling M F M

F

M F M

F

M F Grandmother

Maternal

M F Grandfather

Maternal

M F Grandmother

Paternal

M F Grandfather

Paternal

PROBLEMS Check if you have or have had any symptoms in the following areas to a significant degree and briefly explain

Skin ChestHeart Recent changes in

HeadNeck Back Weight

Ears Intestinal Energy level

Nose Bladder Ability to sleep

Throat Bowel Other paindiscomfort

Lungs Circulation I attest that the above information is complete and true to the best of my knowledge Signed __________________________________________ Date _________________

AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION I ____________________ HEREBY AUTHORIZE THE RELEASE OF MY HEALTH INFORMATION AS LISTED BELOW

Patientrsquos name ________________________________________ Date of Birth________________________ Address___________________________________________________________________________________ Telephone ____________________________________________________________________________________ Provider or facility authorized to release information ______________________________________________ Person or entity authorized to receive information ___DeArment Endocrinology LLC__________

2800 Market Street Camp Hill PA 17011 Fax 717-303-3589

Dates of Service 1048709 All 1048709 Specific Dates of Service __________________________________

Description of information 1048709 Entire Record Other ___________________________________ Special Records Include the following medical records if such information is included in your records Checking the boxes is not a representation that such information exists (See waiver below) 1048709 Include Drug and Alcohol Treatment Records (protected by the Pennsylvania Drug amp Alcohol Abuse Control Act 71 PS sect 1690108) 1048709 Include Mental Health Records (protected by the Mental Health Procedures Act 50 PS sect 7111) 1048709 Include AIDSHIV - Related Records (protected by Confidentiality of HIV-Related Information Act 35 PS sect 7607) 1048709 Include Sexual AbuseAssault and Domestic Violence Counseling Records (protected by 42 PaCSA sect 59451 and 23 PaCSA sect 6116 respectively)

Purpose of Release of Information

1 This authorization will expire 1048709 Date____________ 1048709 Event _______________________________ 1048709 One year Unless otherwise specified this authorization will expire 1 year after the date of this request

2 I understand that I may revoke this authorization at any time by notifying my provider or by notifying the provider or entity that is authorized to receive these records I understand that revocation will not have any effect on actions taken prior to any revocation

3 This authorization is voluntary 4 I understand that if the organization authorized to receive the information is not a health plan or a health care provider t he

information may no longer be protected by federal privacy regulations I also understand that this information may be rereleased and no longer protected

5 By signing below I certify that I understand the nature of this Release 6 If mental health records are being released as permitted by the Mental Health Procedures Act I understand that I have a

right subject to 55 Pa Code sect 510033 to inspect the material to be released 7 If AIDS or HIV-related information is being released this information has been disclosed to you from records protected

by Pennsylvania law Pennsylvania law prohibits you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or is authorized by the Confidentiality of HIV-Related Information Act A general authorization for the release of medical or other information is not sufficient for this purpose

8 By signing below I authorize the release of the medical information requested and specifically waive the confidentiality protection afforded by Pennsylvania statutory law for the Special Records indicated above

This waiver is applicable only to this request and is not meant to be a general waiver

_____________________________________________________ ____________________________________ Signature of Patient or Patientrsquos RepresentativeGuardian Date Printed Name of Patientrsquos Representative ___________________________ Relationship to the Patient____________

Patient Signature Authorization (Medicare Patients)

_____________________________________________ _____________________________________________

Name of Beneficiary Health Insurance Claim Number ldquoI request that payment of authorized Medicare benefits be made either to me or on my behalf to DeArment Endocrinology LLC for any services furnished to me by that provider of service or supplier I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related servicesrdquo _________________________________________________ _______________________________ Beneficiary Signature Date

Medigap Patient Signature Authorization (Medicare and Medicaid Patients)

____________________________________ ___________________________________ ______________________________________ Name of Beneficiary Health Insurance Claim Number Medigap Policy Number ldquoI request that payment of authorized Medigap benefits be made either to me or on my behalf to DeArment Endocrinology LLC for any services furnished to me by that provider of service and (or) supplier I authorize any holder of Medicare information about me to release to ___________________________________________________________ (Name of Medigap Insurer) any information needed to determine these benefits payable for related services _________________________________________________ _______________________________ Beneficiary Signature Date

