NEW / WELL PEDIATRIC PATIENT – 11 through 17 YEARS

Please tell us the REASON FOR TODAY’S VISIT or any special concerns to discuss with the doctor today:

__________________________________________________________________________________________________

Please list your child’s CURRENT MEDICIATIONS/VITAMINS/SUPPLEMENTS: Name Dosage (i.e., MG) How Taken (i.e., 1 tablet daily)

Please list any ALLERGIES to medications/foods: Allergy Type of Reaction (i.e., rash, nausea

IMMUNIZATION PREFERENCE (circle one): Traditional Delayed Indefinitely Delayed

Please provide your child’s IMMUNIZATION HISTORY: Yes No Date Yes No Date

Tetanus-Diphtheria Booster Hepatitis A Vaccine Influenza Vaccine (Flu Shot) Hepatitis B Vaccine Pneumococcal Vaccine Human Papilloma Virus (HPV) Tuberculosis (TB) Skin Test Varicella Vaccine

Please provide your child’s PAST MEDICAL HISTORY:

____ ADD/ADHD ____ Bronchiolitis ____ Fracture ____ Prematurity ____ Abdominal Pain ____ Bronchitis ____ GERD (reflux) ____ Pyelonephritis ____ Acne ____ Chicken Pox ____ Headaches ____ Recurrent otitis media ____ Allergic Rhinitis ____ Concussion, CHI ____ Hearing problems ____ Seizure disorder ____ Allergies ____ Congenial heart disease ____ Heart murmur ____ Seizures - febrile ____ Anemia ____ Constipation ____ Menstrual problems ____ UTI ____ Asthma ____ Diabetes ____ Migraines ____ Vesicoureteral reflux____ Bleeding Disorder ____ Eczema ____ Pneumonia __________: Other

For Nurse Use Only: Ht. _____ Wt. _____ Temp. _____ BP. _____ Pulse_____ Resp. _____ SpO2_____ VS; R_____L_____

Name: __________________________ Date of Birth: _____________

Sex: Male_____ Female_____ Today’s Date: _____________________

Accompanying Adult’s Name/Relation: _________________________

Please tell us about any SURGERIES your child has had, indicate the date/year if known:

____ Appendectomy ____ Adenoidectomy __________: Other ____ Inguinal Hernia Repair ____ PET placement ____ Fracture with Small Reduction ____ Lymph node biopsy/excision ____ Dental Surgery ____ Umbilical Hernia Repair ____ Tonsillectomy ____ Hernia repair

Please list any ADDITIONAL PAST MEDICAL OR PAST SURGICAL HISTORY:

_______________________________________________________________________________________________________

Please provide age-appropriate SOCIAL HISTORY:

Please provide additional SOCIAL HISTORY as appropriate:

Do they Smoke? Yes No Former Are they currently sexually active? Yes No Former Type of tobacco: _______________________ Total # of Lifetime Partners: ________________Packs per day: _________________________Years smoked: _________________________ Alcohol consumption? Yes No Former Years quit: ____________________________ Type of alcohol: _________________________Have you ever tried to quit? Yes No Frequency and Amount: ___________________ Job: _________________________________ When was last drink? _____________________Last Grade Completed: ________________________ Use of Illegal drugs? Yes No Former Hours a Day watching TV: _____________________ Type of drug: ___________________________Exercise: #of days/wk: ______ #of hrs./day ______ Frequency and Amount: ___________________Have they seen a counselor? Yes No Do they have an eating disorder? Yes No Former If yes, what for? _____________________________ Do they view pornography? Yes No Former

Other Addictions? ________________________

Primary Residence: Who lives with your child? __________________ ________________________________________

Tobacco Exposure: Are there smokers at home? Yes No If yes, do they smoke outside only? Yes No

Home Environment: What is the age of the home: __________ Is water Chlorinated? Yes No Is water Fluorinated? Yes No Is there lead in the home? Yes No Education: School Name: ____________________________ School Grade: ____________________________ Does child have any learning disabilities? ________________________________________ Does child have any special needs? ________________________________________

#days/wk: _____ days/wk. _____ days/wk. _____ days/wk. _____ days/wk.

Child Care: Who provides care for your child?____ Mother____ Father____ Grandparent____ Other ______________ Day Care _____ days/wk.

