Monroe Naturopathic Medical Clinic, Inc.
17801 W. Main St, Monroe, WA 98272
(360) 794-4539
HEALTH HISTORY QUESTIONNAIRE
All questions contained in this questionnaire are strictly confidential and will become part of your medical record.
Date & Time of Initial Visit: ______Name(Last, First, M.I.): / M F /
DOB:
Social Security Number:
Address: Street
City, Zip code
Email address:
Home Phone: / Cell Phone:Preferred method of contact: home phone / cell phone / other:
Marital status:
/ Single Partnered Married Separated Divorced WidowedPrevious or referring doctor:
/Date of last physical exam:
How did you hear about us: Referred by: Dr. Alice Harper Website/Health ProfsPhone book / Newspaper Ad / Brochure in community / Saw Signs / Insurance Website / Other
PERSONAL HEALTH HISTORY
Childhood illness:
/ Measles Mumps Rubella Chickenpox Rheumatic Fever PolioDate of Last Tetanus Shot:
List any medical problems that other doctors have diagnosed and approximate date of diagnosis (Past Medical History)
Surgeries
Year / Reason / HospitalOther hospitalizations
Year / Reason / HospitalHave you ever had a blood transfusion?
/ / Yes / / NoList your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers
Name of the Drug / Dosage / Frequency TakenAllergies to medications
Name the Drug / Reaction You HadFAMILY HEALTH HISTORY
Age / Significant Health Problems / Age / Significant Health ProblemsFather
/Children
/ M F
Mother
/ M F
Sibling
/ M F / M
F
M
F / M
F
M
F /
Grandmother
Maternal M
F /
Grandfather
Maternal M
F /
Grandmother
Paternal M
F /
Grandfather
PaternalMENTAL HEALTH
Is stress a major problem for you? / / Yes / / NoDo you feel depressed? / / Yes / / No
Do you panic when stressed? / / Yes / / No
Do you have problems with eating or your appetite? / / Yes / / No
Do you cry frequently? / / Yes / / No
Have you ever attempted suicide? / / Yes / / No
Have you ever seriously thought about hurting yourself? / / Yes / / No
Do you have trouble sleeping? / / Yes / / No
Have you ever been to a counselor? / / Yes / / No
Womens Health
Age at onset of menstruation:Date of last menstruation (this is the date you began your period):
Period every _____ days and they last for _____ days
Heavy periods, irregularity, spotting, pain, or discharge? / / Yes / / No
Number of pregnancies _____ Number of live births _____ Number of Abortions _____ Number of Miscarriages _____
Are you pregnant or breastfeeding? / / Yes / / No
Did you breastfeed your children? If yes, for how many months? ______/ / Yes / / No
Have you had a D&C, hysterectomy, or Cesarean? / / Yes / / No
Any urinary tract, bladder, or kidney infections within the last year? / / Yes / / No
Any blood in your urine? / / Yes / / No
Any problems with control of urination? / / Yes / / No
Any hot flashes or sweating at night? / / Yes / / No
Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period? / / Yes / / No
Experienced any recent breast tenderness, lumps, or nipple discharge? / / Yes / / No
Have you ever had an abnormal pap? / / Yes / / No
If you’ve had an abnormal pap, did you have HPV? ______What was the treatment/outcome?
Date of last pap and rectal exam?
Monroe Naturopathic Medical Clinic, Inc.
INSURANCE INFORMATION
_____I do not have insurance or my insurance will not cover Naturopathic services and I am paying cash. (Please skip to next page)
_____Please bill my insurance and I will pay the remaining balance and copay.
My copay is: $______
My insurance will cover ______% of Naturopathic Services and I am responsible for the remaining.
Insurance Information
Insurance Carrier: ______
Patient Name: ______DOB: ______
Patient’s Address: ______City: ______State: ____ Zip: ______
Patient’s Phone #: ______Cell Phone: ______
Subscriber ID:______Group #: ______
Subscriber: ______Subscriber SS#: ______DOB: ______
Relationship to Patient: ______
Insurance Billing Address: ______
Insurance Phone #: ______
I, ______, certify that the above information is correct to the best of my knowledge.
