Download to our New Patient paperwork

Julianne M. Dunne, MD
1230 Mamaroneck Avenue ● Suite 100 ● White Plains, NY 10605
telephone (914) 948-1020 ● fax (914) 948-1002
PATIENT INFORMATION
Today’s Date
Name
Age
Date of Birth
Marital Status: S M W D SEP
Social Security #
Home Address
City
State
Zip Code
Home Phone #
Cell Phone #
Pharmacy
Pharmacy Phone #
Email Address:
Occupation
Employer
Phone #
Employer Address
City
State
Zip
Primary Care Physician
Phone #
How did you hear about my practice?
Primary Insurance
Policy Holder
Policy Number
Group Number
Secondary Insurance
Policy Holder
Policy Number
Group Number
(POLICY HOLDER)
Guarantor
Relationship
Date of Birth
Social Security #
Address
City
State
Zip
Employer
Phone #
Address
City
State
Zip
Emergency Contact Information
Name
Relation to Patient
Address
Phone Number
Acknowledgment Receipt of Notice of Privacy Practices
Julianne Dunne, MD, reserve the right to modify the privacy practices outlined in the notice. I have
received and/or reviewed a copy of the Notice of Privacy Practices for Julianne Dunne, MD.
Name of Patient_________________________________________________________
Signature of Patient______________________________________________________
Signature of Patient Representative (required for minor) __________________________
*Disclaimer
I hereby authorize payment from Medicare or other insurance carriers to Julianne M. Dunne, MD, for
professional services rendered. I agree to pay for services not covered by Medicare or my insurance
plan. I hereby authorize the release of medical information necessary to process claims for payment
of services.
Signature________________________________________ Date_____________
If my account is ever turned over to a collection agency for non-payment or payment after insurance
has already made payment, I will be responsible for the balance as well as any collection agency fees
and attorney fees.
Signature________________________________________Date_____________
Julianne M. Dunne, MD, PC * 1230 Mamaroneck Avenue Suite 100 White Plains, NY 10605 ( (914) 948-1020
Patient Responsibilities As a patient, it is in your best interest to know and understand your insurance plan benefits and your responsibility for any deductibles, co-­‐insurance, or co-­‐payment amounts prior to any visit. Not all services are covered in all insurance contracts. If your insurance plan does not cover a service or procedure, you are responsible for payment of these charges. To find out what your insurance plan covers and what your financial obligation may be, call the customer service or member services department of your insurance company (the phone numbers are on your insurance card). Your employer's human resources department may also be a source of information and assistance. While you may have insurance coverage to pay your medical bills, you are ultimately responsible for all charges. You are responsible to notify us of any insurance changes and to provide the necessary information about your insurance plan; therefore, please have your current insurance card with you at all times. Make sure that both your physician and hospital are listed as a participating provider by your insurance company. It is possible that only the physician or only the hospital participates with your insurance plan. If not listed, contact your plan's customer service department to verify. It is your responsibility to know your insurance company's patient responsibilities and procedures. If proper procedures are not followed, you may be liable for full payment of the bill. If your insurance company requires a referral and/or prior authorization, contact your primary care physician prior to seeing a specialist. A referral may be required to see a specialist, while a prior authorization is usually required for most in-­‐hospital procedures. If your insurance company requires a referral and/or prior authorization and you do not have one, you may be responsible for full payment of your bill at the time of service. Benefit and coverage rules and policies differ among insurers and even between different plans of the same insurer. If you go to an out-­‐of-­‐network provider, your insurance company may only pay a percentage of the rates they determine are usual, customary, and reasonable (UCR) rates. You will be responsible for the amount of charges over the insurer's UCR plus your usual deductible and co-­‐payment. Your insurance company can assist you in finding an in-­‐network provider to limit the amount of money you will have to pay for care. Thank you for your cooperation. Julianne Dunne, MD Signature:___________________________________________________ Date:_________________________________________________________ Julianne M. Dunne, MD, PC * 1230 Mamaroneck Avenue Suite 100 White Plains, NY 10605 ( (914) 948-1020
