New Patient Forms

Patient Name:

Last Name:

First Name:

Middle Initial:

DOB:

Soc. Sec #:

Sex:

Male Female

Marital Status:

Minor Single Married Divorced Widowed Separated

Home Phone:

Cell Phone:

Address:

City:

State:

Zip:

Emergency Contact:

Name:

Contact Number:

Relationship to Patient:

Physician Information

Referring Physician:

Contact #:

Reason for Referral:

Primary Physician:

Contact #:

Address:

City:

State:

Zip:

Insurance Information

Primary Insurance:

Policy Holder Name:

DOB:

Soc. Sec #:

Address:

City:

State:

Zip:

Contact #:

Policy ID#:

Grp #:

Effective Date:

Secondary Insurance:

Policy Holder Name:

DOB:

Soc. Sec #:

Address:

City:

State:

Zip:

Contact #:

Policy ID#:

Grp #:

Effective Date:

Disclosure of Health Information

Under the new HIPPA regulations that went into effect on April 14, 2003, we are only privileged to disclose health information to family members/individuals that you designate us to.

Please check off and provide the names and contact information for the following family members/individuals that you would like us to release your health information to.

Wife

Yes No

If yes, please provide name:

Husband

Yes No

If yes, please provide name:

Mother

Yes No

If yes, please provide name:

Father

Yes No

If yes, please provide name:

Son

Yes No

If yes, please provide name:

Daughter

Yes No

If yes, please provide name:

Entire Family

Yes No

If yes, please provide names:

Other

Yes No

If yes, please specify:

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:

Date:

Medication List

Patient Name:

DOB:

Date:

Allergies:

Medication Name:

Dosage:

Frequency:

Add New Medication

Patient Name:

DOB:

Primary Pharmacy

Pharmacy Name:

Pharmacy Phone #:

Pharmacy Address:

Secondary Pharmacy

Pharmacy Name:

Pharmacy Phone #:

Pharmacy Address:

Additional Pharmacy

Pharmacy Name:

Pharmacy Phone #:

Pharmacy Address:

Patient Health History

Patient Name:

DOB:

Date:

Social History:

Do you smoke?

Yes No

If yes, how many cigarettes/cigars per day do you smoke?

How long?

Do you drink alcohol?

Yes No

If yes, how many drinks do you consume per day?

How long?

Do you use any drugs?

Yes No

If yes, what type of drug(s)?

How long?

Immunizations:

Influenza shot:

Yes No

If yes, please specify date:

Pneumonia:

Yes No

If yes, please specify date:

Family/Personal History:

Kidney Disease

None

Father

Mother

Sibling

Child

Self

Type if Known:

Diabetes

None

Father

Mother

Sibling

Child

Self

Type if Known:

Hypertension

None

Father

Mother

Sibling

Child

Self

Type if Known:

Heart Disease

None

Father

Mother

Sibling

Child

Self

Type if Known:

Cancer

None

Father

Mother

Sibling

Child

Self

Type if Known:

Stroke

None

Father

Mother

Sibling

Child

Self

Type if Known:

Mother

Living Deceased Unknown

Reason Deceased:

Father

Living Deceased Unknown

Reason Deceased:

Other:

Surgical History

Add new row

Cultural Competency:

State of New Jersey mandates that every physician documents and barrier to care including cultural and linguistic needs in the medical record. Factors affecting care are visual or auditory factors which may impede your ability to comprehend medical discussions and language, cultural and/or religious customs which may impact the medical provider’s ability to provide medical care. Addressing these needs will improve patient satisfaction and also decrease health care disparities.

Do you have any Impairment (i.e. visual, hearing, speech, learning, physical or language/cultural barrier)?

Yes No

Impairment:

Do you have any religious or culture customs that the doctor should know about?

Yes No

Description:

Race:

Asian Black/African American Native Hawaiian American Indian/Alaskan Native Other Pacific Islander White

Ethnicity:

Latino or Hispanic Identity Non- Latino or Hispanic Identity Refuse/Unreported

What Language do you speak?

English

French

German

Spanish

French Creole

Arabic

Chinese

Advance Directives: For all patients 18 years and older

Advance Directives is a federal and state mandates Self-Determination Act enacted in 1990. This allows you to provide specific instructions and directions regarding your own medical care wishes if you become incapacitated. The patient-physician relationship provides a direct opportunity for you to discuss these types of decisions.

Do you have a “Living Will” or “Advance Directive”?

Yes No

Would you like to know more about a living will?

Yes No

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:

Date:

Medical Records Release Statement

Patient name:

DOB:

Address:

City:

State:

Zip:

I authorize the use and disclosure of the health information for the individual named above as described below.

Treatment Dates and Locations:

Emergency Department Location/Date(s):

Outpatient Location/Date(s):

Inpatient Location/Date(s):

If Other is selected, please specify:

This information may be disclosed to and used by the following organization:

Organization Name: Nephrology & Hypertension Associates of NJ

Address:

City:

State:

Zip:

Phone:

Fax:

Reason / Purpose for the request: Continuity of Care

I understand that the information in my health records may include information relating to the (HIV) Human Immunodeficiency Virus, (AIDS) Acquired Immune Deficiency Syndrome, psychological conditions or treatment, sexually transmitted diseases, drug/alcohol dependence status, detoxification or rehabilitation services.

I understand that I have the right to revoke this authorization at any time. I understand if I revoke this authorization, I must do so in writing and present my revocation to the Nephrology & Hypertension Assoc. of New Jersey. I understand that the revocation will not apply to information that has already been released in response to the authorization. I understand that the revocation will not apple to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event or condition

I understand the authorizing this disclosure of health information is voluntary and I can refuse to sign this form if I do not wish this request to be processed. I do not need to sign to assure treatment. I understand I may inspect or obtain a copy of the information to be used or disclosed as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules.

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.

Printed Name of Patient or Legal Representative:

Date:

Your information will be encrypted.