Signature: ______Date: ______
Monroe Naturopathic Medical Clinic, Inc.
SIGNATURE PAGE
FINANCIAL POLICY
Patient Authorization and Understanding
I have read and understand the financial policies of Monroe Naturopathic Medical Clinic, Inc.. I agree to abide by the terms of the financial policy. I request that payment of benefits be made to Monroe Naturopathic Medical Clinic, Inc., and hereby authorize the release of any information necessary to determine the liability of payment and obtain reimbursement on any claim. I further authorize the use of my signature below on all insurance submissions for services rendered or to be rendered. I agree that a photocopy of this agreement shall be as valid as the original. This authorization shall remain valid until revoked by me in writing and there has been a termination of services with Monroe Naturopathic Medical Clinic, Inc..
Patient’s Printed Name: ______Date of Birth: ______
Signature: ______Date: ______
Name of person completing form if other than patient: ______
Relationship to patient: ______
CONSENT FOR TREATMENT
I understand that I may ask questions regarding my treatment before signing this form and that I am free to withdraw my consent and to discontinue participation in these procedures at any time. With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by Monroe Naturopathic Medical Clinic, Inc.. I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by me or a representative or otherwise permitted or required by law. I understand that I have the right to review my record and obtain a copy of my record upon request (see Notice of Privacy Practices) and that obtaining a copy of my record may require payment of a fee.
______
Guardian/personal Representative’s Name (Print)Patient’s Name (Print)
______
Guardian/personal Representative’s SignaturePatient’s Signature
______
Relationship/Representative’s AuthorityDate
HIPAA
I hereby certify that I have received the Notice of Privacy Practices for Monroe Naturopathic Medical Clinic, Inc.. I understand that if I have objections or concerns with this policy, I must notify Monroe Naturopathic Medical Clinic, Inc.per the instructions in the Notice of Privacy Practices.
______
Name (printed)
______
Signature
______
Date
Monroe Naturopathic Medical Clinic, Inc.
Financial Policy
Thank you for choosing Monroe Naturopathic Medical Clinic, Inc., for your Naturopathic care. We know you have many choices in providers and we appreciate your business. We look forward to a relationship with mutual trust and an opportunity to help you obtain optimal health. As you know, payment for services is part of your care and part of our professional relationship. We have developed a financial policy to make these obligations clear from the beginning.
Cash Payments
Payment is due at time of service (cash, check, or credit card), and reflects a pay-at-time-of-service discount.*
FEE SCHEDULE (paid at time of service)
60 minutes / $235 / 20 minutes / $10545 minutes / $180 / 15 minutes / $85
30 minutes / $125 / 10 minutes / $60
These fees do not include lab fees or supplements. *There is an additional discount for seniors who have only Medicare coverage.
Insurance Coverage and Payments
We will gladly bill your insurance if you have a PPO or out-of-network coverage. Medicare does not cover naturopathic services. It is your responsibility to obtain and verify your insurance coverage prior to your scheduled appointment.
If you have a copay, this will be due at the time of service. If your insurance covers only a portion, it is your responsibility to pay the remaining balance that will be billed to you by the clinic. If you have a deductible, this will be billed to you after receiving notification of payment from your insurance company. This will be clearly noted on your bill, and you are obligated to pay your deductible. According to your insurance plan,you are responsible for any and all co-payments, deductibles, and coinsurances.Nonpayment of balance due within 90 days will result in collection procedures.
In the event that your insurance coverage has changed, you will be responsible for the full cost of the office visit that is not covered by your insurance company. At that time, you may personally submit the bill to your insurance company for reimbursement.
Past Due Accounts
If we have to turn your account over to collection, you will be responsible for all costs and expenses of collection including, but not limited to our reasonable attorneys’ fees.
TELEPhone Consultations
Telephone consults are not covered by insurance. Telephone consults can be scheduled and will be billed the same pay-at-time-of service fees as established office visits (see above). The fee will be waived if it is determined that an in-person office visit is required or if you are referred for emergency services. The fee will also be waived if it is a question limited to a current and documented treatment plan.
Email Correspondence
Due to liability and privacy policies, email consultations are not permitted.