“NO SHOW” Policy Julianne M, Dunne, MD You will be considered a NO SHOW if you miss an appointment without notifying “us” in advance We understand that there are unpredictable events or emergencies that arise that will make it unable for you to keep your scheduled appointment. However, we do expect notification prior to your visit. Please call the office to reschedule or cancel your appointment as soon as you anticipate a change in your schedule. You will receive a phone call confirming you appointment one to two business days prior as well as an email reminder for those patients signed up with our patient portal. Keeping follow-­‐up appointments are an important part of the legal contract that forms between you and the physicians when you agree to become our patient. Our follow-­‐up protocols are based on years of experience and provide you with the highest standard of care. We will extend a courtesy for the first NO SHOW. However, with a second NO SHOW we will be unable to care for you with the standards we have set for our practice and you will be discharged from our care. We will provide your medical records to you at your expense so you may seek care with another physician. We try to schedule adequate time with your physician for your routine visits. We also do our best to run on schedule and minimize your time in the waiting room. And we also like to accommodate all patient emergencies with timely appointments. If a patient makes an appointment that she cannot keep, we can use that time to accommodate your emergency visit but only if she calls ahead of time to notify us. We appreciate you being courteous and thoughtful of our other patients and this will lead to a smooth visit for all. In order to maintain adequate communication with our office, please update your home, cell and work numbers as well as mailing address each time you visit. Thank you for your cooperation. Julianne M. Dunne, MD Signature:___________________________________________________ Date:_________________________________________________________ Julianne M. Dunne, MD, PC * 1230 Mamaroneck Avenue Suite 100 White Plains, NY 10605 ( (914) 948-1020
Name_______________________________
Age___________
Date_______________
PATIENT SELF-HISTORY
GYNECOLOGIC HISTORY
When was the first day of your last period?
If menopause, what year?______________
Are your periods regular? £ yes £ no
Do you experience bleeding mid-month? £ yes £ no
How would you describe your periods? £ light £ moderate £ heavy £ heavy with clots £ other_________
Have you experienced any abnormal bleeding? £ yes £ no If yes, how would you describe it?
£ heavy bleeding with clots £ bleeding between periods £ post-menopausal bleeding £ other_______________
When was your last Pap smear?
What was the result?______________________
Have you ever had an abnormal Pap smear? £ yes £ no
If yes, have you ever had any of the following procedures for an abnormal Pap smear?
£ none £ colposcopy £ cryosurgery £ LEEP procedure £ cone biopsy £ laser £ hysterectomy
When was your last mammogram?
When was your last bone density test?
When was your last colonoscopy?
What was the result? __________________
What was the result? __________________
What was the result? __________________
Do you have any of the following GYNECOLOGIC conditions? £ none
£ fibroid uterus £ recurrent ovarian cysts £ endometriosis £ recurrent vaginal infections £ infertility
£ painful periods £ sexual dysfunction £ painful intercourse £ premenstrual syndrome £ pelvic pain
Are you currently sexually active? £ yes £ no
If yes, are you currently planning pregnancy? £ yes £ no
If you are not planning pregnancy, what method of pregnancy prevention are you currently using?
£ none £ condoms £ diaphragm £ vaginal spermicide £ withdrawal £ natural family planning
£ oral contraceptives £ depo-provera £ Mirena £ Copper IUD £ tubal ligation £ Essure £ vasectomy
Would you like to discuss other options for birth control today? £ yes £ no
Are you interested in a permanent form of birth control? £ yes £ no
Have you ever been diagnosed with or treated for a sexually transmitted infection?
£ none £ gonorrhea £ chlamydia £ herpes £ trichomonas £ HPV £ hepatitis £ syphilis £ HIV
OBSTETRIC HISTORY
How many times have you been pregnant?__________How many live births?________________________
Have you had any miscarriages? £ yes £ no
Have you had any abortions? £ yes £ no
If you have children, were they delivered by £ vaginal birth £ cesarean delivery £ both
MEDICATION
List any medications, vitamins or herbal remedies you are taking on a regular basis.
