Download patient history - Eastside Medical Group

PATIENT REGISTRATION
Patient’s Last Name:_________________________ First Name:_____________________ Initial: ________
Address:________________________________________________________________________________
City: ____________________________________ State:___________ Zip Code:______________________
Primary Phone:_______________________________ Work or Cell: _______________________________
Date of Birth: _____________________ Social Security #: ___________________________ Sex:  M  F
Email:________________________________________ Employer: ________________________________
Emergency Contact Name: _____________________________ Phone: _____________________________
Marital Status:  Single  Married  Widowed
Race:  White  African American  Indian Asian  Other
Ethnicity: Hispanic or Latino  Not Hispanic or Latino  Declined to specify Preferred Language: __________________
Who referred you to Eastside Medical Group? _________________________________________
Primary Insurance Information
Insurance Company Name: ________________________ Insured’s Name:___________________________
Insured’s Date of Birth:___________________ Subscriber’s ID#:__________________________________
Group #:_______________________________ Employer:________________________________________
We must have a copy of your insurance card and the above information to file claims.
Release of Information
1. EMG may mail medical reports through the US Postal Service.  Yes  No
2. EMG may contact me and send medical reports through email address provided.  Yes  No
3. EMG may leave a message on my voicemail. (please check appropriate boxes)  Yes  No
 all information  billing information  test results  appointment information
4. EMG may release medical information to:
Name: _____________________________ Relationship: _______________ Phone: ___________________
 all information  billing information  test results  appointment information
Name: _____________________________ Relationship: _______________ Phone: ___________________
 all information  billing information  test results  appointment information
I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy
the protected health information to be disclosed in this document by signing a written notification to Eastside Medical
Group (EMG). I understand that a revocation is not effective in cases where information has already been disclosed
but will be effective going forward. I understand that information used or disclosed as a result of this authorization
may be subject to disclosure by the recipient and may no longer by protected by federal or state law. I understand that
I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. This
authorization shall be in effect until revoked by the patient.
Assignment of Benefits/Authorization to Release Information
I authorize the release of any medical or other information necessary to process all claims. I also authorize payment of
medical benefits to Eastside Medical Group for services described on all claims. The assignment will remain in effect
until revoked by me in writing. I understand that I am responsible for all charges whether or not paid by said
insurance companies.
I acknowledge that I have reviewed the HIPAA Notice of Privacy Practices.
Patient Signature: _________________________________________ Date:___________________________
Guarantor Signature: _______________________________ Relationship to patient:____________________
FINANCIAL POLICY
Thank you for choosing our practice! We believe that establishing a written financial policy is mutually
beneficial for all parties. It is our goal to avoid any miscommunication or concerns regarding financial
matters in order to focus our energies on providing healthcare services to our patients.
We participate with most insurance plans. Each plan has different benefits for you as well as different
financial obligations. Not all insurance policies cover all services. It is your responsibility to check with
your insurance company to determine covered benefits.
The following are our financial guidelines relative to financial responsibility:
 Payment is expected at the time of service. This includes co-pays, co-insurance, and deductibles.
 Patients must provide a copy of the insurance card at each visit.
 For our self-pay patients, we offer a discount for professional services and labs paid in full at the
time of service. Please see the receptionist for details.
 We do not file insurance for cosmetic procedures and/or durable medical equipment (i.e. supplies,
splints, braces, dressings, ace wraps).
 You may be charged at $20.00 no-show fee for any appointments missed, not cancelled or
rescheduled with a 24 hour notice. You may be charged a $30.00 no-show fee for physicals or
appointments with our allergist, dietician, or nutritionist that have not been cancelled or
rescheduled with a 24 hour notice.
 All balances over 3 months past due, whether “waiting on insurance” or settling disputes with the
insurance company, must be paid in full before being seen.
 Accounts may be turned over to a collection agency if past due 60 days or more.
 Patients are legally responsible for all collection costs involved with the collection of an account
including court cost, reasonable attorney fees, and all other expenses incurred with collection if
there is a default on any unpaid balances.
 A service charge or $30.00 will be added for returned checks.
 There is a $20.00 charge for any prescription called in without an appointment. This includes lost
prescriptions, prescriptions which have lapsed prior to appointment, and requests for prescriptions
rewritten for insurance, managed care, or quantity reasons.
 There is a $15.00 monthly refill charge for the following medications that can be filled for only
30 days at a time due to state law: ADD medications (i.e. Adderall, Concerta, Ritalin, Vyvanse)
and pain medications (i.e. norco, oxycontin). This must be paid each month before the
prescription will be released.
We appreciate the opportunity to participate in your family’s healthcare. If you have any questions
regarding this policy, please let us know.
I have read, understand and agree to the above financial policy. I understand that charges not covered by
my insurance company, as well as applicable co-pays and deductibles are my responsibility.
Patient Name: __________________________ Signature: ________________________ Date:___________
Signature of Guarantor:____________________________ Relationship to Patient:_____________________
PATIENT HISTORY
Patient Name: _______________________ DOB: _______________ Date: _________________
Allergies: Please list any allergies you have to any medication, adhesive tapes, latex, etc...
_______________________________________________________________________________________
Smoking: Have you ever smoked?  Yes  No
If you used to smoke, what year did you quit? __________ How many years did you smoke? ____________
How many packs a day did you smoke on average? _____________________________________________
If you currently smoke, what year did you begin?________________________________________________
How many packs a day do you smoke on average? _____________________________________________
Alcohol: Do you use any alcohol at all in a typical year?
 Yes  No
If you use alcohol during the year, would you describe it as:  Rarely  Socially
If you use alcohol, approximately how many drinks do you have per day or week? _____________________
Check any beverage you enjoy?  Beer  Wine  Mixed drinks  Liquor
Medical History: Do you now or have ever been diagnosed with: Place a  if “Yes”. Put an M, F, or S next to each
condition if your mother, father, or sibling has any of these conditions.
 High Blood Pressure
 Cholesterol Problems
 Diabetes
 Gout
 Kidney disease
 Kidney stones
 Hypothyroidism
 Thyroid Tumor
 Erectile dysfunction
 Low Testosterone
 Menopause
 Skin Cancer of any type
 Any other Cancer of any type
 Hepatitis
 Fibrocystic Breasts
 Arthritis
 Rheumatoid Arthritis
 Migraines
 Depression
 Anxiety
 ADD/ADHD
 Alcoholism/Drug Addiction
 Obesity
 Coronary Artery Disease
 Stroke
 Reflux
 Hiatal Hernia
 Ulcer
 Blood Clots in lungs or legs
 Allergies/Sinus Problems
 Blood Cancers
 Glaucoma
 Colon Polyps
 Asthma
 COPD
 Sleep Apnea
 Other _________________
________________________
________________________
Surgical History: Check any surgery you have had in the past:
 Appendix Removed
 Kidney Stone Removal
 C-Section(s)
 Gallbladder Removed
 Vasectomy
 Open Heart Surgery
 Skin Cancer Removal
 Hysterectomy complete
 Carotid Artery Surgery
 Breast Biopsy(ies)
 Hysterectomy partial
 Sinus Surgery
 Hernia
 Cervical Procedure
 Thyroid Surgery
 Other _______________________________________________________________________
Please state the year of your last: Flu vaccine: _______________ Pneumonia vaccine: _______________
Tetanus vaccine: _______________ Colonoscopy: _______________ Vision Screening: _______________
Mammogram (date and location): ____________________________________________________________
Current Medications:
__________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
____________________________________________________________________________