Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
J&J Medical 5920 North La Cholla Blvd Suite 150
Tucson, Arizona 85741
Phone (520) 547-5836
Fax (520) 547-5841
Welcome to J&J Medical. Please take a moment to review our office policies. If you have any questions,
please address them with our Site Coordinator.
1. Patients need to arrive 15 minutes prior to their scheduled appointment time. This is to allow
for verification of insurance and completion of all necessary paperwork. We reserve the right to
ask you to reschedule if you are more than 5 minutes late.
2. Please note annual mammography is recommended after the age of 40. Dexa scans and
colonoscopies are recommended after the age of 50 or sooner based on family history.
3. If there is a need to cancel your appointment, please do so 24 hours in advance. There will be a
$25.00 fee if you do not show for your appointment or if you do not give 24 hours’ notice when
canceling.
4. Co-pays are due at the time of services as dictated by your insurance. We do not bill co-pays.
We will accept cash, check, Visa, Mastercard and Discover. We do not accept American Express.
5. To assist us in providing good medical care, it is very helpful if you bring in an updated list of
medications and doses to each visit. If we are managing your diabetes or hypertension, bring in
your readings.
6. Please provide us with at least two phone numbers that we can contact you at regarding your
healthcare.
7. There is a $25.00-$50.00 charge for filling out forms for FMLA and disability. The price is based
on the amount of time required to complete the forms. There is no charge for filling out
physical or MVD handicap forms.
8. Contact your pharmacy for all prescription refill requests. Please allow 48 hours for prescription
refills. Please note, any prescriptions that are called in after hours will not be authorized until
the following business day. Medications prescribed by specialists must be refilled by the
specialist that prescribed them.
Office Hours
Monday, Tuesday, Thursday 7:00 – 5:00
Wednesday 9:00 – 5:00
Friday 8:00 – 5:00
All of our staff members are trained to assist you in obtaining the best care possible and to do so with
courtesy and compassion. We strive to provide the best professional care possible. In turn, our
provider expects our patients to treat our staff with courtesy and respect. Abuse of our staff will not be
tolerated and may result in termination of your care at J&J Medical.
Name:_________________________ DOB:____________ Date:____________________ MRN:___________
HEALTH QUESTIONNARE GENERAL
By what name do you wish to be called? _______________________________Marital Status S □ M□ W□ D□
Where were you born? ____________________. Do you live in Arizona all year? □ YES □ NO
Did you move here for health reasons? Yes□ No□
What is your occupation? __________________________________________How long? ________________
PERSONAL HABITS
Tobacco Yes □ No □ Quit □ When__________ Yes □ No□ Alcohol: How many? _______drinks per week
Cigars □ Cigarettes □ Pipes □ Yes □ No □ Coffee: How many? __________ Cups per day
How much? __________ How long? ______ Years Yes □ No □ Regular Exercise: How often? ___________
MEDICATIONS
*Please write, name of medication, dose and frequency or attach medication list. Name & Reason Name & Reason
________________________ ________________________
________________________ _________________________
_________________________ _________________________
_________________________ _________________________
□ Other Drugs (include marijuana, etc.) _____________________________________________
ALLERGIES (if you are allergic to any drugs, foods, pollens, etc, describe effect)
Allergic To: Effect:
____________________________________ __________________________________________
____________________________________ __________________________________________
VACCINATIONS (Check those you have had and write in dates below)
□Tetanus________________ □Polio _________________ □German Measles ______________
□Diphtheria _____________ □Flu ___________________ □Zostavax (shingles) ____________
□Mumps _________________ □Pneumonia/ Prevnar 13 _________ □Other _______________________
PERSONAL HISTORY (Check those you have had)
□High Blood Pressure □Kidney Trouble □Mental Illness □Hay Fever, Asthma
□Sugar Diabetes □Liver Trouble □Suicide Attempts □Breathing Trouble
□Heart Trouble □Anemia □Epilepsy □Valley Fever
□Stroke □Arthritis □Excess Drugs □Cancer
PRIOR OPERATIONS/ PROCEDURES (e.g. Colonoscopy, mammography, bone density, hysterectomy,
and mastectomy) list all dates. __________________________________________________________________________________________
__________________________________________________________________________________________
FAMILY HISTORY (Include parents and grandparents)
□High Blood Pressure □Kidney Trouble □Mental Illness □Hay Fever, Asthma
□Sugar Diabetes □Liver Trouble □Suicide Attempts □Breathing Trouble
□Heart Trouble □Anemia □Epilepsy □Valley Fever
□Stroke □Arthritis □Excess Drugs □Cancer
Family
History
Age State of Health or
Cause of Death
Check if
Deceased
Family
Member
Age State of Health or
Cause of Death
Check if
Deceased
Mother Children
Father Husband/
Wife
Sister/ Brother
Name:_________________________ DOB:____________ Date:____________________ MRN:___________
IF YOU HAVE OR HAVE HAD ANY PROBLEMS IN THE FOLLOWING AREAS. IF IS YES, CHECK
PROBLEMS AND GIVE DETAILS OF EACH SECTION BELOW.