Acknowledgement-of-Receipt-of-Notice-of-Privacy-Practices--

IacknowledgethatIreceivedtheNoticeofPrivacyPracticesforDeArmentEndocrinologyLLC____________________________________________PatientrsquosName____________________________________________ ________________________________PatientrsquosSignature DateofReceipt(orpatientrsquospersonalrepresentative)Personal-representative-information-(if-applicable)-__________________________________________ _____________________________________PersonalRepresentativersquosName RelationshiptoPatient

(orotherauthority)

Disclosure-of-Personal-Health-Information--

I-authorize-my-personal-health-information-my-be-disclosed-to-the-following-individual(s)-and-acknowledge-that-I-have-the-right-to-add-or-remove-any-names-on-this-list-at-any-time---Name Relationship EffectiveDate--Name Relationship EffectiveDate--Name Relationship EffectiveDate--Name Relationship EffectiveDate--Name Relationship EffectiveDate

copy 2012 Stevens amp Lee

1

NOTICE OF PRIVACY PRACTICES

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

Effective 112012

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about your health is personal We are committed to protecting medical information about you This notice applies to all of the records of your care generated by the COVERED ENTITY This notice tells you about the ways we may use and disclose medical information about you We also describe your rights and certain obligations we have regarding the use and disclosure of medical information We are required by law to

diams Make sure that medical information that identifies you is kept private diams Give you this notice of our legal duties and privacy practices with respect to medical information

about you and diams Follow the terms of the notice that is currently in effect

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe different ways that we use and disclose medical information For each category of uses or disclosures we will explain what we mean and try to give some examples Not every use or disclosure in a category will be listed However all of the ways we are permitted to use and disclose information will fall within one of the categories For Treatment We may use medical information about you to provide you with medical treatment or services We may disclose medical information about you to other health care providers and facilities that provide your with treatment services For Payment We may use and disclose medical information about you so that payment may be made for the treatment or services you receive We will use your PHI in our billing departments and disclose your PHI to insurance companies hospitals physicians and health plans for payment purposes or to third parties to assist us in creating bills claim forms or getting paid for our services For Health Care Operations We may use and disclose medical information about you for health care operations These uses and disclosures are necessary to run the COVERED ENTITY and to help ensure quality care For example we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you Business Associates We may disclose medical information to ldquobusiness associatesrdquo who provide contracted services for us if it is necessary If we do disclose medical information to a business associate we will do so subject to an agreement that provides that the information will be kept confidential


2

Appointment Reminders We may use and disclose medical information to contact you as a reminder of an appointment for treatment or medical care Unless you object we may leave a message on an answering machine to contact you or provide you with appointment reminders No details regarding your diagnosis or treatment will be left on an answering machine Individuals Involved in Your Care or Payment for Your Care Unless you object we may release medical information about you to a friend or family member who is involved in your medical care We may also give information to someone who is involved in payment for your care OTHER USE AND DISCLOSURES THAT MAY BE MADE WITHOUT YOUR AUTHORIZATION As Required by Law We will disclose medical information about you when we are required to do so by federal state or local law Public Health Risks We may disclose information about you for public health activities These activities generally include the following

bull Prevent or control disease injury or disability bull Report births and deaths bull Report child abuse or neglect bull Report reactions to medications or problems with products bull Notify people of recalls of products they may be using bull Notify a person who may have been exposed to a disease or may be at risk for

contracting or spreading a disease or condition bull Notify the appropriate government authority if we believe a patient has been the victim

of abuse neglect or domestic violence We will only make this disclosure if you agree or when required or authorized by law

Health Oversight Activities We may disclose medical information to a health oversight agency for activities authorized by law These oversight activities include for example audits investigations inspections and licensure These activities are necessary for the government to monitor the health care system government programs and compliance with civil rights laws Lawsuits and Disputes We may disclose medical information about you in response to a court or administrative order We may also disclose medical information about you in response to a subpoena discovery request or other lawful process by someone involved in the dispute but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested Law Enforcement We may release medical information if asked to do so by a law enforcement official

bull In response to a court order subpoena warrant summons or similar process bull To identify or locate a suspect fugitive material witness or missing person bull About the victim of a crime if under certain limited circumstances we are unable to

