Demographics

Please fill out the form below completely. This is required once a year or if any information has changed. Please circle all appropriate answers for questions posed. If you have any questions about the form please ask anyone at the front desk.

Last First NameMiddle Int.Suffix_____

Maiden Gender M/ F SSN Marital Status DOB______

SINGLE

RaceEthnic GroupMARRIED

DECLINEDECLINEWIDOWED

AMERICAN INDIANHISPANIC OR LATINOSEPERATED

ALASKA NATIVE NOT HISPANIC OR LATINODIVORCED

ASIANLanguage______

BLACK/AFRICAN AMERICAN

NATIVE HAWAIIAN/PACIFIC ISLANDER

WHITE

OTHER RACE

Address______

Zip CityState ______

Phone (H) Phone (C)Phone (W) EXT______

Email Preferred Contact Method Preferred Reminder Method

PHONECELL PHONE

TEXTHOME PHONE

MAILOFFICE PHONE

E-MAILMAIL

PATIENT PORTALE-MAIL

PATIENT PORTAL

Emergency Contact Phone# ______

Insurance Carrier Primary ______Insurance Secondary______

Driver’s license # Date Expired State ______

(Fill in below if Guarantor not self)

*Guarantor ______*Relationship to Guarantor ______

DOB ______Gender Male / Female SSN ______

Address State Zip ______

(Signature and Date Required Please)

Signature: ______

Date: ______

*Guarantor is the person who has the insurance thru their work or is primary on the insurance. Or is the responsible party for a minor or a caregiver for another person.

Sean C. O’Donnell M.D.

Cynthia K. Jordan N.P.

CYNTHIA K. JORDAN, NP

629 N. Nevada Ave. Ste. 110 Office Hours:

Colorado Springs, CO 80903 Only urgent calls after hours PLEASE

(719) 473-6171 office Monday-Thursday 8:30-4:30

(719) 473-0740 Fax Friday 8:30-12:30

Welcome! We want to keep you healthy with high quality medical care. Our telephone is always answered either by our staff or

the nurses at our answering service.

APPOINTMENTS: ONLY ONE PATIENT PER APPOINTMENT, PLEASE

Routine…………………………….make at least 4 weeks in advance

Same-day…………………………..made for urgent cases only

Cancellations………………………at least 24hrs in advance for no charge

Broken/Cancelled appointment……less than 24hr notice $25.00 charge

Broken/Cancelled Physical..……….less than 24hr notice $75.00 charge

PRESCRIPTION REFILLS:

General…………Require 48 hours notice, call pharmacy at least 2 days before medication depleted

Antibiotics………Must be examined by the doctor before we will dispense.

Pain, Sleeping meds, and Tranquilizers……..After hours, we cannot OK refills without you visiting the ER

BILLING POLICY:

Payment due………………..at the time of visit (including copayment)

Late payments………………$5.00 late charge

Delinquent…………………..sent to a collection agency $10.00 service charge

Insurance…………………….If we participate in your plan and you meet your deductible

I herby authorize Sean O’Donnell MD to furnish any necessary information to my insurance company to secure payment

I verify that I have read and agree to abide by the office policies set forth above

PRINT NAME______DOB______

SIGNATURE: ______

DATE: ______

THIS NOTICE DESCRIBES HOW

MEDICAL INFORMATIONABOUT YOU MAY BE

USED AND DISCLOSED AND HOU YOU CAN GET

ACCESS TO THIS INFORMATION

This notice is effective as of January 1, 2008

USES AND DISCLOSURE OF HEALTH INFORMATION

TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

Dr. Sean O’Donnell uses and discloses your protected health information for treatment, payment and care operations. Some examples of when our office may use or disclose y our health care information for these purposes:

Sharing test results with other health care providers for confirmation of a diagnosis.

Providing your diagnosis or other information about your health to your insurance provider or our billing department to obtain payment for the health care service we provide

Reviewing information as part of our quality improvement program

OTHER USES AND DISCLOSURES

Dr. Sean O’Donnell may also use or disclose your protected health information for the following purposes:

Providing you with information related to your health.

Contact in you regarding appointments, information about treatment alternatives; or other health related services.

Compliance with all laws(including reports of suspected abuse, neglect, or violence)

Providing certain specified information to law enforcement of correctional institutions

Providing information to coroner, medical examiner, funeral director, or organ procurement organization

Public health activities when requested by a public heath authority or the FDA

Responding to health oversight agencies

Responding to court or administrative tribunal, order, subpoena as, discovery request or other lawful process

When necessary to avert a serious threat to health or safety

Military and Veteran affairs, national security, Department of state, or Presidential service activities

Informing a family member, partner or your voicemail when

  1. Information is relevant to the individual’s involvement with your care
  2. Notification of your location, general condition or health
  3. To assist in your health car (e.g. pick up prescriptions or other documents)
  4. The family member or partner is reached on your main contact number and informs us that you are not available
  5. The voice mail is reached on your main contact number

AUTHORIZATION FOR OTHER USES

Dr. Sean O’Donnell will make other uses and disclosure of your protected health information only after obtaining your written authorization. If you authorized a use not contained in this notice, you may revoke your authorization at any time by notifying us in writing that you want to revoke your authorization.

PRINT NAME______DOB______

SIGANTURE______

DATE______