GENERAL □Fever □Sweats □Chills □Headaches □Weight Change □Faintness
□Excess Tiredness, Fatigue □Nose □Throat □Sinuses
□ Other: __________________________________________________________________________________
HEART, LUNGS ______________________________________________________
□Last Chest x-ray- When? _____________________ □Last EKG- When? ___________________
□Cough, Wheezing or Asthma □Chest Tightness, Pain
□Coughing Blood □High Blood Pressure
□Irregular Heartbeat □Shortness of breath □Other: ___________________
BREAST □Pain □Lumps □Regular Self-Exam □Prior breast surgery
STOMACH, DIGESTION
□Constipation □Indigestion
□Bloody or Black stools □Vomiting
□Rupture or Hernia □Diarrhea
□Hemorrhoids □Change in Bowel Habits
Other: ____________________________________________________________________________________
KIDNEYS, URINATION
□Kidney or Bladder Infection □Frequent Urination
□Kidney Stone □Blood in the urine
□Pain with Urination □Urination at night
Other:____________________________________________________________________________________
INTEGUMENTARY □Skin □Hair □Nails
SKELETAL □Bones □Joints □Muscles
NERVERS, EMOTIONS
□History of child abuse □Psychiatric Care or Counseling
□Convulsions □Suicide Attempts
□Depression □Sleep Disorders or Problems
□Excess Anxiety □Problems with Family Relationships?
SURGERY Have you ever been advised to have a surgical operation which you have not undergone?
□Yes □No If is yes, explain ________________________________________________________________
Are you satisfied with your sexual relationships? □Yes □No
Do you have any problems or questions about sex that you would like to discuss with your doctor? □Yes □No
MEN ONLY
□Male surgeries? Type_________________________ □Weak or slow urine stream
□Pain or lump in testicles □Discharge from penis
Difficulty with Erection □Discharge from penis
□Sexually Transmitted Disease
WOMEN ONLY
Length of Periods______ days Date of last Period______________ Age of menstruation began_____________
Last Pap and Pelvic____________________ □Are you pregnant? __________________
□Pain or Bleeding with intercourse □Bleeding between periods __________________
□Irregular Periods, Severe Cramps □Using Birth Control? Type: _________________
□Female Surgery? Type ____________________ □Sexually transmitted Disease
□Current Vaginal Infection □Other: ___________________________
Arizona Community PhysiciansPatient Information
/ /
FIRST NAME LAST NAME
HOME PHONE
ADDRESS CITY STATE ZIP
CELL PHONE
PRIMARY CARE PHYSICIAN PREVIOUS NAMESTUDENT? FT OR PT
EMPLOYER NAME EMPLOYER PHONEEMPLOYER ADDRESSBilling Information
(If different than patient)
FIRST NAME MI LAST NAME ADDRESS CITY STATE/ZIP PHONE
EMERGENCY PHONE# EMERGENCY CONTACT NAME
Primary Insurance Information
INSURANCE NAME MEDICAL CLAIMS ADDRESSEFFECTIVE DATE
GROUP ID# POLICY ID#
CO-PAY AMOUNT
SUBSCRIBER NAME (POLICY HOLDER)
RELATIONSHIP OF PATIENT TO SUBSCRIBER
SELF SPOUSE CHILD OTHER
SUBSCRIBER DATE OF BIRTH SUBSCRIBER SEX SUBSCRIBER SSN#
SUBSCRIBER EMPLOYER EMPLOYER ADDRESS EMPLOYER PHONE#
Secondary Insurance Information
alcohol abuse and HIV/AIDS for the purpose of carrying out treatment, payment and healthcare operations. I have been provided or offered a copy of Arizona Community Physicians' Privacy Statement. I assign all medical and/or surgical benefits including major medical benefits to Arizona Community Physicians for services rendered. By signing this form I am confirming that the above demographic and insurance information is current and correct. If the information is not correct I understand I will be held responsible for all charges incurred in today's visit.
