__________________________________ _____/_____/__________

Patient’s First and Last Name Date of Birth

ADULT MEDICAL HISTORY FORM

PRESENT HEALTH CONCERN (Reason for today’s visit.) ______________________________________________ __________________________________________________________________________________________________

ALLERGIES List all allergies to medications. Medication Side Effect or Allergic Reaction

MEDICATIONS List all prescription medications, nonprescription medications, vitamins, and birth control pills. Medication/Other Dose How Many Times Per Day

PERSONAL MEDICAL HISTORY Mark the following medical issues or conditions that you have experienced. oFainting Spells oSeizures oTremors/Shakes oNumbness in Hands/Feet oBroken Bones oMuscle Pain oScoliosis oWeight Issues oStroke oMemory Problems oHeadaches oDizziness oMental Health Issues oADHD oAnxiety oDepression oAlcoholism

oDrug Addiction oSuicide Attempt oFatigue oWeakness oSleeping Issues oIssues with Urination oBlood in Urine oKidney Stones oKidney Issues oConstipation oDiarrhea oHemorrhoids oBlood in Stool oColon Polyps oAbdominal Pain oAppetite Issues oDigestion Issues

oProblems Swallowing oReflux oSexual Dysfunction oWheezing/Cough oShortness of Breath oAsthma oAllergies oThyroid Problems oDiabetes oIncreased Thirst oPain in Joints oBack Pain oChest Pain oOsteoporosis oPalpitations oHeart Attack oBypass/Stent Surgery

oBleeding/Clotting Issues oAnemia oBlood Transfusion oHigh Blood Pressure oHigh Cholesterol oLeg Swelling oVision Problems oHearing Problems oRinging in Ears oProblems with Teeth oSinus Problems oHoarseness oSkin Issues oFever oNausea or Vomiting oCancer, Type/Age oOther ______________

WOMEN’S GYNECOLOGIC HISTORY # of Pregnancies _________ # of Deliveries _________ # of Abortions __________ # of Miscarriages _________ 1st Day Most Recent Period _________ Period Frequency _______ Period Length _______ Age at 1st Period _________ Period Abnormalities o Yes o No Explain: ____________________________________________________________ Last Pap Smear Date ________________ Abnormal Pap Smear History o Yes o No Menopause Issues o Yes o No Explain: _______________________________________________________________ History of Breast Lumps o Yes o No Nipple Discharge o Yes o No Last Mammogram Date _______________ Abnormal Mammogram History o Yes o No Colonoscopy o Yes o No Abnormal Colonoscopy o Yes o No

MEN’S HISTORY Ever Had Prostate Cancer Screening o Yes o No Colonoscopy o Yes o No Abnormal Colonoscopy o Yes o No Ever Had a Prostate Blood Test (PSA) o Yes o No Abnormal Prostate Blood Test o Yes o No

__________________________________ _____/_____/__________ Patient’s First and Last Name Date of Birth

SURGICAL, HOSPITALIZATION AND MEDICAL ILLNESS HISTORY

Surgery, Hospitalization, and/or Medical Illness Date FAMILY HISTORY Mark the following medical issues or conditions that any of your family members have experienced. Specify if it is mom, dad, brother, sister, child, or other blood relative. oCancer, type/age oHigh Cholesterol oHigh Blood Pressure oEarly Heart Attack, specify age oBypass/Stent Surgery, specify age

oHeart Disease

oBleeding/Clotting Issues oStroke

oSeizures oMental/Emotional Issues oDepression oAnxiety oAlcoholism oDrug Addiction oThyroid Abnormalities oKidney Disease

oDiabetes o Type 1 o Type 2 oArthritis oAsthma oAllergies oSickle Cell o Other_________________

PERSONAL HEALTH AND SOCIAL HISTORY Lifestyle Exercise Regularly o Yes o No Regularly Eat Nutritious Meals o Yes o No Fill in the Number Indicating the Stress Level in Your Life (Not Stressful) � � � � � (Very Stressful) Feel Sad or Depressed Often o Yes o No Describe _____________________________________________________ Substances Cigarettes o Quit, Date ____________ o Never o Current Smoker, Packs/Day _______ # of Years __________ o Pipe o Snuff o Cigar o Chew Interested in Quitting o Yes o No Drink Alcohol o Yes o No If Yes, # of Drinks Per Day _______________________________________________ Use Any Recreational Drugs o Yes o No If Yes, Specify and How Often ___________________________________ Ever Used Needles o Yes o No Contraception Birth Control Method _________________________________________________ o None Needed If Sexually Active Do You Practice Safe Sex o Yes o No Do You Have a Sexually Transmitted Disease o Yes o No Interested in Being Screened for Sexually Transmitted Diseases (STDs) o Yes o No IMMUNIZATIONS Circle the immunizations you have received and list the date they were administered. Tetanus Pneumonia HPV Shingles Hepatitis A Hepatitis B Chicken Pox Influenza OTHER Advanced Directive or Living Will o Yes o No Medical/Mental Power of Attorney o Yes o No If Yes, Who Is Designated ____________________________ Contact Information_____________________________ I hereby certify that the above information is true and correct to the best of my knowledge. Patient/Representative Name (Print) _______________________________ Relationship to Patient _________________ Signature ____________________________________________________ Date ________/_________/____________ 1/7/14

