Internal Medicine Form

PATIENT:

Last Name:

First Name:

MI:

Address:

City:

State:

Zip:

Soc. Sec#:

Date of Birth:

Sex:

Race:

Telephone Number:

E-mail:

Laguage Spoken:

Preference for Reminder

Phone

Mail

Employer:

Work Number:

EMERGENCY CONTACT (OTHER THAN SPOUSE)

Name:

Relationship to Patient

Telephone:

Address:

City:

State:

Zip:

Whom should we thank for referring you:

RESPONSIBLE PARTY:

Name:

Relationship to Patient

INSURANCE:

Company Name:

ID #:

GROUP #:

Policy Holder:

Relationship to Patient

Company Name:

ID #:

GROUP #:

Policy Holder:

Relationship to Patient

BENEFITS AUTHORIZATION:

I authorize treatment of the patient named above and agree to pay all fees and charges billed by Progressive Physicians Practice. I request that payment of authorized Insurance Company or third party insurance be made to Progressive Physicians Practice or one of its physicians if assignment is accepted in which case agree to pay any deductible, co-payment or disallowed charges. If assignment is not accepted I agree to pay the entire amount due. I authorize any holder of medical information about me to be released to the Health Care Financing Administration and its agents, the Division of Medicaid and their Fiscal Agent or any third party insurance, any information needed to determine these benefits. If you default on any payment you will be responsible for any COLLECTION AGENCY CHARGES.

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

Signature:

Date

AUTHORIZATION FOR DISCLOSER OF HEALTH INFORMATION

Patient Name:

Date of Birth:

Phone:

Address:

City:

State:

Zip:

1. I authorize the use or disclosure of the above named individual's health information as described below.

2. The following individual or organization is authorized to make this discloser:

Name of Hospital, Clinic, and/or Facility:

Address:

City:

State:

Zip:

Phone:

Fax:

3. The type and amount of information to be used or disclosed is as follows: (Includes dates where appropriate.)

Compare health records

Lab results/ X-ray reports

Physical exam

Consultation reports

Immunization records

Other (Please specify)

4. I understand that the information in my health record may include information relating to sexual transmitted disease, acquired immunodeficiency syndrome (AIDS) or human Immunodeficiciency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.

5. This information may be disclosed to and used by the following individual or organization

PROGRESSIVE PHYSICIANS PRACTICE, PLLC8412 AIRWAYS BLVD SOUTHAVEN, MS

38671662-536-2100 PHONE | 662-536-2211 FAX

6. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the Health Information Management department at PROGRESSIVE PHYSICIANS PRACTICE 8412 AIRWAYS BLVD, SOUTHAVEN MS. 38671. I understand that the revocation will not apply 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 in 60 days.

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

PATIENT SIGNATURE(OR LEGAL REPRESENTATIVE)

DATE

REASON FOR VISIT:

Why are you here today?

MEDICAL HISTORY:

When was your last physical exam?

Physician's Name

Phone#

1. Are you currently under medical treatment?

Yes No

Please describe

2. Have you ever had any serious illness or operations?

Yes No

Please describe

3. Are you currently taking any medications?

Yes No

Please describe

4. Do you smoke?

Yes No

5. Do you use alcohol?

Yes No

6. Do you use any illegal drugs?

Yes No

7. Have you had any allergic reaction to the following:

Local Anesthitics (Novocain)

Yes No

Penicillin or other Antibiotics

Yes No

Sulfa Drugs

Yes No

Barbiturates(Sleeping pills)

Yes No

Sedatives

Yes No

Iodine

Yes No

Aspirin

Yes No

Other Please. describe:

WOMEN ONLY:

When was your last menstrual period?

Do you get regular periods?

Yes No

Are you taking birth controls?

Yes No

Have you ever been pregnant?

Yes No

HAVE YOU EVER HAD THE FOLLOWING:

Anemia (low blood count)

Yes No

Liver Disease

Yes No

Anorexia(no appetite)

Yes No

Low Blood Pressure

Yes No

Arthritis

Yes No

Measles

Yes No

Asthma

Yes No

Migraine Headaches

Yes No

Back Problems

Yes No

Mitral Valve Prolapse

Yes No

Bleeding Tendency

Yes No

Mumps

Yes No

Blood Disease

Yes No

Multiple Sclerosis

Yes No

Cancer

Yes No

Pacemaker

Yes No

Chemical Dependency (addicted to drugs)

Yes No

Pneumonia

Yes No

Chemotherapy

Yes No

Polio

Yes No

Chicken Pox

Yes No

Prostate Problem

Yes No

Chronic Fatigue Syndrome

Yes No

Psychiatric Care

Yes No

Congenital Heart Lesions

Yes No

Respiratory disease

Yes No

Cough (persistent or bloody)