obtain the persons agreement bull About a death we believe may be the result of criminal conduct bull About criminal conduct at the COVERED ENTITY and bull In emergency circumstances to report a crime the location of the crime or victims or

the identity description or location of the person who committed the crime


3

Coroners Medical Examiners and Funeral Directors We may release medical information to a coroner medical examiner or funeral directors under certain circumstances if it is necessary for them to carry out their duties Organ and Tissue Donation If you are an organ donor we may release medical information to organizations that handle organ procurement or organ eye or tissue transplantation or to an organ donation bank as necessary to facilitate organ or tissue donation and transplantation Research In most cases we will ask for your written authorization before using your information or sharing it with others in order to conduct research Under some circumstances we may use and disclose your health information without your authorization if we obtain approval through a special approval process to ensure that any disclosures for research pose a minimal risk to your privacy Under no circumstances would we allow researchers to use your name or identity publicly To Avert a Serious Threat to Health or Safety We may use and disclose medical information about you when we determine it is necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person Any disclosure however would only be to someone able to help prevent the threat Military and Veterans If you are a member of the armed forces we may release medical information about you as required by military command authorities We may also release information to components of the Department of Veterans Affairs to determine whether you are eligible for certain benefits National Security and Intelligence Activities We may release medical information about you to authorized federal officials for intelligence counterintelligence and other national security activities authorized by law Workers Compensation We may release medical information about you for Workers Compensation or similar programs These programs provide benefits for work-related injuries or illness State Confidentiality Laws Certain state laws may provide greater privacy protections for some health information such as information related to HIV status We will use and disclose your health information only in accordance with these more restrictive laws


4

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU You have the following rights regarding medical information we maintain about you Right to Inspect and Copy You have the right to inspect and to receive a copy of medical information that may be used to make decisions about your care You must submit your request in writing to The Privacy Officer If you request a copy of the information we may charge a fee for the costs of copying mailing or other supplies we use to fulfill your request We will ordinarily respond to your request within 30 days We may deny your request to inspect and copy in certain very limited circumstances We will inform you if your request is denied for any reason and will let you know what other rights you may have Right to Amend If you feel that medical information we have about you is incorrect or incomplete you may ask us to amend the information To request an amendment your request must be made in writing and submitted to The Privacy Officer In addition you must provide a reason that supports your request If your request for amendment is denied we will let you know the reason and what further rights you may have Right to an Accounting of Disclosures You have the right to request an accounting of disclosures This is a list of the disclosures we made of medical information about you The list does not include uses and disclosures that have been made for treatment payment or health care operations disclosures that were made to you or with your authorization or consent or disclosures that are incidental to other permissible disclosures (such as someone overhearing a conversation between you and your doctor) To request this list or accounting of disclosures you must submit your request in writing to The Privacy Officer Your request must state a time period which may not be longer than six years Right to Request Restrictions You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment payment or health care operations We will abide by any request not to disclose information to a health plan for purposes of carrying out payment or health care operations provided that such medical information pertains solely to a service that we have provided and for which you have paid us directly in full We are not otherwise required to agree to your request to restrict disclosures for treatment payment or health care operations although we will consider your request and will abide by any restrictions that we agree to Right to Request Confidential Communications You have the right to request that we communicate with you about medical matters in a certain way or at a certain location To request confidential communications you must make your request in writing to the Privacy Coordinator at Medical Center We will accommodate reasonable requests Your request must specify how or where you wish to be contacted Right to a Paper Copy of This Notice You have the right to a paper copy of this notice You may ask us to give you another copy of this notice at any time Right to Notice if Your Health Information is Breached If the privacy andor security of your health information is compromised in a manner that creates a significant risk of financial reputational or other harm we will provide you with written notice of the breach


5

CHANGES TO THIS NOTICE We reserve the right to change this notice We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future We will post a copy of the current notice in the COVERED ENTITY The notice will contain on the first page in the top right-hand corner the effective date COMPLAINTS

If you believe your privacy rights have been violated you may file a complaint with us or with the Department of Health and Human Services Office of Civil Rights You will not be penalized for filing a complaint

OTHER USES OF MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission If you provide us permission to use or disclose medical information about you you many revoke that permission in writing at any time If you revoke your permission we will no longer use or disclose medical information about you for the reasons covered by your written authorization You must understand that we are unable to take back any disclosures we have already made with your permission