                                 PATIENT  INFORMATION  FORM    

 

PATIENT  DEMOGRAPHICS    

Last  Name:__________________________  First:  ____________________________Middle:________________________  Date  of  Birth:    ________/_________/______________                              Social  Security  #:_________-­‐_________-­‐_____________    

Sex:        Male              Female                              Marital  Status:        Single        Married      Partnered        Divorced        Widowed        Separated        Other    

Home  Address:  _____________________________________________________________________________________  City:  ____________________________________          State:___________________          Zip  Code:  ______________________  2nd  Seasonal  Address:  ________________________________________________________________________________  City:  ____________________________________          State  ___________________            Zip  Code:  _____________________  Home  Phone:  _____________________          Cell  Phone:  _______________________      Email:  ________________________  Occupation:  ___________________________________                      Status:      Full  Time      Part  Time          Retired          Student          Other  Employer:  _______________________________________________                Work  Phone:  ____________________________  Employer  Address:    __________________________________________________________________________________  Preferred  Pharmacy:  ______________________________________          Phone  #:  _________________________________    How  did  you  hear  about  our  practice:  ___________________________________________________________________    

RESPONSIBLE  PARTY                                            RELATION  TO  PATIENT        Self      Spouse      Parent      Legal  Guardian      Other  Last  Name:__________________________  First:  ____________________________Middle:________________________  Date  of  Birth:    _________/__________/_____________     Social  Security  #:_________-­‐_________-­‐____________  Home  Address:  _____________________________________________________________________________________  City:  ____________________________________          State:___________________          Zip  Code:  ______________________  Home  Phone:  _____________________          Cell  Phone:  _______________________      Email:  ________________________  Occupation:  ___________________________________                      Status:      Full  Time      Part  Time          Retired          Student          Other  Employer:  _______________________________________________                Work  Phone:  ____________________________  Employer  Address:    __________________________________________________________________________________    

EMERGENCY  INFORMATION  In  case  of  emergency  notify:  _______________________________        Relation:  __________________________________  Home  Address:  _____________________________________________________________________________________  City:  ____________________________________          State:___________________          Zip  Code:  ______________________  Home  Phone:  _____________________          Cell  Phone:  _______________________      Email:  ________________________    

INSURANCE  INFORMATION                Please  provide  your  current  insurance  card.  PRIMARY  INSURANCE             SECONDARY  INSURANCE  Insurance  Name:  ____________________________________     Insurance  Name:  ____________________________________  Policy  ID  #:  _________________________________________     Policy  ID  #:  _________________________________________  Group/Account#:    ___________________________________     Group/Account#:    ___________________________________  Cardholders  Name:      _________________________________     Cardholders  Name:      _________________________________  DOB:  _________________    SSN:    _______________________     DOB:  _________________    SSN:    _______________________  Relation  to  Patient:      _________________________________     Relation  to  Patient:      _________________________________    I  hereby  certify  the  above  information  is  true  and  correct  to  the  best  of  my  knowledge.    I  understand  that  while  Desert  Wells  Family  Medicine  contracts  with  many  insurance  companies,  it  is  my  responsibility  to  verify  with  my  plan  that  Desert  Wells  Family  Medicine  is  a  participating  provider.    It  is  also  my  responsibility  to  find  out  what  my  coverage  options  and  benefits  are  with  my  insurance  plan.    I  hereby  authorize  Desert  Wells  Family  Medicine  to  submit  insurance  claim  forms  along  with  medical  records  necessary  to  obtain  payment  from  my  insurance  company.    I  understand  that  I  am  responsible  for  all  charges  regardless  of  insurance  coverage.    I  acknowledge  that  photo  IDs  taken  are  used  to  assist  in  patient  recognition  per  HIPAA  guidelines.    SIGNED:  ________________________________________________________     DATE:  __________________________________________    WITNESS  SIGNATURE:  _____________________________________________     DATE:  __________________________________________                                                                                          1/7/14  

SICK VISITS VS. WELL VISITS OR BOTH?

SICK VISIT This is an office visit for an acute problem or flare-up of a chronic problem. This could also be an office visit to follow-up on chronic problems (Diabetes, Cholesterol, Blood Pressure, etc.).

WELL VISIT This is an office visit for a routine physical exam or yearly health maintenance exam.

SICK/WELL VISIT This is a combination visit of a routine physical exam where an acute or chronic issue is addressed as well. For example, if you presented today for a well visit and you have an acute or chronic issue you would like addressed, it is considered a combination visit and must be billed differently than just a well visit or just a sick visit.

WHY IT IS BILLED DIFFERENTLY It is billed differently to account for the additional work, expertise and time required for a combination visit (additional lab work, x-ray, referrals and/or prescription medications). It involves additional documentation as well. For example, think about taking your vehicle in for an oil change (routine maintenance), and mentioning to the mechanic that your brakes are squeaking and your windshield wipers are not working well. In addition to the oil change, you might require additional brake work if a problem was found, and replacement windshield wipers. Since additional services were provided, you would be charged more than just for the oil change.