Activity: Exercise/Sports: _____ hrs./day TV/Computer Games: _____ hrs./day

Safety: Does child use a car seat? Yes No

If yes, is car seat facing: Front Rear Is there a carbon monoxide detector? Yes No Are smoke detectors in the home? Yes No Are there firearms in the home? Yes No Are there pets in the home? Yes No

If yes, what kind? ____________________________

Sleep: Does child get 8.5 hrs. of sleep? Yes No Does child have sleeping problems? Yes No Does child take naps? Yes No Does child sleep with parents? Yes No Does child sleep through the night? Yes No What position does child sleep in? ______________ ___________________________________________

FOR FEMALES ONLY:

Please provide your child’s FAMILY HISTORY:

FATHER: Alive Deceased Age _____ Reason Deceased? ____________ Health Problems__________________________________________________________________________

MOTHER: Alive Deceased Age _____ Reason Deceased? ____________ Health Problems__________________________________________________________________________

BROTHERS AND SISTERS: (Each one: Are they living? Reason Deceased? Ages? Other health problems?) _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

OTHER: (NAMES AND AGES, Are they living? Reason Deceased? Ages? Other health problems?) _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________

Does anyone in the family have these health conditions? (Please check even if listed above)

HEALTH MAINTENANCE: (Please list Date) Last Dental Appointment: _________________________ Last Eye Doctor Appointment: ______________________

PARENT/GUARDIAN SIGNATURE: _____________________________________ DATE: __________________

PHYSICIAN REVIEWED: ______________________________________________ DATE: __________________

Age at First Period: __________ Are periods Regular Irregular Cycle Length (days): ________

Date of Last Menstrual Period: _________ Hysterectomy # of days Bleeding: ________

Date of Last Mammogram: __________ Is Flow: Normal Heavy Light Spotting # of Pregnancies: ________

Date of Last Pap Smear: __________ Do you have pain with period? Yes No # of Live Children: ________

Any history of abnormal pap smears? Yes No Or any of the following: ___ Pelvic Pain # of Miscarriages: ________

If Yes, When: __________ ___ Back Pain ___ Breast Tenderness # of Abortions: ________

___ Mood Swings ___ Headaches

____________Heart Problems (Heart Attacks, Heart Failure) ____________ Breast Cancer

____________Colon Cancer

____________ Prostate Cancer

____________ Skin Cancer

____________ Diabetes

____________ Strokes

____________ Mood Disorders (Anxiety, Depression, Bipolar, etc.)

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Magnificat Family Medicine, LLC

Patient Information Sheet

Date: _____________

Name:_____________________________________________________________________________________________ First Middle Last Maiden

I prefer to be called: ______________________ Date of birth:______________ Social Security #:_________________

Home Phone #:_________________ Cell Phone #:__________________ Work #:_________________ (circle preferred #)

Home Address:_____________________________________________________________________________________ Street City State Zip Code

Employer:____________________________________ Occupation:____________________________________

Employer Address:__________________________________________________________________________________ Street City State Zip Code

Marital status: _________ Male____ Female_____ Email:______________________________________________

Pharmacy name:______________________________________________ Pharmacy phone #: _____________________

Pharmacy Address:__________________________________________________________ Zip Code: _______________

Person responsible for account:__________________ Consent to receive text/email appt. alerts? Yes____ No____

PARENT/GUARDIAN (IF PATIENT IS A MINOR)

Name:_____________________________________________________________________________________________ First Middle Last Maiden

Relationship to patient:__________________________ Social Security #:____________________________________

Home Phone #:_________________ Cell Phone #:__________________ Work #:_________________ (circle preferred #)

Home Address:_____________________________________________________________________________________ Street City State Zip Code

Employer:____________________________________ Occupation:____________________________________

Employer Address:__________________________________________________________________________________ Street City State Zip Code

2

EMERGENCY CONTACT INFO:

Name: _________________________________________ Relationship:____________________________________

Home Phone #:_________________ Cell Phone #:__________________ Work #:_________________

INSURANCE CARRIER

Name:________________________________________________________________ Date of birth:________________ First Middle Last

Home Address:________________________________________________________ Social Security #:_______________ Street City State Zip Code

Home Phone #:_________________ Work #:_________________ Relationship to patient:_______________________

Employer Name/Address:_____________________________________________________________________________ Street City State Zip Code

AUTHORIZATION FOR MEDICAL INFORMATION

I authorize that Magnificat Family Medicine, LLC, may communicate with me regarding appointments/scheduling, lab results, as well as but not limited to, brief treatment and follow-up instructions, and which may be communicated by the following : (please initial where applicable)

Home answering machine/voicemail ____________

Cell phone voicemail ____________

Work voicemail ____________

Clinic secure email account ____________

Other ____________

Authorization for communication with family member(s) (Please include their name) _____________ ______________________________

___________________________________________

___________________________________________

The patient (parent/guardian) is responsible for all fees, regardless of insurance coverage. This includes, but is not limited to, co-

insurance, co-payment, deductible, and non-covered services.

