NEW PATIENT FORMS

Patient History Questionnaire - New Patient

Name:

Age:

Date

Last 4 of S.S.#

Birth Date:

Marital Status:

Sex:

Address:

City:

Zip:

Home Telephone:

Cell Telephone:

Next of Kin/Emergency Contact (name and phone #):

Relationship:

Referral Doctor:

Primary Doctor:

Employer:

Employer Address:

Employer Phone Number:

INSURANCE INFORMATION:

Type of Insurance:

Policy Holder:

Policy Holder Birth Date:

Policy Holder S.S.#:

Policy Holder Address:

Relationship to Patient:

Policy Holder Employer:

CHIEF COMPLAINT:

(What brought you to the doctor today?)

Past Medical History:

If other, speicfy:

Past Surgical History:

(Have you had any surgery before?)

Yes No

If yes, please list procedure and date:

Social History:

How much?

What type of job do you have?

Family History:

(Do any illnesses run in your family?)

Review of Systems:

(Please check if you have any of the following)

CONSTITUTIONAL

Fever

Weight Loss

Lethargy

EARS, NOSE, MOUTH & THROAT

Tinnitis

Nose bleeds

Nasal congestion

Sore throat

Difficulty swallowing

GENITOURINARY

Frequency

Blood in urine

Abnormal urine color

Painful urination

Awaken to urinate

Unable to fully empty bladder

Incontinence

НЕМАТOLOGIC/ LYMPHATIC

Easy bruising

Anemia

Blood abnormalities

Blood thinners

Lymph node enlargement

EYES

Blurred vision

Cataracts

Glasses/Contacts

RESPIRATORY

Chronic cough

Wheezing

Cough blood

Productive cough

Asthma

MUSCULOSKELETAL

Pain

Limited range of motion

Limited strength

Arthritis

NEUROLOGICAL

Headache

Fainting

Dizziness

Memory loss

Numbness

CARDIOVASCULAR

Shortness of breath

Chest Pain (angina)

Heart Palpitations

Cold Extremities

INTEGUMENTARY

Rash

Itching

Dry Skin

ENDOCRINE

Night sweats

Reviewed by Physician

Breast Patients Only:

(Please complete the following to help our physicians assess your risk for breast cancer.)

1. How many times have you been pregnant?

2. How many children did you give birth to?

3. How old were you when you gave birth to your first baby?

4. Did you breast feed the babies?

5. How old were you when you had your first menstrual period?

6. If you are post-menopausal, what is the age of onset of menopause?

7. Are you on any hormone replacement therapy?

8. Have you ever had an abnormal mammogram or breast mass?

9. Have you ever had a breast biopsy or cyst aspiration?

10. Have you ever had breast cancer?

11. Do you have any relatives (maternal) with

breast cancer

ovarian cancer

colon cancer

HEIGHT:

WEIGHT:

EMAIL:

PRIMARY PHYSICIANS FULL NAME

PRIMARY PHYSICIANS PRIMARY PHYSICIANS PHONE NUMBER:

MEDICATION ALLERGIES:

Yes No

IF YES, PLEASE LIST:

LATEX ALLERGY:

Yes No

PATIENT MEDICATION LIST

Add Medication

DO YOU SEE A CARDIOLOGIST?

Yes No

IF YES, NAME AND PHONE NUMBER:

DO YOU HAVE A PACEMAKER:

Yes No

DEFIBRILLATOR:

Yes No

PHARMACY NAME

PHARMACY ADDRESS AND PHONE NUMBER

АССЕРТANCE OF FINANCIAL RESPONSIBILITY, ASSIGNMENT OF
BENEFITS & AUTHORIZATION TO RELEASE INFORMATION

FINANCIAL RESPONSIBILITY: Due to the many changes in insurance policies, it is no longer an easy task to interpret each individual policy. Although we try to stay aware of these changes, it is not always possible. We therefore urge you, the patient, to please check with your insurance company prior to any office visit/procedure. It is your responsibility to know your individual coverage. Failing to comply with this suggestion could result in you, the patient, being responsible for all costs incurred. Please remember your insurance policy is between you and your company, not the insurance company and your doctor

INSURANCE AUTHORIZATION AND ASSIGNMENT: I request that payment of authorized Medicare/Other Insurance Company benefits be made on my behalf to Oakland Macomb Surgical Group, P.L.L.C. for any services furnished to me by that physician. I authorize any holder of medical information to release it to the Health Care Financing Administration/Other Insurance Company and its agents any information needed to determine these benefits payable to related services. I understand my signature request that payment be made and authorizes release of medical information necessary to pay the claim. In Medicare/Other Insurance Company assigned cases, the physician agrees to accept the charge determined as full charge, and the patient is responsible only for the deductible, coinsurance, copays and noncovered services. Coinsurance, deductibles and copays are based upon the charge determination of Medicare/Other Insurance Company. I authorize doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf

AUTHORIZATION TO RELEASE INFORMATION: I authorize any holder of information concerning my treatment to release that information to the Social Security Administration and its intermediaries, insurance carriers or other governmental offices if needed for this or related claim for payment. I also authorize release of information concerning care and treatment including copies of my medical record and information related claim for payment. I also authorize release of information concerning care and treatment including copies of my medical record and information relating to treatment for serious communicable diseases, (as defined by the Michigan Public Health Code), to my Health Plan Administrator, its agents and representatives, insurance carrier or its authorized agent, for the purpose of conduction, concurrent or retrospective, of medical review of treatment and services provided at Oakland Macomb Surgical Group, P.L.L.C.

A photocopy of this assignment shall be considered as effective and valid as the original.

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

(patient)

Signature

(guardian)

(relationship)

Many insurances require referrals from your PCP. If we believe your insurance is among that list of insurances you will be responsible for obtaining the referral from your primary Doctor. If you cannot supply us with the referral you will be responsible for the medical bills from this office. Some insurances may consider us to be out of network which will also require a referral.

Date

Patient Name:

Insurance:

I realize if I do not supply this office with a referral for my insurance from my PCP I will be responsible for any medical bills from this office, that are not paid by my Insurance Company

Signed:

Witness:

ACKNOWLEDGEMENT OF RECEIPT OF PATIENT NOTICE OF PRIVACY PRACTICES

I acknowledge that I received a copy of the Oakland Macomb Surgical Group, PLLC Patient Notice of Privacy Practices effective September 23, 2013.

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.

Date

Patient Name Printed:

Patient Signature:

I would like my physicians to be able to discuss my medical condition with family, relatives, and friends that I have identified as being involved with my healthcare. Please list these individuals below:

I wish to have the following individuals as authorization, to share my health information:

Date

Patient Signature:

Your information will be encrypted.

NEW PATIENT FORMS

Patient History Questionnaire - New Patient

INSURANCE INFORMATION:

CHIEF COMPLAINT:

Past Medical History:

Past Surgical History:

Social History:

Family History:

Review of Systems:

Breast Patients Only:

PATIENT MEDICATION LIST

АССЕРТANCE OF FINANCIAL RESPONSIBILITY, ASSIGNMENT OF BENEFITS & AUTHORIZATION TO RELEASE INFORMATION

ACKNOWLEDGEMENT OF RECEIPT OF PATIENT NOTICE OF PRIVACY PRACTICES

АССЕРТANCE OF FINANCIAL RESPONSIBILITY, ASSIGNMENT OF
BENEFITS & AUTHORIZATION TO RELEASE INFORMATION