____________________________
____________________________
___________________________
____________________________
____________________________
___________________________
____________________________
____________________________
___________________________
____________________________
____________________________
___________________________
Would you like to discuss what vitamins and supplements would benefit your health needs? £ yes £ no
MEDICAL HISTORY
List any medical conditions for which you are currently under a doctor's care.
____________________________
____________________________
___________________________
____________________________
____________________________
___________________________
____________________________
____________________________
___________________________
____________________________
____________________________
___________________________
Julianne M. Dunne, MD, PC * 1230 Mamaroneck Avenue Suite 100 White Plains, NY 10605 ( (914) 948-1020
ALLERGIES
List any medications you are allergic to.
____________________________
____________________________
____________________________
____________________________
Are you allergic to latex? £ yes £ no
___________________________
___________________________
SURGERIES
Date
_______________________
_______________________
_______________________
_______________________
Surgical procedure
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
HOSPITALIZATIONS
Date
_______________________
_______________________
_______________________
_______________________
_______________________
Reason for hospitalization
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
FAMILY HISTORY
Medical condition
If yes, which family member(s) i.e. mother, maternal aunt, etc.
diabetes
heart disease
high cholesterol
high blood pressure
stroke
breast cancer
ovarian cancer
uterine cancer
colon cancer
pancreatic cancer
other medical conditions
£ no £ yes __________________________________________________________________
£ no £ yes __________________________________________________________________
£ no £ yes __________________________________________________________________
£ no £ yes __________________________________________________________________
£ no £ yes __________________________________________________________________
£ no £ yes __________________________________________________________________
£ no £ yes __________________________________________________________________
£ no £ yes __________________________________________________________________
£ no £ yes __________________________________________________________________
£ no £ yes __________________________________________________________________
_______________________________________________________________________________
SOCIAL HISTORY
What is your occupation? ________________________________________________________________________________
Do you smoke cigarettes? £ never £ former smoker £ 1ppd or less £ 2 ppd £ 3 ppd or more
Do you drink alcohol? £ 0-12 drinks/year £ 1-13 drinks/month £ 4-14 drinks/week £ >2 drinks/day
Do you use recreational drugs? £ no £ marijuana £ cocaine £ crack £ other__________________________
Do you exercise regularly? £ no £ 1x per week or less £ 2-3x per week £ 4-5x per week £ daily
Are you currently at your ideal weight? £ Yes £ No
How tall are you?________________________
REVIEW OF SYSTEMS
Have any of the following general symptoms affected your daily living significantly?
£ no £ weight gain £ difficulty losing weight £ weight loss £ loss of appetite £ fatigue £ weakness
£ unexplained fever £ night sweats £ trouble falling asleep £ wake up over night or early morning
Do any of the following urinary symptoms occur frequently or interfere with your daily living?
£ no £ difficulty urinating £ pain with urination £ blood in urine £ frequent urination £ urgency
£ hesitancy £ urination more than one time overnight £ loss of urine with cough or sneeze
Do any of the following gastrointestinal symptoms occur frequently or interfere with your daily living?