I authorize the release of any medical information necessary to process medical claims on my behalf. I also request payment of

benefits to myself or Magnificat Family Medicine, LLC. I authorize the release of my medical records to consulting specialists or

facilities for the continuation of care as deemed necessary by my physician. I authorize the release of my financial records to my

spouse or authorized parent/guardian for the purpose of reconciliation of my account.

Patient’s or Authorized Person’s Name __________________________________________________________

Patient’s or Authorized Person’s Signature __________________________________________________________

Date Signed ________________________

Magnificat Family Medicine, LLC Meaningful Use Patient Registration Form

In compliance with the HITECH Act (HER) to attain meaningful use, we are required to capture demographic data including your preferred language, race, and ethnicity. This is an important part of your medical history and will assist us during our clinical quality improvement process. Please complete the information below.

Patient Name:_______________________________________________

Date of birth:________________ Age:____________ Race: ____ African-American ____ Arab ____ Asian ____ Caucasian ____ Filipino ____ Hispanic ____ Other __________________________ Ethnicity: ____ Hispanic ____ Non-Hispanic Primary language: ____ Arabic ____ Chinese ____ English ____ French ____ Korean ____ Spanish ____ Other ___________________________

Please provide information about previous tests, immunization (including date or year of the last).

Flu shot ________________ Pneumococcal Vaccine ____________________

Male: Female: Colonoscopy ______________ Colonoscopy _______________

Mammogram _______________

Tobacco use: ____ Never ____ Current every day smoker ____ Current smoker – does not smoke every day ____ Former smoker

Patient/ Authorized Person Signature:_______________________________________ Date:________________

Magnificat Family Medicine, LLC

Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I understand Magnificat Family Medicine, LLC, Notice of Privacy Practices, containing a description of the uses and disclosures of my health information. I further understand that Magnificat Family Medicine, LLC may update its Notice of Privacy Practices at any time and that I may receive an updated copy by submitting a request in writing to the office or by going online to www.magnificatfamilymedicine.com.

Printed Patient Name _____________________________________________________

Patient Signature _____________________________________________________

Date Signed _____________________________________________________

Date of Birth _____________________________________________________

If completed by Patient’s Authorized Person (parent/guardian), please print name and sign below.

Printed Authorized Person’s Name __________________________________________________

Signature of Authorized Person __________________________________________________

Relationship to patient __________________________________________________

Date Signed ___________________________________________________

*While Magnificat Family Medicine will not charge you to release or obtain records, the physicians we

are requesting your records from may have a fee for this service. Please contact them about their policy.

Magnificat Family Medicine, LLC

Authorization to Release/Obtain Medical Information

Date:__________________

Patient Name:_________________________________________ Date of birth:_____________

Home Address:_______________________________________________________________________

Street City State Zip Code

Please release the following:

____ Progress notes ____ Mental health/counseling records

____ Labs/imaging reports ____ Substance abuse treatment records

____ All records ____ Other ___________________________________

Release records to: Magnificat Family Medicine, LLC

8240 Naab Rd, Suite 416

Indianapolis, IN 46260

Office: 317-306-5588

Fax: 317-550-1544

Dear Patient, Please list the NAME AND FAX NUMBER of any doctor, specialist

or hospital that you have previously seen. Then sign at the bottom.

Dr./Practice Name: FAX:

Dr./Practice Name:

FAX:

Dr./Practice Name: FAX:

Dr./Practice Name:

FAX:

By signing I authorize and request disclosure of all protected information. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations. This release is effective for one year from the date of execution; however, I may revoke it at anytime by providing notice in writing to the above named party. I accept and understand this will not be sent without acorrect FAX number.

Patient Signature:________________________________________ Date:_________________

Magnificat Family MedicineOffice and Financial Policies

We would like to thank you for choosing Magnificat Family Medicine as your medical provider. We have written this policy to keep you informed of our current office and financial policies.

Appointments: We see patients by appointment only. Same day appointments are usually available for urgent or sudden illness/injury with one of our providers as long as you call before 9AM that day.

After hours and Emergencies: For a serious emergency call 911 right away. If you are not sure and you call our office if will send you to our after-hours answering service. Choose option #3 to speak to a medical professional on call.