Yes No

Rheumatic Fever

Yes No

Diabetes

Yes No

Scarlet Fever

Yes No

Emphysema

Yes No

Shortness of Breath

Yes No

Epilepsy

Yes No

Sinus Trouble

Yes No

Glaucoma

Yes No

Skin Rash

Yes No

Heart Murmur

Yes No

Stroke

Yes No

Heart Disease

Yes No

Thyroid Problems

Yes No

Hepatitis Type

Yes No

Hepatitis Type:

Hernia

Yes No

Tonsillitis

Yes No

Hespes

Yes No

Tuberculosis

Yes No

High Blood Pressure

Yes No

Ulcer

Yes No

HIV / AIDS

Yes No

Venereal Disease

Yes No

Jaundice

Yes No

Kidney Disease

Yes No

Latex Sensitivity

Yes No

Any Other Conditions

Yes No

Please list and describe:

ASSIGNMENT AND RELEASE:

I Hereby authorize payment directly to for all benefits otherwise payable to me for services rendered, I understand that I am directly responsible for ALL charges whether or not paid by insurance and for ALL service rendered on my behalf or my dependents.

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

Signed

Date

FAMILY HISTORY

Please indicate if a Family member has or had one of

ALCOHOLISM

MOTHER

FATHER

SISTER

BROTHER

NONE

ANEMIA

MOTHER

FATHER

SISTER

BROTHER

NONE

ASTHMA

MOTHER

FATHER

SISTER

BROTHER

NONE

BLOOD DISEASE

MOTHER

FATHER

SISTER

BROTHER

NONE

CANCER

MOTHER

FATHER

SISTER

BROTHER

NONE

PLEASE LIST WHAT TYPE OF CANCER:

CONVULSIONS/EPILEPSY

MOTHER

FATHER

SISTER

BROTHER

NONE

DEAFNESS

MOTHER

FATHER

SISTER

BROTHER

NONE

DIABETES

MOTHER

FATHER

SISTER

BROTHER

NONE

PLEASE INDICATE WHICH TYPE OF DIABETES

TYPE I TYPE II

DRUG ABUSE

MOTHER

FATHER

SISTER

BROTHER

NONE

HEART DISEASE

MOTHER

FATHER

SISTER

BROTHER

NONE

HIGH CHOLESTEROL

MOTHER

FATHER

SISTER

BROTHER

NONE

HIGH BLOOD PRESSURE

MOTHER

FATHER

SISTER

BROTHER

NONE

HIV/AIDS

MOTHER

FATHER

SISTER

BROTHER

NONE

IMMUNE PROBLEM

MOTHER

FATHER

SISTER

BROTHER

NONE

KIDNEY DISEASE

MOTHER

FATHER

SISTER

BROTHER

NONE

LIVER DISEASE

MOTHER

FATHER

SISTER

BROTHER

NONE

MENTAL DISORDER

MOTHER

FATHER

SISTER

BROTHER

NONE

MENTAL RETARDATION

MOTHER

FATHER

SISTER

BROTHER

NONE

MIGRAINE HEADACHES

MOTHER

FATHER

SISTER

BROTHER

NONE

NASAL ALLERGIES

MOTHER

FATHER

SISTER

BROTHER

NONE

THYROID PROBLEMS

MOTHER

FATHER

SISTER

BROTHER

NONE

TUBERCULOSIS

MOTHER

FATHER

SISTER

BROTHER

NONE

RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT OF RECEIPT

I, (Please input Name below) have received a copy of Progressive Physicians Practice's Notice of Privacy Practices and I have been given an opportunity to ask questions.

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

Signature of Patient/Parent

Date

PROGRESSIVE PHYCISIANS PRACTICE, PLLC GENERAL CONSENT FOR DIAGNOSIS AND TREATMENT

I, THE UNDERSIGNED PATIENT OR RESPONSIBLE PERSON, HAVING REGISTERED AT PROGRESSIVE PHYSICIANS PRACTICE FOR THE PURPOSE OF OBTAINING KEALTH SERVICES, DO HEREBY VOLUNTARILY CONSENT TO SUCH DIAGNOSTIC AND TREATMENT SERVICES AS NIGHT BE PROVIDED BY OR THE DIRECTION OF A PHYSICIAN. OR OTHER QUALIFIED HEALTH CARE PROVIDER IN THE CLINIC.

I, RECOGNIZE THAT I HAVE THE RIGHT TO REFUSE ANY SPECIFIC DIAGNOSTIC OR TREATMENT SERVICE WITHOUT JEOPERDIZING MY RIGHT TO RECEIVE HEALTH SERVICES AT THE CLINIC. I ALSO RECOGNIZE THAT I WILL BE ASKED TO SIGN A SPECIFIC CONSENT, AS NEEDED, FOR SURGICAL AND OTHER SPECIAL PROCEDURES INCLUDING GENERAL AND/OR EXTENSIVE LOCAL ANESTHESIAS.

I AM AWARE THAT HEALTH SERVICES ARE NOT BASED ÖN EXACT SCIENCE; BUT ARE PROVIDED ACCORDING TO JUDGEMENT OF THE PHYSICIAN, DENTIST, OR OTHER QUALIFIED HEALTH CARE PROVIDER OF THE CLINIC. I ACKNOWLEDGE THAT NO GUARANTEES HAVE BEEN MADE TO ME AS TO THE RESULTS OF ANY:DIAGNOSTIC OR TREATMENT SERVICES, FURTHER, I AUTHORIZE THAT CLINIC TO FURNISH REQUESTED PATIENT INFORMATION TO REQUISITE LEGAL, HEALTH, SOCIAL, AND GOVERNMENT ENTITLES, AS. NEEDED.

I CERTIFY THAT I HAVE THE LEGAL CAPACITY TO GIVE THIS CONSENT FOR DIAGNOSTIC AND TREATMENT SERVICES ON THE PATIENT NAMED BELOW, I FURTHER CERTIFY THAT THS FORM HAS BEEN FULLY EXPLAINED, TO ME AND THAT I. UNDERSTAND ITS CONTENTS.

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

PRINT NAME OF PATIENT

Date

SIGNATURE OF PATIENT

SIGNATURE OF STAFF

RELATIONSHIP TO PATIENT (IF NOT SIGNED BY PATIENT)

COMPLETE THIS SECTION ALSO IF PATIENT IS A MINOR SEEKING REPRODUCTIVE HEALTH CARE

I RECOGNIZE THAT, ACCORDING TO THE LAWS OF THAT STATE OF MISSISSIPPI.PARENTAL CONSENT IS NOT REQUIRED IN THAT CADE OF A MINOR SEEKING TREATMENT OF A VENEREAL DISEASE OR A FEMALE. REGARDLESS OF THE AGE OR I/ARITAL STATUS, SEEKING DIAGNOSTIC OR TREATMENT SERVICE IN CONNECTION WITH PREGNANCY OR CHILDBIRTH.

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

PRINT NAME OF PATIENT

Date

SIGNATURE OF PATIENT

TERMS OF PAYMENT AFTER YOUR INSURANCE HAS BEEN FILED AND PAYMENT HAS BEEN POSTED TO YOUR ACCOUNT

THE POLICY OF PROGRESSIVE PHYSICIANS PRACTICE, LL., IS TO ASK FOR PAYMENT ON BALANCES DUE ON YOUR ACCOUNT WE WILL FILE YOUR INSURANCE CLAIM FOR PAYMENT FOR ALL COVERED SERVICES PROVIDED TO YOU IN THE OFFICE.

THIS IS TO ADVISE YOU THE PATIENT OF OUR TERMS FOR FILING YOUR INSURANCE CLAIM. ONCE YOU THE PATIENT HAS SEEN THE DOCTOR WE WILL FILE YOUR INSURANCE CLAIM. WE WILL RECEIVE AND EXPLANATION OF BENEFITS FROM YOUR INSURANCE COMPANY AT THAT TIME WE WILL POST THE PAYMENTS AND OR THE ADJUSTMENTS TO YOUR ACCOUNT.THE AMOUNT YOUR INSURANCE PUTS TO YOUR RESPONSIBILITY YOU WILL BE RESPONSIBLE FOR PAYING. WE WILL SEND YOU A STATEMENT FOR ANY BALANCE DUE FROM. YOU. IF YOU NEED TO SEE THE DOCTOR AND YOU HAVE A BALANCE ON YOUR ACCOUNT, THIS BALANCE WILL NEED TO BE TAKEN CARE OF BEFORE SEEING THE DOCTOR.

BY SIGNING BELOW, YOU ARE STATING THAT YOU UNDERSTAND THE ABOVE AND AGREE TO PAY ANY BALANCES DUE FROM YOU AFTER YOUR INSURANCE HAS BEEN FILED BY OUR OFFICE. IF YOU DO NOT UNDERSTAND PLEASE ASK ONE OF THE OFFICE STAFF AND THEY WILL BE GLAD TO ASSIST YOU.

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

Print Name

Witness Printed

Sign Name

Witness Signed

Date

AGREEMENT FORM REGARDING SCHEDULE PRESCRIPTIONS

BY SIGNING THIS FORM I AGREE THAT I DO NOT USE MULTIPLE PHYSICIANS FOR TREATMENT OF BACK PAIN AND ANY OTHER PROBLEM THAT REQUIRES TREATMENT WITH NARCOTIC MEDICATION. I ALSO UNDERSTAND THAT IF I RECEIVE TREATMENT AND/OR NARCOTIC PRESCRIPTIONS BY MULTIPLE PHYSICIANS AND IF I USE MULTIPLE PHARMACIES TO GET MY PRESCRIPTIONS FILLED THAT I AUTOMATICALLY BREAK THIS AGREEMENT. AT THAT TIME I WILL NEED TO FIND ANOTHER PHYSICIAN FOR TREATMENT. BY SIGNING THIS FORM I AM AGREEING THAT I HAVE READ AND UNDERSTAND IT COMPLETELY.

NAME

Date

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