New Patient Packets

PATIENT INFORMATION

Last

First

Nickname

Date of Birth

Sex

Male Female

SSN

Marital Status

Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

Veteran

Yes No

Student

Yes No

Employer

Occupation

Please select a Primary Care Provider

Pamela Abrams, MD Laura Bland, PA-C Jeffrey Mandl, NP

EMERGENCY CONTACT INFORMATION

Emergency Contact

Relationship

Home Phone

Cell Phone

Work Phone

ACCOUNT INFORMATION

The Primary Insurance Holder (the person that pays for the insurance plan which is called the policy holder):

Self

Other (please complete)

Policy Holder

Date of Birth

Sex

Male Female

SSN

Relationship to the patient

Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

Employer

Occupation

INSURANCE INFORMATION

The patient’s insurance card must be presented at the time of your appointment for each visit. Insurance won’t be billed until a copy of the card is received. COPAYS are due at the appointment. Failure to pay the copay will result in a $10 fee. Self-Pay patients and out-of-network patients are required to pay for the visit in full at the time of service. The patient authorizes Family Practice Associates to release information to the insurance company in order for current and future claims to be processed. Patients 18 years and older will be responsible for the account unless we received signed notification from your responsible party.

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

Signature of Patient OR Responsible Party (relationship)

Date

HIPAA Privacy Authorization Form

Authorization for Use or Disclosure of Protected Health Information

AUTHORIZATION: I authorize Family Practice Associates to use and/or disclose certain Protected Health Information (PHI) about me to the following individuals. (Please print full name.)

None

Spouse

Family Member

Other

This authorization includes the release of my complete medical record for past, present and future periods unless otherwise specified here:

From

Your initials are required to withhold the following information:

Alcohol/Drug Abuse Treatment

Communicable Diseases

Mental Health Records

Other

Please specify.

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. The medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I direct. I understand that treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization. I may revoke this authorization at any time by notifying FAMILY PRACTICE ASSOCIATES, in writing, of my desire to revoke it. The notice will not apply to actions taken by the requesting person/entity prior to the date FAMILY PRACTICE ASSOCIATES receives the request.

This authorization is automatically in force for 3 years or until (date), at which time this authorization expires.

Signature of Patient OR Personal Representative (Relationship)

Date

REQUIRES PATIENT SIGNATURE:

I acknowledge that I have received a copy of the NOTICE OF PRIVACY PRACTICES regarding my health information.

Signature of Patient OR Personal Representative (Relationship)

Date

I acknowledge that I have received a copy of the NOTICE OF OFFICE AND FINANCIAL POLICIES.

Signature of Patient OR Personal Representative (Relationship)

Date

As part of our electronic health record standard, would you be willing to state your race and ethnicity? This is an important part of your medical history. Some medical conditions are more prevalent in certain races, such as diabetes, hypertension and cancer

Name

Date of Birth

RACE: please check only one

Native American Indian / Alaska Native

Asian

Black or African American

Native Hawaiian

Other Pacific Islander

White

Unreported / Refused to Report

ETHNICITY: please check only one

Hispanic or Latino

Non-Hispanic

Decline to Specify

Unknown / Not Reported

Refused to Report

Informed Consent for Telemedicine Services

I understand that telemedicine is the use of electronic information and communication technologies by a healthcare provider to deliver services to an individual when he/she is located at a different location or site than I am, and I must be physically located in the state of Colorado when receiving this service through Family Practice Associates.
I understand the potential limitations of telemedicine, and that services will be provided to the best ability of the healthcare provider.
I understand that Family Practice Associates utilizes the Hippo Health software program to conduct telemedicine services, and I agree to installing this application (app) on my cell phone, computer and/or tablet in order to receive telemedicine.
I understand that the telemedicine visit will be performed through a two-way video link-up. The healthcare provider will be able to see my image on my cell phone screen, computer monitor or tablet, and the provider will hear my voice. I will be able to hear and see the healthcare provider.
I understand that technical difficulties may occur before or during the telemedicine session, and that the healthcare provider may conduct the appointment via regular telephone communication if such difficulties interfere with utilizing Hippo Health.
I understand the the laws that protect privacy and the confidentiality of medical information, including HIPAA, also apply to telemedicine.
I understand that I will be responsible for any copayments or other financial patient responsibility, and that I am responsible for knowing whether my insurance plan covers telemedicine.
I understand that by signing this form that I am consenting to receive health care services via telemedicine.