Urgent or Sudden Illness/Injury: This is option #3 on our phone tree. We have a limited number of same day or “urgent” appointments available every day. Please call early in the day, as these spots fill up quickly. If there are no available appointments, the front office coordinator will offer an appointment at the next soonest availability or transfer you to the nurse who will discuss your needs and determine what you should do.

Cancellations: Please call at least 24 hours in advance if you are unable to keep your scheduled appointment. This allows us to provide that time slot to another patient. You may be assessed a $25 fee if we are not notified within 24 hours. Treatment of Minors: Patients under the age of 18 must be accompanied by a responsible adult or have written permission for treatment from a parent or guardian. Complete Physical Exams: We believe that routine, annual complete physical exams with screening lab tests are very important to the maintenance of good health. However, insurance benefits vary. All policies cover one “wellness” visit per year, however additional visit charges may occur at your wellness visit that your insurance plan may not cover. Please learn about your benefits prior to your appointment so you will know what is covered by your insurance plan.

Medical Requests: This is option #3 on our phone tree. If you call before noon and leave a message on our nurse line, we will respond back same day. Any messages left after noon will be responded to the next day. Please leave a detailed message, including your full name and date of birth, and the nurse will call you back usually the same day.

Prescriptions and Refills:

• The best time to get a prescription refill is at your appointment.• Be sure to contact us before you run out of your medication, not the day you run out.• All refill requests require 48 business hours to process.• Don’t go to the pharmacy to wait for our prescription to be called in. Call them first to see if it is ready.• Some medications have potential side effects that must be monitored. We require check-ups every 3 months for

these medications. Be sure to keep those follow-up appointments.• The completion of Prior Authorizations for medications is a courtesy service. Depending on the nature of your

prior authorization, an office visit may be required.

Controlled Substances: We cannot make any promises your controlled substance can be filled. We require an office visit to have these scripts filled, and we must have a controlled substance agreement on file.

Referrals: Referrals to specialists will be sent within one week. If someone hasn’t contacted you within 5 days from the specialist, we are sending you to, please follow up with our office. Any problem with the referral may require an office visit.

Patient Rights and Responsibilities and Notice of Privacy Practices: A copy of these forms is available to you at your request. They are also posted on our website.

Lab Work: All lab services are billed by the contracted lab. You may receive a bill from MACL, Genpath, or LabCorp. Please contact their billing department prior to calling our office. We do not have access to their billing information. If you are having your labs done at an outside lab, it is your responsibility to ensure we have the results.

Liability Injury: If your injury is a result from another party’s negligence, you are required to pay for services and then collect from the responsible party. We will not file your insurance but will provide you with a receipt to do so.

Worker’s Compensation: If your injury is due to an accident in your work place, please inform the front desk staff immediately. We are not authorized to treat you for this type of claim. You will need to contact your supervisor for instructions on how to file a worker’s compensation claim. We regret any inconvenience this may cause.

Disability, Insurance Forms, Attending Physician Statements, FMLA: There will be a charge of $25.00 for the completion of medical forms, and we only complete them in office visits. Payment is due at the time of receiving completed forms.

Medical Records: We will provide you with a copy of your medical records upon request. You will need to sign a letter of release prior to having them copied and depending on the number of pages we will charge you accordingly. Please allow up to 30 days for this request to be processed.

Insurance: Although we are contracted with many insurance companies, it is your responsibility to make sure that our practice is in your plan. It is also your responsibility to know your insurance benefits.

As a courtesy to our patients we will file primary insurance forms from our office. We will need all your demographic information prior to your appointment. We ask that at the time of your appointment you bring your insurance card and photo ID as well as any other forms that will assist in making sure that your claim is filed correctly. At the time of service, you will be responsible for all fees that are not covered by your insurance, including co-pays, co-insurance, deductibles, and non-covered services for items received. You may receive a statement from our office for any balance due.

Collections: Accounts that are not paid within 30 days begin our in-house collection process. If your balance becomes 61 days old, and you may be subject to dismissal from the practice.

Return Checks: There will be a charge assessed for any check returned by your bank for any reason.

Dismissal: If you are “dismissed” from the practice it means you can no longer schedule appointments, get medication refills or consider us to be your primary care physician. We are happy to fax over your records to a new location.

Possible Reasons for Dismissal

• No-Showing scheduled office appointments.• Failure to adhere to office policies.• Communicating in a disrespectful manner towards staff.• Balance being sent to collections.

I acknowledge that I have received and read a copy of the Magnificat Family Medicine Office and Financial Policies.

_______________________________________________

Signature/ Patient or Guardian Date