BRUNSWICK FAMILY MEDICINE

Patient Information

Provider Choice:

Slade A. Suchecki, DO – MDVIP provider Sherrie G. Cass, FNP-C – Traditional provider

Date:

Patient Name:

First Name:

Middle Initial:

Last Name:

Date of Birth:

SSN:

Gender:

Male Female

Mailing Address:

City:

State:

Zip Code:

Home Phone #:

Cell Phone #:

Work Phone #:

How do you prefer us to contact you?

Home Phone Cell Phone Work Phone

May we text reminders to your cell phone?

Yes No

Email Address:

Would you like to sign up for our patient portal?

Yes No

Marital Status:

Single Married Separated Divorced Widowed

Race:

White Black/African American Asian American Indian Other Declined

If Other, please specify:

Ethnicity:

Hispanic/Latino Not Hispanic/Latino Other Declined

If Other, please specify:

Preferred Pharmacy:

Name:

Location:

Phone:

Emergency Contact:

Name:

Relationship to Patient:

Phone:

Billing Information

Person Responsible for the Charges:

Self Spouse Parent Other

Name:

Mailing Address:

City:

State:

Zip Code:

Home Phone #:

Cell Phone #:

Work Phone #:

Primary Insurance Carrier:

Policy Number:

Policy Holders Name:

Policy Holders Date of Birth:

Secondary Insurance Carrier:

Policy Number:

Policy Holders Name:

Policy Holders Date of Birth:

Financial Authorization

By signing below I understand and agree to the below statements:

I understand that I am financially responsible to Brunswick Family Medicine for all charges regardless of insurance coverage. If insured, I agree to provide updated insurance information. I will pay any and all copayments, co-insurance, deductible, and/or charges not covered, approved or considered necessary by my insurance company upon notification. If un-insured, I agree to pay all charges at the time of service or upon notification by Brunswick Family Medicine. I hereby agree to pay all costs and reasonable attorney's fees in the event my account is turned over to an attorney for collection.
I hereby authorize payment directly to Brunswick Family Medicine or its affiliates of the surgical and/or medical benefit, if any, otherwise payable to me for services rendered.
I authorize Brunswick Family Medicine or its affiliates to release any information acquired in the course of my examinations and/or treatment to my insurance carriers, third party payers, or others involved in processing and collection of any claims submitted on my behalf.
I have received a copy of the HIPAA, Privacy Notice, and Financial Policy from Brunswick Family Medicine.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Parent or Guardian:

Date:

Policies & Consents

Narcotic/Controlled Medication Notice

, do understand that Brunswick Family Medicine providers will not automatically prescribe narcotic/controlled substance-based medication to any patient. It is up to each provider to exercise professional judgment regarding whether to prescribe narcotic/controlled substance-based medication to patients in accordance with Brunswick Family Medicine policies and procedures and all applicable laws (see North Carolina Controlled Substances Act, NCGS §90).

Should it be determined that I require such a prescription, I shall be required to execute a “Controlled Medication Treatment Agreement”, the terms of which will be explained to me. If applicable, I will be required to renew this agreement on an annual basis or when any changes are made (e.g., change in dosage or the addition of a new medication that is a narcotic or controlled substance).

Violation of any executed Controlled Medication Treatment Agreement will result in discharge from the practice.

I also understand that providers will not write prescriptions for any narcotic/controlled-substance based medications during my initial visit without a full evaluation in which the provider determines necessity and a review of all appropriate records from previous providers. Brunswick Family Medicine may also choose to coordinate my care with other experts, including but not limited to pain management specialists, neurologists and psychiatrists when managing chronic pain.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Parent or Guardian:

Date:

PLEASE LIST ALL NARCOTIC/CONTROLLED SUBSTANCE-BASED MEDICATION YOU ARE CURRENTLY TAKING BELOW WITH THE NAME & PHONE NUMBER OF THE PRESCRIBING PROVIDER AND THE DATE THE MEDICATION WAS LAST FILLED.

Add another

HIPAA Consent

In regards to HIPAA our office is not allowed to release any of your medical information to others unless we have your written consent.