The effective period of this authorization is from today's date to a future date, when I am no longer a patient of the Arizona Community Physicians, P.C. group or am deceased.
PERSON GIVING CONSENT RELATIONSHIP IF NOT THE PATIENT DATE
Form #101
/ RELATION
SUBSCRIBER ADDRESS (if different than patient) SUBSCRIBER PHONE (if different than patient)
/ /
MIDDLE
INSURANCE NAME MEDICAL CLAIMS ADDRESSEFFECTIVE DATE
GROUP ID# POLICY ID#
CO-PAY AMOUNT
SUBSCRIBER NAME (POLICY HOLDER)
RELATIONSHIP OF PATIENT TO SUBSCRIBER
SELF SPOUSE CHILD OTHER
SUBSCRIBER DATE OF BIRTH SUBSCRIBER SEX SUBSCRIBER SSN#
SUBSCRIBER EMPLOYER EMPLOYER ADDRESS EMPLOYER PHONE#
SUBSCRIBER ADDRESS (if different than patient) SUBSCRIBER PHONE (if different than patient)
/ /
By signing this form, I am consenting to Arizona Community Physicians' use and disclosure of my Protected Health Care Information, including information related to psychiatric care, drug and
DOB SEX MARITAL STATUS EMAIL RACE (o p t i o n a l )
Name:____________________________
Occupation: _______________ Age: _________
COMPLAINTS: Please circle the appropriate number 1-5 according to severity: 1 = mild, 5 = very
Severe, 0 = no problem:
Nasal discharge 0 1 2 3 4 5 Chronic fatigue 0 1 2 3 4 5 Nasal obstruction 0 1 2 3 4 5 Food intolerance 0 1 2 3 4 5 Watery or itchy eyes 0 1 2 3 4 5 Frequent sinus or ear infection 0 1 2 3 4 5 Sneezing 0 1 2 3 4 5 Frequent colds or sore throats 0 1 2 3 4 5 Wheezing 0 1 2 3 4 5 Learning disability 0 1 2 3 4 5
Cough 0 1 2 3 4 5 Poor memory or concentration 0 1 2 3 4 5 Itching 0 1 2 3 4 5 Hyperactivity 0 1 2 3 4 5 Eczema 0 1 2 3 4 5 Abdominal gas or cramping 0 1 2 3 4 5 Hives 0 1 2 3 4 5 Arthritis or muscle aching 0 1 2 3 4 5 Headache 0 1 2 3 4 5 Asthma 0 1 2 3 4 5
Other symptoms:
Which (if any) foods cause you any problems?
________________________________________________________________________
In what year did your allergies start? ____________________________________________
How many months of the year do you have allergies?
___________________________________________________________________
Have you been allergy tested before? __________ If yes, did you receive desensitization shots?
______________________________________
What prescription medications have you tried for allergies? How long did you use them?
1. ___________________________________________For how long? ______________________
2. __________________________________________ For how long? _____________
3. __________________________________________ For how long? _____________
Does any medication give you relief of symptoms?
_____________________________________________________________________
List any animals you have in or around the home_________________________________________________
Who else in your family has allergies?__________________________________________________
How did you hear about our office? (Be specific. If a newspaper, please give
name)________________________
Arizona Community Physicians, P.C.
Release of Information Form
Account #_____________
Patient Name __________________________________ DOB________________ Date_______________
The confidentiality of our patients’ medical information is very important to us. We understand there
may be circumstances in which a family member or close friend needs access to your health
information, or to the health information of someone under your care.
Please list the names and phone numbers of anyone who has your permission to have access to your
medical records, or to your dependents medical records. This information is not limited to but includes
appointments, billing information and test results.
Spouse’s Name ___________________________________Contact Number_______________________
Child’s Name_____________________________________ Contact Number______________________
______________________________________Contact Number_______________________
Parent’s Name____________________________________ Contact Number_______________________
____________________________________Contact Number______________________
Other’s Name ____________________________________ Contact Number_______________________
_____________________________________Contact Number_______________________
DO NOT RELEASE Information to the following people: ________________________________________
_____________________________________________________________________________________
Please check if applicable:
_______ I give permission for my child (of >15 years old) to be seen without the presence of an
adult.
