patient · last na me first name middle name pre vious last nickname ... please list any health...

LAST NAME FIRST NAME MIDDLE NAME PREVIOUS LAST NICKNAME

SOCIAL SECURITY BIRTHDATE SEX

BILLING ADDRESS STREET CITY STATE ZIP CODE

COUNTY RACE LANGUAGE ETHNICITY

MARITAL STATUS PRIMARY CARE PROVIDER

HOME PHONE NUMBER DAY PHONE NUMBER CELL PHONE NUMBER

ALTERNATE PHONE FOR EMERGENCY E-MAIL

PAYER NAME

ADDRESS CITY STATE ZIP CODE

PLAN NUMBER POLICY NUMBER

GROUP NAME GROUP NUMBER EFFECTIVE DATE

SIGNATURE DATE

Patient

Insurance

Neal Anson, M.D.Lori Baughman, M.D.Heather Doss, M.D. Kyle Schneweis, M.D.

Jay Patel, D.O.Sheila Owens, M.D.

Rebecca Fisher, M.D.Elizabeth Gerstner, M.D.

Brian Gillenwater, D.O.

Ryan Huyser, M.D.Adam Harrold, M.D.

Robin Morris, M.D. Yvonne Spurlock, D.O.Paula Brown, APRN-BC

2609 Glenn Hendren Drive, Liberty, Missouri 64068 P 816-781-7730 F

816-781-7550 www. thelibertyclinic.com

LIBERTYT H E

C L I N I CAn a�liate of Liberty Hospital

TLC-004

Guarantor: Person Responsible for this Account

LAST NAME FIRST NAME MIDDLE NAME PREVIOUS LAST NICKNAME

SOCIAL SECURITY BIRTHDATE SEX

BILLING ADDRESS STREET CITY STATE ZIP CODE

COUNTY RACE LANGUAGE ETHNICITY

MARITAL STATUS PRIMARY CARE PROVIDER

HOME PHONE NUMBER DAY PHONE NUMBER CELL PHONE NUMBER

INSURANCE HOLDER YES NO

CHECK IF ADDRESS IS SAME AS PATIENT









LIBERTYT H E


TLC-004 2

Comprehensive Health HistoryPATIENT FULL LEGAL NAME DATE OF BIRTH

Home Phone Cell Phone Occupation

Marital Status Work Phone Employer

Spouse’s Legal Name Total years of education completed

Number of children At home Outside of home

What current concerns do you have about your health?

FEMALES MALES

Date of last pap Date of last prostate exam

Date of last breast exam Date of last PSA blood test

Date of last mammogram

Menstrual age onset regular irregular pain/cramps LEARNING PREFERENCES

Menopause? yes no age What is your learning preference verbal written

# of pregnancies live births miscarriages abortions Do you have any learning barriers? yes no

Form of birth control What are those barriers?

PEDIATRIC (under 18 years old only) Mother’s Name

Birth history vaginal c-section single birth multiple birth birth order Phone

Please indicate any complications during mother’s pregnancy or birth Father’s Name

Was your home built prior to 1977? yes no How long have you lived in this area? Phone

WELLNESS

Date of last colonoscopy Date of last flu vaccine shot nasal spray

Date of last vision exam Date of last Tetanus shot

Date of last cholesterol blood test Do you wear a seatbelt? yes no

Was it abnormal or high? yes no Do you wear sunscreen? yes no

Do you have seasonal allergies? yes no Do you practice safe sex? yes no

Any firearms in the home? yes no Do you exercise regularly? yes no

Have you ever, or do you:

SMOKE yes no Packs per day Year quit Any smokers in the home? yes no

SMOKELESS TOBACCO yes no quit How much? Year quit

DRINK ALCOHOL yes no What forms? Quantity Frequency

ILLICIT DRUGS yes no What forms? Quantity Frequency

ALLERGIES (medication & food) No known medication allergies No known food allergies

List all medication and food allergies, please identify reaction

Are you allergic to latex or latex based products? yes no unknownTLC-012 1









LIBERTYT H E


PATIENT FULL LEGAL NAME DATE OF BIRTH

MEDICATIONS

Medication Dose How often do you take Medication Dose How often do you take

FAMILY HISTORY

Are your parents living? Mother yes no Father yes no Cause of death?

Please list any health conditions/serious illnesses that your mother, father, sister(s) or brother(s) have or have been told they have

had in the past (i.e. diabetes, heart condition, high blood pressure, stroke, high cholesterol, cancer, thyroid, etc.)