, give permission for the following to have access to my medical information.

Add another

Are we allowed to leave messages on your answering machine or voicemail? (ex. Lab results, xray results, confirm appointments, etc.)

Yes No

From time to time we may need to mail something to you. Is this okay? (Please choose)

Yes No

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Parent or Guardian:

Date:

No Show Policy

Brunswick Family Medicine, PA has a formal policy regarding “no shows”. A “no show” is defined as a scheduled appointment that the patient does not keep and does not call to cancel.

POLICY:

We understand that there are extenuating circumstances beyond your control that may lead to missed appointments, but we request that you call us as much in advance as possible to cancel (at least 3 or more hours prior to appointment time).

When we reserve appointment time for patients who do not come, we deprive other patients in need of care. After your 3rd no show visit you may be dismissed from our practice and asked to find a new provider within 30 days.

By signing below I acknowledge that I fully understand the above policy. I am aware that possible termination from Brunswick Family Medicine, PA may occur if I miss 3 scheduled appointments without giving proper notice.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Parent or Guardian:

Date:

PCMH Patient/Provider Contract

Good communication between patients, providers and provider support staff is the key to better health & outcomes. Our providers and staff are committed to providing you the highest quality medical care. This can best be accomplished by a clear understanding about our responsibilities to you, and your rights and responsibilities as a patient in our practice.

Our Responsibilities to You:

Provide timely access to appointments with your clinican of choice when the office is open and information about Urgent Care Facilities when the office is closed.
Listen to your questions and concerns and give responses in a way you can understand.
Make management and treatment plans for your condition easy for you to understand.
Make sure you have a good understanding of all medications prescribed.
Refer you to specialists and assist you in getting appointments.
Give you disease-specific educational materials to assist in self-management.

Your Responsibilities to Us:

Ask questions about your conditions and take an active role in your care.
Give detailed history of your entire family.
Review your health history & medications each time you come in for a visit and provide updated information of any changes have occurred.
Take all medications as prescribed as directed by your provider, and provide information about OTC and Herbal Medications that you are taking.
Keep all scheduled appointments with your provider and other specialist(s).
Discuss and be involved in your treatment plan with your provider, follow orders as given.
Call your provider first with medical problems, unless it is a medical emergency.
Avoid using the Emergency Room in non-emergency situations. Instead use Urgent Care Facilities, lists are available upon request.
Bring all discharge papers from Emergency Room and Urgent Care visits.
Inform your provider of all self-referred visits, or special test(s). Bring documents when available.
Provide updated information such as phone numbers, addresses & insurance information as quickly as possible when there is a change.

PLEASE NOTE: Same day appointments are available as needed. When the office is closed, we have an answering service that will contact the provider on call to address medical issues, which cannot wait until regular office hours. It is important that you keep all scheduled appointments and notify us at lease 3 hours or more in advance if you need to cancel or reschedule appointments.

Urgent or Emergent Care: Please attempt to call the provider on call before going to an after-hours urgent care facility or to an emergency room unless you believe you have a serious problem requiring immediate medical attention.

By signing below, you indicate that you have read this document, that it is your wish to join our medical home and to do your best to abide by the statements listed above. This is not a legally binding contract, but is intended to provide a framework upon which we can build a relationship that will allow you to maximize your health state in a comfortable and welcoming environment.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Parent or Guardian:

Date:

Medication Formulary Benefit Consent

Formulary Benefit data is maintained for health insurance providers by organizations known as Pharmacy Benefit Managers (PBM). PBM's are third-party administrators of prescription drug programs whose primary responsibilities are processing and paying prescription drug claims. They also develop and maintain formularies, which are lists of dispensable drugs covered by a particular drug benefit plan.

Having access to your data as maintained by the PBM's to know what medications have been prescribed to you in the past, and to know what drugs are covered by your insurance plan is very helpful and beneficial to us as your primary care provider.