_______ I give permission for my child (of >15 years old) to have minor procedures or
immunizations without the presence of an adult.
_______ I give permission for my child to be taken to medical appointments
by:_____________________________________________________________________
________________________________________________________________________
Patient/Parent/Guardian Contact Numbers: Home____________ Work___________ Other__________
Signature of the Patient or their Parent/Legal Guardian ________________________________________
Form #116
02/15/2012
ARIZONA COMMUNITY PHYSICIANS REGISTRATION ADDENDUM
Patient Name:____________________________________________ Account Number:_________________________________________
Due to a governmental mandate that all healthcare is provided fairly, without regard to race or ethnicity, we have added new fields to our patient registration form. This information will be kept confidential.
Race (check one)
Black, African American (01)
Asian (02)
Caucasian (White) (03)
American Indian, Alaskan Native (08)
Native Hawaiian/Other Pacific Islander (09)
Unknown (98)
Declined (99)
Ethnicity (check one)
Hispanic
Non- Hispanic
Unknown
______________________________
______________________________
Patient Signature
Preferred Language (check one)
English (EN)
Spanish (ES)
Arabic (AR)
Chinese (all types) (ZH)
French (FR)
German (DE)
Greek (EL)
Italian (IT)
Japanese (JA)
Korean (KO)
Navajo (NV)
Polish (PL)
Russian (RU)
Tagalog’ (TL)
Ukrainian (UK)
Vietnamese (VI)
Other________________ (Specify)
______________________________ _________________________
Parent/Guardian Signature Patient declined filing out the
form. Staff signature required
ARIZONA COMMUNITY PHYSICIANS, P.C. AUTHORIZATION TO DISCLOSE MEDICAL INFORMATION
PATIENT INFORMATION Patient Name_________________________________________ Account #_____________________ Former Name (If any)________________________________________________________________ Daytime Telephone____________________________________ Birth Date_____________________ INFORMATION TO BE RELEASED FROM I hereby authorize (name of organization)_________________________________________________ To release the following medical information contained in patient’s medical record. INFORMATION TO BE RELEASED TO Name of Physician/Organization _____________________________________________________ Street Address ____________________________________________________________________ City/State/Zip_____________________________________________________________________ Phone # _________________________________________________________________________ PURPOSE FOR THE REQUEST (Please check a box) Moving Treatment or consultation Dissatisfaction Change of Insurance Plans At patients requestٱ Other (specify) _____________________________________________________________________ TYPE OF INFORMATION TO BE RELEASED (No information will be released unless a box is checked)
General Release DATES OF TREATMENT Medical Records/Excluding Protected Records (This will be limited to 1 year of information including Lab, x-ray reports From________ To_______
unless otherwise stated)
Other Records (specify) ________________________________ From________ To________ Information Protected by State/Federal Law All of my records including: From_______ To________
AIDS/HIV and Other Communicable Disease Information, Behavioral Health Care/Psychiatric Care, Alcohol and/or Drug Abuse Treatment
THIS AUTHORIZATION WILL AUTOMATICALLY EXPIRE AFTER ONE YEAR (or 60 days for drug and alcohol abuse records) from the date of signing. The undersigned may revoke this authorization at any time by providing written notice of revocation. With respect to drug and alcohol abuse treatment, information or records regarding communicable disease-related information, the recipient of this information understands that it is prohibited from making any disclosure of this information unless further disclosure is expressly permitted by written consent of the undersigned or otherwise permitted by applicable law. Signature of Patient or Personal Representative Who May request Disclosure I understand that Arizona Community Physicians may not condition my treatment on whether I sign this authorization form unless specified above under Purpose for Request. I can inspect or receive a copy of the protected health information to be used or disclosed. I authorize Arizona Community Physicians to use and disclose the protected health information specified above _______________________________________ __________ __________________________________ Signature of Patient OR Legal Representative Date Please Print Name of signing party FORM # 100
Patient Requesting Medical Record Copies The charge for copying medical records from a paper chart will be $0.50 a page. For offices using our Electronic Health Record system, patients may request a copy of their chart on a “CD” for $10.00