Father

Mother

Sister(s)

Brother(s)

PATIENT PAST MEDICAL

Allergies CHF Immune system disorder

Anemia COPD (Chronic Obstructive Pulmonary Disease) Irritable bowel disease

Angina (chest pain) Coronary artery disease Liver disease

Anxiety Crohn’s disease Migraine headaches

Arthritis Depression Myocardial infarction (heart attack)

Asthma Diabetes Osteoarthritis

Atrial fibrillation Gallbladder Disease Osteoporosis

Benign Prostatic Hypertrophy GERD or chronic heartburn Peptic ulcer disease

Blood clots location Hepatitis A B C Renal (kidney) disease

Cancer location Hyperlipidemia (high cholesterol) Seizure disorder

Cerebrovascular accident (stroke) Hypertension (high blood pressure) Thyroid high low other

Other

PATIENT PAST SURGICAL

Angioplasty (heart cath) year Cataract extraction year Lasik year

Angio (heart cath) w/stent year Gallbladder surgery year Liver biopsy year

Appendectomy year Colectomy (colon resection) year ORIF (fracture repair) year

Arthroscopy knee year Colostomy year Pacemaker year

Back surgery year Gastric bypass year Small bowel resection year

CABG (heart bypass) year Hernia repair year Thyroidectomy year

Carpal tunnel release year Hip/Knee replacement year Tonsillectomy year

Other

PATIENT PAST SURGICAL Women only

Augmentation mammoplasty (implants) year D & C year Myomectomy (Fibroidectomy) year

Bilateral tubal ligation year Hysterectomy (abdominal) year Reduction mammoplasty year

Breast Biopsy year Hysterectomy (vaginal) year Oopherectomy (ovary removal) year

Cesarean Section year Mastectomy year TAH/BSO year

Other

PATIENT/PARENT/GUARDIAN SIGNATURE DATE

I hereby allow The Liberty Clinic to disclose the following information. (check all that apply) This form does not authorize releasing copies of my medical records.

Appointment times and dates Medical information, including my symptoms, diagnosis, medications and treatment plan Tests that have been performed Test results Billing/payment information

Other health information (describe)_____________________________________________To the following people who are involved with my healthcare and/or payment information: (check all that apply and list names and telephone numbers) Spouse_________________________________________ Phone:__________________ Friend____________________________________________ Phone:__________________ Child(ren)_________________________________________ Phone:__________________ Other_____________________________________________ Phone:__________________

Can confidential messages (i.e. appointment information, prescription information, test results) be left on your answering machine or voicemail? (circle how you wish to receive messages, and provide the phone number) No, DO NOT leave any messages Yes, at home, cell phone or work: Home Phone:__________________

Cell Phone:__________________Work Phone:__________________ Yes, only at home Home Phone:________________________________ Yes, only on cell phone Cell Phone:_____________________________

I understand that in certain situations The Liberty Clinic may speak to other individuals who are involved in my care or payment of that care, if permitted by law, that may not be identified on this form.

I understand that I have the right to revoke (stop) my permssion at any time.

Patient Name (please print):_____________________________________ Date of birth:______________

Patient/Guardian Signature:_______________________________________Date:___________________

If patient is a minor, please complete the following information:Mother’s name/contact number:__________________________________________________________Father’s name/contact number:___________________________________________________________

Permission to Disclose Information to �ose Involved in My Care









LIBERTYT H E


Patient Name

Pediatrics I parent/guardian of hereby give permission for the following individual(s) to pick up perscriptions for my child. To ensure proper handling of all controlled substances, I understand they/I will be required to show proper photo identification each time.

1.

2.

3.

4.

Adults I hereby give permission for the following individual(s) to pick up my perscriptionsin my absence. To ensure proper handling of all controlled substances, I understand they/I will be required to show proper photo identification each time.

1.

2.

3.

4.

No one other than myself (patient) has permission to pick up my presciptions.

Date of Birth

SIGNATURE DATE

TLC-003









LIBERTYT H E


Financial Policy

1. Fees are due and payable at the time of your appointment. If we are contracted with your insur-ance, you will be billed any remainder after we hear from them. As a courtesy, we accept cash, checks, Visa, Discover, and Master Card.

2. If you have an HMO or PPO insurance with a designated primary care physician, please make

card or information, you will be required to pay the entire fee including any lab services.3. All co-pays must be paid at the time of your service4. Not all services are a covered benefit in all contracts. If you have a question regarding benefits,

insurance policy is a contract between you and your insurance company.5. All services must be paid in full within 30 days after your insurance has paid their portion. If your

visit is due to a Motor Vehicle Accident, payment in full is due at the time of the service. 6. The person who brings a child for care is ultimately responsible for their bill. The physician will

not get involved in court decisions or support disputes.7. Accounts become past due after 30 days. We reserve the right to send an account to collections

if not paid in full8. All returned checks must be paid with cash or money order within 5 working days or they will be

9. 10. All deductibles and co-payments for Obstetric (OB) services must be paid in full by the 7th month

with regular payments due each month by cash, check or credit card.

I hereby acknowledge that I have read, understand, and agree to the terms of this document relating

to insurance coverage and payment of my bill.

PATIENT/GUARDIAN’S SIGNATURE PRINT PATIENT’S NAME & BIRTH DATE DATE

Signature On File

I authorize use of this form on all my insurance submissions. I authorize release of information to all of my insurance companies. I authorize direct payment to The Liberty Clinic. I permit a copy of this authorization to be used in place of the original. I understand I am financially responsible for all

charges whether or not covered by insurance.

SIGNATURE DATE

TLC-005









LIBERTYT H E


patient · last na me first name middle name pre vious last nickname ... please list any health...

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