HOW THIS AFFECTS ME Although many insurance companies acknowledge the sick/well visit combination, some of them still require the patient to pay two co-pays or have additional costs applied to his/her annual deductible.

ANNUAL PHYSICAL EXAMS Annual physical exams target preventative care and are billed as such. Medication refills and/or other ailments, injuries, or illnesses addressed during an annual physical exam are billed IN ADDITION to the annual physical. These charges may be passed on to the patient. Please check with your insurance company to confirm your coverage for all types of doctor visits.

We realize this can be confusing, and if you have any questions or concerns after reviewing this material, please ask.

_______________________________________ __________________________________ Print Patient’s Name Patient’s Signature

_______________________________________ __________________________________ Date of Birth Today’s Date

1/7/14

PAYMENT POLICY

Thank you for choosing us as your primary care provider. We are committed to providing you with quality health care. Please read this payment policy, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request. INSURANCE Desert Wells Family Medicine contracts with many insurance companies. It is the patient’s responsibility to verify with their plan that Desert Wells Family Medicine is a participating provider. It is also the patient’s responsibility to find out what coverage options and benefits are with your insurance plan. Desert Wells Family Medicine will submit insurance claim forms along with the medical records necessary to obtain payment from your insurance company. The patient is responsible for all charges regardless of insurance coverage. If you are not insured by a plan we are contracted with, payment in full is due at each visit. If you are insured by a plan we are contracted with, but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Please contact your insurance company with any questions you may have regarding your coverage.

CO-PAYMENTS AND DEDUCTIBLES All co-payments must be paid at the time of service. Deductibles must be paid upon receipt of the invoice. A $40 fee will be charged in the event of a returned check. NON-COVERED SERVICES Please be aware that any services considered to be a non-covered benefit by your insurance will be your financial responsibility.

PROOF OF INSURANCE We must obtain a copy of your current insurance card. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.

CLAIMS SUBMISSION We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly to them. It is your responsibility to comply with their request. NONPAYMENT Please be aware that if a balance remains unpaid, we may refer your account to a collection agency, and you and your immediate family members may be discharged from the practice. MISSED AND LATE APPOINTMENT POLICY Our office has a 24 business hour cancellation policy, otherwise there will be a $30 fee billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment.

I have read and understand the payment policy and agree to abide by its guidelines.

_________________________ Patient’s Name (Print)

_________________________ Date of Birth

_________________________ Patient’s Signature

_________________________ Today’s Date

CONSENT FOR PHONE CONTACT Desert Wells Family Medicine MAY leave a voice mail message for me on my:

oYes Home Phone: _________________________________ oYes Cell Phone: __________________________________ oYes Work Phone: _________________________________ oYes Other (specify): _______________________________ oNever leave any medical information on any voice mail message for me, simply ask me to call back. Please note, this does not apply to messages regarding unpaid bills.

Desert Wells Family Medicine MAY discuss medical information regarding me with:

o Yes My husband/wife/partner (Name/Relationship): __________________________________________________ o Yes Power of Attorney (Name/Relationship): __________________________________________________ o Yes Other (Name/Relationship): __________________________________________________

__________________________________________ __________________________________________ Patient’s Signature (Parent or Legal Guardian If a Minor) Date 1/03/2014

20715 E. Ocotillo Road, Suite 102 Queen Creek, AZ 85142

Tel: 480-987-0987 Fax: 480-987-0940

NOTICE OF PRIVACY POLICY FOR PROTECTED HEALTH INFORMATION (PHI)

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. How we may use and disclose medical information about you: TREATMENT We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other practice personnel who are involved in your medical care and treatment. PAYMENT We may use and disclose medical information about you so that the treatment and services which we provide to you at our practice may be billed to you, and payment may be collected from you and/or your insurance company or other responsible third party. HEALTH CARE OPERATION We may use and disclose medical information about you for our practice operations. These uses and disclosures are necessary to operate our practice and make sure that all of our patients receive quality care. EMERGENCIES We may use or disclose your medical information in an emergency treatment situation. WORKERS’ COMPENSATION We may release medical information about you to comply with worker’s compensation laws or similar programs. WHO HAS ACCESS TO THIS INFORMATION Any person or persons you designate in writing, people directly involved in your medical care, and/or people creating and maintaining your medical record. YOUR RIGHTS You have the right to inspect your Protected Health Information. You also have the right to amend any errors you may find in your records. COMPLAINTS If you have any complaints concerning our privacy practices, you may contact the Secretary of the Department of Health and Human Services. All complaints must be made in writing. To file a complaint with the practice contact the office manager at (480) 987-0987. This practice reserves the right to amend our privacy policy as dictated by law, without sending you a copy of the amendment. Any changes to this policy will be posted in our office. This notice is effective as of January 31, 2003. I understand I will be provided a copy of the Privacy Policy upon request. _________________________________________ ____________________________

Print Patient Name Patient Date of Birth

________________________________________ ____________________________ Signature of Person Authorizing Consent Date

1/7/2014