I AGREE

I DECLINE

Patient Name

Date of Birth

Patient Signature

Date

- OR - Legal Guardian Name

Legal Guardian Signature

Date

New Patient - Health History Questionnaire

Name

DOB

Date

Have you even been exposed to or do you have a family member with ...

HIV/AIDS

Hepatitis

Other medical conditions not listed above:

Add Medical Condition

List all surgeries you have had:

Add Surgery

List all medication allergies:

Add Medication Allergy

List all medications, vitamins, and supplements you are currently taking:

Add Medication, Vitamins, and Supplements

List all health care providers you have seen in the past or are currently seeing:

Add Healthcare Provider

Please list your use of tobacco products:

None

Cigarettes

Smokeless Tobacco

Pipe

Cigars

Marijuana

How much do you or did you smoke per day?

For how many years?

Do you wish to quit?

Now Soon Eventually Never

Have you quit?

Yes No

If so, when?

Have you used illicit drugs (heroin, cocaine, LSD, etc.)?

Yes No

How much alcohol do you drink weekly on average?

Do you have a problem with alcohol?

Yes No

How much caffeine do you drink daily (include coffee, tea, cola)?

Are you sexually active?

Yes No

What is your sexual preference?

Male Female Both

Do you use contraception?

None Rhythm Condoms Pill Vasectomy IUD Diaphragm Tubal Ligation

Do you practice safe sex?

Never Sometimes Always

Have you ever had a blood transfusion?

Yes No

If yes, what year?

Have you recently traveled outside the U.S.?

Yes No

Where?

Marital Status

Single Married Separated Divorced Widowed Partner

Are you currently…

Employed Self-Employed Unemployed Retired

What is or was your occupation?

Do you exercise regularly?

Yes No

What activity?

How often?

Please check if there is a history of any of the following diseases in your family:

Heart Disease

Diabetes

Breast Cancer

Ovarian Cancer

Osteoporosis

Skin Cancer

Colon Cancer

Prostate Cancer

High Cholesterol

Please fill in the following family history of medical problems:

Father

Mother

Brother(s)

Son(s)

Sister(s)

Daughter(s)

REVIEW OF SYSTEMS

Current health symptoms. Please complete all questions.

1. Have you had a recent weight gain or loss that worries you?

Yes No

2. Have you had any unexplained fevers or night sweats?

Yes No

3. Do you have sinus or nasal allergy symptoms that affect your quality of life?

Yes No

4. Do you have any vision or hearing problems that are bothersome?

Yes No

5. Are you experiencing chest pains or irregular beats that worry you?

Yes No

6. Do you have unusual shortness of breath or a persistent cough?

Yes No

7. Do you have leg swelling that is recurrent or bothersome?

Yes No

8. Do you experience wheezing when you breathe?

Yes No

9. Do you have sleep problems that interfere with your quality of life?

Yes No

10. Have you been told that you snore and stop breathing during sleep?

Yes No

11. Do you have constipation, diarrhea, stomach pain or other problems with digestion that interfere with your quality of life?

Yes No

12. Have your bowel movement patterns changed in recent months?

Yes No

13. Do you have problems with urination that affects your quality of life?

Yes No

14. Do you have problems with sexual function that affects your quality of life?

Yes No

15. Do you have joint or back problems that affect your quality of life?

Yes No

16. Do you have leg pain, numbness or weakness that limits how fast or how far you can walk?

Yes No

17. Do you have headaches that affect your ability to function?

Yes No

18. Have you had an unexpected fall with injury in the past year?

Yes No

19. Do you have poor balance or fear of falling?

Yes No

20. Do you have little pleasure in doing things?

Yes No

21. Do you feel down, depressed, or hopeless?

Yes No

22. Are you concerned about anxiety or stress in your life?

Yes No

23. Are you concerned about your memory?

Yes No

24. Have you noticed unusual bruising or bleeding?

Yes No

25. Do you have unusual skin lesions that concern you?

Yes No

Comments

Note: Evaluation of these concerns is not usually part of the annual wellness or preventative exam. It is likely that your doctor will need to schedule an additional appointment to follow up on these problems.

Patient Signature

Date

Physician Signature

Date

Your information will be encrypted.

New Patient Packets - Adults

PATIENT INFORMATION

EMERGENCY CONTACT INFORMATION

ACCOUNT INFORMATION

INSURANCE INFORMATION

HIPAA Privacy Authorization Form

REQUIRES PATIENT SIGNATURE:

Informed Consent for Telemedicine Services

New Patient - Health History Questionnaire

REVIEW OF SYSTEMS