By signing below, you give your permission for Brunswick Family Medicine to access your pharmacy benefits data electronically. This consent will enable us to:

Determine the pharmacy benefits and drug copays for a patient's health plan.
Check whether a prescribed medication is covered (in formulary) under a patient's plan.
Display therapeutic alternatives with preference rank (if available) within a drug class for non-formulary medications.
Determine if a patient's health plan allows electronic prescribing to mail order pharmacies, and if so, e-prescribe to these pharmacies.
Download a histories list of all medications prescribed for a patient by another provider.

In summary, we ask your permission to obtain formulary information and information about other prescriptions by other providers using this electronic system.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Parent or Guardian:

Date:

Patient Record Sharing Consent

With Patient Record Sharing, we can securely exchange your medical records with other participating providers regardless of where you receive care. Your records will only be exchanged with healthcare organizations where you've been treated.

Patient Record Sharing will benefit you in the following ways:

Providers at Brunswick Family Medicine (and other offices you visit that are using Patient Record Sharing) can receive a more comprehensive view of your care and see what tests other providers have performed, so you won't receive duplicative care.
Time is valuable. Spend less of it waiting for your medical records to be sent to providers or offices.
In case of an emergency (although we hope there never is), the healthcare organization where you go for emergency care may have access to relevant health information, helping them promptly provide appropriate care.

I choose to have my records shared through Patient Record Sharing at this time and give my permission to Brunswick Family Medicine to share my records from their office with other connected providers that I see.

I choose to opt out of Patient Record Sharing at this time.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient or Parent or Guardian:

Date:

Health History Questionnaire

SOCIAL HISTORY

Alcohol Use:

Current Use Never Quit

If you quit, When?

Usage Information: How much?

Type?

Tobacco Use:

Current Use Never Quit

If you quit, When?

Usage Information: How much?

Type?

Drug Use:

Current Use Never Quit

If you quit, When?

Usage Information: How much?

Type?

GENERAL INFORMATION ABOUT YOU

Employment:

Full-Time Part-Time Self Stay-At-Home Retired

Occupation: (past or present)

Children:

Hobbies:

Exercise: (type & how often)

Do you have a Living Will?:

Yes

(if yes, please provide us a copy)

CURRENT MEDICATIONS

(name of medication, dosage (mg’s), and directions on how to take)
Please included all prescriptions, over-the-counter medications, vitamins, and supplements

Add another

ALLERGIES

Add another

LIST OF OTHER PROVIDERS

Add another

YOUR MEDICAL HISTORY

Which of the following conditions are you currently being treated or have been treated for in the past?

If you checked Breast, which side?

Endocrine:

Cushing’s Disease

Diabetes – Type I

Diabetes – Type II

Gestational Diabetes

Hyperthyroidism

Hypothyroidism

Renal/Gynecological:

Renal Failure (acute or chronic)

Endometriosis

Urinary Incontinence

Abnormal PAP

Polycystic Kidney Disease

Polycystic Ovarian Disease

Kidney Stones

Recurrent UTI’s

Erectile Dysfunction

Hematologic:

Anemia

Iron Deficiency

Sickle Cell Anemia

Vitamin B12 Deficiency

If you checked Chronic pain, where?

If you checked Fractures, where?

Other:

Immunodeficiency

Glaucoma

Cataract

Obesity

Vitamin D Deficiency

YOUR SURGICAL HISTORY

Cosmetic Procedure(s) details & dates:

Appendectomy details & dates:

Gall Bladder Removal details & dates:

Colon Resection details & dates:

Hysterectomy details & dates:

Lung Resection details & dates:

Tonsil/Adenoidectomy details & dates:

Thyroidectomy details & dates:

Myringotomy (ear tubes) details & dates:

Shoulder Surgery or Replacement details & dates:

Hip Surgery or Replacement details & dates:

Knee Surgery or Replacement details & dates:

C-Section details & dates:

Cataract Removal details & dates:

Hernia Repair details & dates:

Pacemaker Implantation details & dates:

Valve Replacement details & dates:

Other details & dates:

FAMILY HISTORY

Were you adopted?

Yes No

Please put a checkmark in all applicable boxes

If you checked Cancer, specify type

If you checked Other, please specify: