Tenet Florida Physician Services

Tenet Florida Physician Services

, Patient Information Form

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Patient Information

Last Name First Name Middle Name

Previous Last Name Birth Date (mm/dd/yyyy) Sex: 0 Male 0 Female

Billing Address:

Street City State Zip

Country

Secondary Alternate Address:

Street City State Zip

Country

Please check page three (3) for Race 6 Language Choices:

Race Language

Ethnicity: 0 Hispanic 0 Non-Hispanic 0 Unknown Marital Status _ Home Phone Day Phone

Cell/Alternate Phone E-Mail

Preferred Contact Method: 0 Home Phone 0 Day Phone 0 Cell/Alternate Phone 0 Email

Primary Care Physician:

How were you referred to our office?

If patient is a minor (under 18 years old):

Father's name Mother's name

Employer Information

Employer

Employer Address:

Occupation Work Phone#

Street City State Zip

Country

Relations Information (Name of person to contact in case of an emergency):

Last Name First Name Relationship to Patient

Home Phone

Insurance

Work Phone Cell/Alternate Phone

Is your visit due to an Auto Accident? 0 Yes 0 No

Worker's Compensation? 0 Yes 0 No

If yes, date of Accident -----

If yes, date of Accident _

Are you personally responsible for payment of the fees for services provided by our office?

DYes 0 No

Ifno, whois?

Guarantor Name

Relationship

Address (if different from patient) City State Zip Code

Country

Guarantor Employer Name

Guarantor Employer Address:

Street City State Zip

Country

Employer Telephone Number ext. Primary Insurance Plan Name Policy Holder Name

Policy Holder Birth Date Policy # Policy Group # Secondary Insurance Plan Name Policy Holder Name

Policy Holder Birth Date Policy# Policy Group#

Preferred Pharmacy #1

Name

Address City Phone#

Preferred Pharmacy #2

Name

Address City Phone#

t • ' I

PLEASE READ AND SIGN THE FOLLOWING

1. Payment for services is expected at time of service.

2. If insurance is filed, I authorize benefits to be paid directly to Tenet Florida Physician

Services, LLC.

3. I am responsible for the balance on my account, regardless of insurance coverage. My failure to pay off outstanding balances on my account may result in collection procedures being taken.

4. I authorize the doctor to release any information requested with regard to the processing of my claims.

5. Failure to give 24 hour notice prior to canceling appointments may result in a cancellation fee charge to my account not payable by health insurance.

Patient/ Parent's/Guardian's Signature Date

Please choose from the following list for your Race:

Asian / Pacific Islander
Black / Unknown
Native American / White
Other Race

Please choose from the following list for your primary Language:

Albanian / English / Indonesian / Portuguese / Thai
Arabic / Estonian / Italian / Romanian / Turkish
Armenian / Farsi / Japanese / Russian / Ukrainian
Azerbaijani / Filipino / Korean / Samoan / Vietnamese
Bosnian / Finnish / Laotian / Serbo-Croatian / Yiddish
Bulgarian / French / Lebanese / Sign Language
Cambodian / German / Lithuanian / Slovak
Chinese / Greek / Malayan / Spanish
Creole / Haitian Creole / Norwegian / Sudanese
Czech / Hebrew / Other / Swedish
Danish / Hmong / Pakistan / Tagalog
Dutch / Hungarian / Polish / Taiwanese

TFP282S_Patient_lnfo_Form_1512

Patient Health History Form

Patient Name Birth Date (mm/dd/yyyy)

Reason for today's visit: When did symptoms begin?

Location: ------­ Onset: Select One: 0 Gradual 0 Sudden 0 Other

Duration: _ Severity: Select one: 0 Mild 0 Moderate 0 Severe 0 Incapacitating 0 Other

Context: (when walking, etc.) Status: Select one: 0 New Diagnosis 0 Improving 0 Stable 0 Worsening 0 Resolved

Aggravating Factors: Relieved By:

List Any Chronic Conditions:
Condition / Date of Onset / Condition / Date of Onset
Anemia / Eye Problems
Anxiety / Gastroesophageal Reflux Disorder
Arthritis / Headaches
Bladder Infections / Heart Attack (Myocardial Infarction)
Cancer (Type) / Hepatitis
Chronic Obstructive
Pulmonary Disease / Hypertension
Insomnia
Constipation/Diarrhea / Irritable Bowel Syndrome
Depression / Stroke
Diabetes Type l / Thyroid Diseases
Diabetes Type 2
Other

Please indicate any past medical history:
0 Allergies (seasonal) O Anemia
O Angina
O Anxiety
0 Arthritis
O Asthma
0 Atrial Fibrillation
0 Benign Prostatic Hypertrophy
0 Blood Clots
0 Cancer Type
0 Cerebrovascular Accident / OCOPD
0 Coronary Artery Disease
0 Crohn's Disease
0 Depression
0 Diabetes
0 Gallbladder Disease
O GERD
0 Hepatitis C
0 Hyperlipidemia
0 Hypertension / 0 Irritable Bowel Disease
0 Liver Disease
0 Migraines
0 MI/Heart Attack
0 Osteoarthritis
0 Osteoporosis
0 Peptic Ulcer Disease
0 Renal Disease
0 Seizure Disorder
0 Thyroid Disease
Other:

. \

Please indicate any past surgical history:

0 Angioplasty Year Hernia Repair Year

0 Angio w/Stent Year Hip Replacement Year

0 Appendectomy Year Knee Replacement Year

0 Back Surgery Year lASIK Year O CABG Year Liver Biopsy Year

0 Carpal Tunnel Release Year ORIF Year

0 Cataract Extraction Year Pacemaker

Year

0 Cholecystectomy Yea r Small Bowel Resection Year

0 Colectomy Year Thyroidectomy Year

0 Colostomy Year Tonsillectomy Year

0 Gastric Bypass Year Other:

Family History
Relation / Alive Well (y/n) / Condition/Diagnosis / Age on Onset / Cause of Death (y/n)
1.
2.
3.
4.
5.
6.

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SocialHistory- Tobacco Usage
Use Tobacco:
0 Current
0 Former
0 Never
0 Unknown / Type:
0 Chewing
0 Cigar
0 Cigarettes
O Pipe
0 Smokeless
0 Snuff / Quantity per day: / Year(s) Used: / Have you ever tried to quit? {y/n)
Year Quit:

SocialHistory- Alcohol

Yes I No/ Former lfYes,Type:

Frequency:

If Former, When Quit?

Amount: Last Drink:

SocialHistory- Caffeine

Use: / Type: / Quantity per day:
Yes / 0 Chocolate
No / 0 Coffee
0 Energy Drinks
0 Soda
0 Tablets
O Tea

Patient Signature: Date:

TFP282S_Patient_H alth_History_1512

TENET FLORIDA PHYSI IAN SERVICES, LLC.

9960 Central Park Blvd. Suite: 150A Boca Raton, FL 33428

Tel: 561-488-7200 Fax: 561-488-4043

A Notice of Privacy Practices (NPP) is provided to all patients. This Notice of Privacy Practices identifies:

1. How medical information about you may be used or disclosed.

2. Your rights to access your medical information, amend . your medical information, request an accounting of disclosures of your medical information, and request additional restrictions on your uses and disclosures of that information.

3. Your rights to complain if you believe your privacy rights have been violated; and

4. Our responsibilities for maintaining the privacy of your medical information.

The undersigned certifies that he/she has read the foregoing, received a copy of the Notice of Privacy

Practices and is the patient, or the patient's personal representative.

Name of Patient Signature of Patient

/ ! _

Date Signed

Name of Patient’s Personal Representative

Signature of Patient’s Personal Representative

! ! _

Date Signed

May we leave a message regarding test results on your answering machine?

D YES O NO

If you wish for us to discuss your health information with anyone, please list their name (s) below:

(i.e. family)

FOR INTERNAL USE ONLY

Name of Employee

Signature of Employee

If applicable, reason patient’s written acknowledgement could not be obtained:

0 Patient was unable to sign.

0 Patient refused to sign.

0 Other

•••Tenet Florida Physician Services

AUTHORIZATION TO RELEASE MEDICAL RECORDS

PATIENT:

Name of Patient/Previous Names Birth Date/Social Security Number

Street Address City, State, Zip

AUTHORIZES MY CURRENT PHYSICIAN:

TO RELEASE PROTECTED HEALTH INFORMATION TO:

Physician Name Physician Name/Self

Street Address Street Address

City, State, Zip City, State, Zip

I FORMATION TO BE RELEASED:

I hereby authorize you to release all of my medical records for any treatment and laboratory/diagnostic tests performed except for information pertaining to:

Sexually transmitted disease

Testing or treatment ofHIV/AIDS

Treatment of alcohol or substance abuse Communication between patient and

Records from other facilities/providers

psychotherapist for mental health treatment

For the Following Date(s): ------­

PURPOSES FOR NEED OF DISCLOSURE: (check one)

Further Medical Care

__ Insurance/Eligibility

Other (Specify):------

YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION:

I understand I must be provided with a signed copy of this authorization. I understand written notification

is necessary to cancel this authorization and I may obtain information on how to withdraw my authorization by contacting the office of the above noted healthcare provider. I understand the Tenet Florida Physicians will not be able to release my records to someone else without a signed authorization. If I decide not to

sign this form, Tenet Florida Physicians will not refuse to continue treatment. By signing this

a uthorization, I do expressly and voluntarily consent to the disclosure of the information checked above to the person/doctor/agency named above. I understand that if the person(s) and/or organization(s) listed above are not mandated by the federal privacy standards, the health information disclosed as a result of this authorization may be redisclosed without obtaining my authorization. I understand that I may be charged a fee for copying these medical records.

SIG ATURE PATIENT/LEGAL REP: . DATE:------

(If signed by other than patient, state relationship and authority to do so)

EXPIRATION DATE: This authorization is good until the following date(s) _ or for si x months from the d ate si gned.