Missed or Late Cancelled Appointments
It is a professional courtesy to provide 24 hours notice if you cannot keep an appointment. There will be a $75 charge for all “no shows” or appointments cancelled less than 24 hours in advance.
If you are late to an appointment, please understand that you have a scheduled time and this may result in your appointment being cut short to remain within the parameters of your scheduled appointment time. If you are more than 15 minutes late, we may need to reschedule your appointment.
Returned Checks
There will be a $35 fee for returned checks. Please note that you will still be responsible for charges and asked to pay with a different form (cash or money order).
MONROE NATUROPATHIC MEDICAL CLINIC, INC.
CONSENT FOR TREATMENT
I hereby authorize Monroe Naturopathic Medical Clinic, Inc., to perform the following specific procedures as necessary to facilitate my diagnosis and treatment:
General Diagnostic Procedures (including but not limited to venipuncture, pap smears, radiography, and blood and urine lab work, general physical exams, neurological and musculoskeletal assessments)
Psychological Counseling; Lifestyle Counseling; Exercise Prescriptions
Herbs/Natural Medicines (prescribing of various therapeutic substance including plants, minerals, and animal materials. Substances may be given in the form of teas, pills, powders, tinctures—may contain alcohol; topical creams, pastes, plasters, washes, suppositories or other forms. Homeopathic remedies, often highly dilute quantities of naturally occurring substance, may also be used.)
Pharmaceutical Prescriptions (prescribing of various pharmaceutical drugs within the scope of practice for Naturopathic Physicians which includes all Legend Drugs and specific Schedule III, IIIN, 4, & 5 per the WAC.)
Dietary Advice and Therapeutic Nutrition (use of foods, diet plans, or nutritional supplements for treatment—may include intramuscular vitamin injections.)
Soft Tissue and Osseous Manipulation (use of massage, neuromuscular techniques, muscle energy stretching or visceral manipulation, as well as manipulations of the extremities and spine including traction and craniosacral therapy.)
Electromagnetic and Thermal Therapies (includes the use of therapeutic ultrasound, low and high volt electrical muscle stimulation, transcutaneous electrical stimulation, microcurrent stimulation, diathermy, and hydrotherapies.)
Potential Risks: Pain, discomfort, blistering, discolorations, infection, burns, loss of consciousness or deep tissue injury from needle insertions, topical procedures, heat or frictional therapies, electromagnetic and hydrotherapies; allergic reactions to prescribed herbs or supplements; soft tissue or bone injury from physical manipulations; and aggravation of pre-existing symptoms.
Potential Benefits: Restoration of health and the body’s maximal functional capacity, relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or its progression.
Notice to Pregnant Women: All female patients must alert the doctor if they know or suspect that they are pregnant, since some of the therapies used could present a risk to the pregnancy. Labor-stimulating techniques or any labor-inducing substances will not be used.
NOTICE OF PRIVACY PRACTICESMONROE NATUROPATHIC MEDICAL CLINIC, Inc.
17801 W. Main Street
Monroe, WA 98272
Dr. Alice Harper; 360-794-4539
Effective Date: September 23, 2013
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. We make a record of the medical care we provide and may receive such records from others. We use these records to provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this medical practice properly. We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. This notice describes how we may use and disclose your medical information. It also describes your rights and our legal obligations with respect to your medical information. If you have any questions about this Notice, please contact our Privacy Officer listed above.
TABLE OF CONTENTS
- How This Medical Practice May Use or Disclose Your Health Information...... p.7
- When This Medical Practice May Not Use or Disclose Your Health Information...... p.9
- Your Health Information Rightsp.9
- Right to Request Special Privacy Protections
- Right to Request Confidential Communications
- Right to Inspect and Copy
- Right to Amend or Supplement
- Right to an Accounting of Disclosures
- Right to a Paper or Electronic Copy of this Notice
- Changes to this Notice of Privacy Practices...... p.10
- Complaints...... p.10
- How This Medical Practice May Use or Disclose Your Health Information
- Treatment. We use medical information about you to provide your medical care. We disclose medical information to our employees and others who are involved in providing the care you need. For example, we may share your medical information with other physicians or other health care providers who will provide services that we do not provide. Or we may share this information with a pharmacist who needs it to dispense a prescription to you, or a laboratory that performs a test. We may also disclose medical information to members of your family or others who can help you when you are sick or injured, or after you die.
- Payment. We use and disclose medical information about you to obtain payment for the services we provide. For example, we give your health plan the information it requires before it will pay us. We may also disclose information to other health care providers to assist them in obtaining payment for services they have provided to you.
- Health Care Operations. We may use and disclose medical information about you to operate this medical practice. For example, we may use and disclose this information to review and improve the quality of care we provide, or the competence and qualifications of our professional staff. Or we may use and disclose this information to get your health plan to authorize services or referrals. We may also use and disclose this information as necessary for medical reviews, legal services and audits, including fraud and abuse detection and compliance programs and business planning and management. We may also share your medical information with our "business associates," such as our billing service, that perform administrative services for us. We have a written contract with each of these business associates that contains terms requiring them and their subcontractors to protect the confidentiality and security of your protected health information. We may also share your information with other health care providers, health care clearinghouses or health plans that have a relationship with you, when they request this information to help them with their quality assessment and improvement activities, their patient-safety activities, their population-based efforts to improve health or reduce health care costs, their protocol development, case management or care-coordination activities, their review of competence, qualifications and performance of health care professionals, their training programs, their accreditation, certification or licensing activities, or their health care fraud and abuse detection and compliance efforts.
- Appointment Reminders. We may use and disclose medical information to contact and remind you about appointments. If you are not home, we may leave this information on your answering machine or in a message left with the person answering the phone.]
- Sign In Sheet. We may use and disclose medical information about you by having you sign in when you arrive at our office. We may also call out your name when we are ready to see you.
- Notification and Communication With Family. We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or, unless you had instructed us otherwise, in the event of your death. In the event of a disaster, we may disclose information to a relief organization so that they may coordinate these notification efforts. We may also disclose information to someone who is involved with your care or helps pay for your care. If you are able and available to agree or object, we will give you the opportunity to object prior to making these disclosures, although we may disclose this information in a disaster even over your objection if we believe it is necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.
- Sale of Health Information. We will not sell your health information without your prior written authorization. The authorization will disclose that we will receive compensation for your health information if you authorize us to sell it, and we will stop any future sales of your information to the extent that you revoke that authorization.
- Required by Law. As required by law, we will use and disclose your health information, but we will limit our use or disclosure to the relevant requirements of the law. When the law requires us to report abuse, neglect or domestic violence, or respond to judicial or administrative proceedings, or to law enforcement officials, we will further comply with the requirement set forth below concerning those activities.
- Public Health. We may, and are sometimes required by law, to disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child, elder or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. When we report suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative promptly unless in our best professional judgment, we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm.
- Health Oversight Activities. We may, and are sometimes required by law, to disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to the limitations imposed by law.
- Judicial and Administrative Proceedings.We may, and are sometimes required by law, to disclose your health information in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a court or administrative order.
- Law Enforcement. We may, and are sometimes required by law, to disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes.
- Coroners. We may, and are often required by law, to disclose your health information to coroners in connection with their investigations of deaths.
- Organ or Tissue Donation. We may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.
- Public Safety. We may, and are sometimes required by law, to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
- Proof of Immunization. We will disclose proof of immunization to a school that is required to have it before admitting a student where you have agreed to the disclosure on behalf of yourself or your dependent.
- Specialized Government Functions. We may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody.
- Workers’ Compensation. We may disclose your health information as necessary to comply with workers’ compensation laws. For example, to the extent your care is covered by workers' compensation, we will make periodic reports to your employer about your condition. We are also required by law to report cases of occupational injury or occupational illness to the employer or workers' compensation insurer.
- Change of Ownership. In the event that this medical practice is sold or merged with another organization, your health information/record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another physician or medical group.
- Breach Notification. In the case of a breach of unsecured protected health information, we will notify you as required by law. If you have provided us with a current e-mail address, we may use e-mail to communicate information related to the breach. In some circumstances our business associate may provide the notification. We may also provide notification by other methods as appropriate.
- When This Medical Practice May Not Use or Disclose Your Health Information