If you have any questions about this notice wish to obtain a copy of this notice or wish to make a complaint regarding our privacy practices please contact our Privacy Officer at

DeArment Endocrinology LLC

2800 Market Street Camp Hill PA 17011

2800 Market Street Camp Hill Pennsylvania 17011

Tel (717) 303-3588 Fax (717) 303 3589

Patient Information Sheet Date _____________________ New Updated

Patient Name ________________________________________ _____ ________________________________________________ First Name MI Last Name

SS _________ - ______ - ______________ Date of Birth _______________ Age ________ Gender Male Female

Address ________________________________________________________ City __________________________________ State _______ ZIP _____________


(Cell) (_______) ________ - ______________ (email) _________________________________________________

Employer Name ____________________________________________________ Telephone (_______) ________ - ____________

Address _____________________________________________________ City ____________________________ State ______ ZIP ___________

Marital Status Single Married Divorced Widowed Separated

If Married Spousersquos Name _________________________________________ ___________ ___________________________________________________ First Name MI Last Name

Telephone (Cell) (_______) ________ - ______________ (Work) (_______) ________ - ______________ Ext ________

Emergency Contact _____________________________________________________ Relationship _____________________________________________

Telephone (Home) (_______) ________ - ______________ (Work) (_______) ________ - ______________ Ext ________

(Cell) (_______) ________ - ______________

May we leave a message regarding your medical care at your home Yes No on your work voicemail Yes No on your cell phone voicemail Yes No

Minor Patient Information ndash If Patient is a minor (under 18 years of age) please complete the following

Motherrsquos Name _______________________________________________ ___________ _________________________________________________________ First Name MI Last Name


(Cell) (_______) ________ - ______________

Fatherrsquos Name _______________________________________________ ___________ ___________________________________________________________ First Name MI Last Name


(Cell) (_______) ________ - ______________

Who has legal custody of the patient Both parents Mother Father Guardian (if Guardian complete the following)

Guardianrsquos Name ____________________________________________ ___________ ___________________________________________________________ (First Name) MI (Last Name) Address _____________________________________________________ City ____________________________ State ______ ZIP ______ ______


(Cell) (_______) ________ - ______________

Referral Information Referred by __________________________________________________________________________________________________ (Referring Physicianrsquos Name)

Have you had information from another DrFacility forwarded to this office Yes No -If yes from whom _______________________________

AUTHORIZATION

bull I hereby authorize DeArment Endocrinology LLC to furnish information to any insurance carriers concerning my medical condition and I hereby irrevocably assign DeArment Endocrinology LLC any payment for services rendered

bull I understand that I am responsible for all charges whether or not covered by insurance bull I certify that this information is accurate and current as of this date

SIGNATURE ________________________________________________________________________________ DATE __________________________________________________

Date









Surgeries














If yes what kind





Yes No



Father Children M F

Mother M F

Sibling M F M

F

M F M

F

M F Grandmother

Maternal

M F Grandfather

Maternal

M F Grandmother

Paternal

M F Grandfather

Paternal

























_____________________________________________ _____________________________________________






(orotherauthority)




1




Effective 112012







2










3



4



5







Date









Surgeries














If yes what kind





Yes No



Father Children M F

Mother M F

Sibling M F M

F

M F M

F

M F Grandmother

Maternal

M F Grandfather

Maternal

M F Grandmother

Paternal

M F Grandfather

Paternal

























_____________________________________________ _____________________________________________






(orotherauthority)




1




Effective 112012







2










3



4



5















If yes what kind





Yes No



Father Children M F

Mother M F

Sibling M F M

F

M F M

F

M F Grandmother

Maternal

M F Grandfather

Maternal

M F Grandmother

Paternal

M F Grandfather

Paternal

























_____________________________________________ _____________________________________________






(orotherauthority)




1




Effective 112012







2










3



4



5
























_____________________________________________ _____________________________________________






(orotherauthority)




1




Effective 112012







2










3



4



5









(orotherauthority)




1




Effective 112012







2










3



4



5








1




Effective 112012







2










3



4



5








2










3



4



5








3



4



5








4



5








5







new!patient!information!packet! - dearment endo patient packet.pdf · 2017-03-03 · list any...

Documents