£ no £ nausea and/or vomiting £ heartburn £ bloating £ abdominal pain £ diarrhea £ constipation
£ blood in stool £ difficulty eating or feeling full quickly £ indigestion
Sign your name_________________________________
Date_______________________________
Julianne M. Dunne, MD, PC * 1230 Mamaroneck Avenue Suite 100 White Plains, NY 10605 ( (914) 948-1020
HIPPA Privacy Rights: In accordance with the Health Insurance Portability and Accountability Act of 1996, as of April 14, 2003 all health care providers are required to provide their patients with a ‘Notice of Privacy Practice’ statement. The following is a generic ‘Notice of Privacy Practice’ statement designed to provide you with an idea of what you should expect to be receiving from your health care provider. JULIANNE M. DUNNE, MD 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. JULIANNE M. DUNNE, MD is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information. Disclosure of Your Health Care Information Treatment We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations. (example) “On occasion, it may be necessary to seek consultation regarding your condition from other health care providers associated with JULIANNE M. DUNNE, MD” “It is our policy to provide a substitute health care provider, authorized by JULIANNE M. DUNNE, MD to provide assessment and/or treatment to our patients, without advanced notice, in the event of your primary health care provider’s absence due to vacation, sickness, or other emergency situation.” Payment We may disclose your health information to your insurance provider for the purpose of payment or health care operations. (example) “As a courtesy to our patients, we will submit an itemized billing statement to your insurance carrier for the purpose of payment to JULIANNE M. DUNNE, MD for health care services rendered. If you pay for your health care services personally, we will, as a courtesy, provide an itemized billing to your insurance carrier for the purpose of reimbursement to you. The billing statement contains medical information, including diagnosis, date of injury or condition, and codes which describe the health care services received.” Workers’ Compensation We may disclose your health information as necessary to comply with State Workers’ Compensation Laws. ©H.J. Ross Company, Inc. 2002, 2003 HIPAA Interactive-­‐All Rights Reserved FORM 03.501 Emergencies We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death. Public Health As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure. Judicial and Administrative Proceedings. We may disclose your health information in the course of any administrative or judicial proceeding. Law Enforcement. We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes. Deceased Persons. We may disclose your health information to coroners or medical examiners. Organ Donation. We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues. Research. We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board. Julianne M. Dunne, MD, PC * 1230 Mamaroneck Avenue Suite 100 White Plains, NY 10605 ( (914) 948-1020
Public Safety. It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public. Specialized Government Agencies. We may disclose your health information for military, national security, prisoner and government benefits purposes. Marketing. We may contact you for marketing purposes or fundraising purposes, as described below: (example)“As a courtesy to our patients, it is our policy to call your home on the evening prior to your scheduled appointment to remind you of your appointment time. If you are not at home, we leave a reminder message on your answering machine or with the person answering the phone. No personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment along with a request to call our office if you need to cancel or reschedule your appointment.” “It is our practice to participate in charitable events to raise awareness, food donations, gifts, money, etc. During these times, we may send you a letter, post card, invitation or call your home to invite you to participate in the charitable activity. We will provide you with information about the type of activity, the dates and times, and request your participation in such an event. It is not our policy to disclose any personal health information about your condition for the purpose of Comeau Health Care Associates sponsored fund-­‐raising events.” Change of Ownership. In the event that JULIANNE M. DUNNE, MD is sold or merged with another organization, your health information/record will become the property of the new owner. Your Health Information Rights You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that JULIANNE M. DUNNE, MD is not required to agree to the restriction that you requested. You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request. You have the right to inspect and copy your health information. You have a right to request that JULIANNE M. DUNNE, MD amend your protected health information. Please be advised, however, that JULIANNE M. DUNNE, MD is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s)and information about how you can disagree with the denial. You have a right to receive an accounting of disclosures of your protected health information made by JULIANNE M. DUNNE, MD. You have a right to a paper copy of this Notice of Privacy Practices at any time upon request. Changes to this Notice of Privacy Practices JULIANNE M. DUNNE, MD reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, JULIANNE M. DUNNE, MD is required by law to comply with this Notice. JULIANNE M. DUNNE, MD is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact: JULIANNE M. DUNNE, MD by calling this office at 914-­‐948-­‐1020. Complaints-­‐ Complaints about your Privacy rights, or how JULIANNE M. DUNNE, MD has handled your health information should be directed to JULIANNE M. DUNNE, MD by calling this office at 914-­‐948-­‐1020 If JULIANNE M. DUNNE, MD is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days. If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to: DHHS, Office of Civil Rights 200 Independence Avenue, S.W. Room 509F HHH Building Washington, DC 20201 This notice is effective as of ______/______/_______ ________I have read the Privacy Notice and understand my rights contained in the notice. Julianne M. Dunne, MD, PC * 1230 Mamaroneck Avenue Suite 100 White Plains, NY 10605 ( (914) 948-1020