Responsible Party Information

PATIENT INFORMATION

Responsible Party Information:

Relationship to patient: Self Parent Other

Name: First: M.I. Last:

S.S.# Date of Birth:

Address: City: State: Zip:

Home Telephone: ( ) Cell #:( )

Patient’s Information:

Patient’s Legal Name: First: M.I. Last:

S.S.# Date of Birth:

Address: City: State: Zip:

Home Phone: ( ) Cell #: ( )

Sex: q Male q Female Marital Status: q Single q Married q Divorced q Widowed Race:

Patient’s Occupation: Employer:

Employer’s Address: City: State: Zip:

Patient’s Work Phone #: ( )

In case of emergency notify: Telephone#: ( )

Primary Insurance Information:

Policy Holder’s Name: DOB: SS#:

Employer of Policy Holder: Telephone #: ( )

Name of Primary Insurance: Policy/ID# Group #:

Claim Mailing Address: City: State: Zip:

Customer Service/Benefits Telephone #: ( )

Secondary Insurance Information:

Policy Holder’s Name: DOB: SS#:

Employer of Policy Holder: Telephone #: ( )

Name of Secondary Insurance: Policy/ID# Group #:

Claim Mailing Address: City: State: Zip:

Customer Service/Benefits Telephone #: ( )

**IMPORTANT: If your insurance company requires you to have a written referral in order to see one of our specialists, please be sure a copy of the referral is on file in our office, or give a copy to the receptionist prior to seeing one of our physicians.

Assignment of Insurance Benefits / Release of Medical Information:

I request that payment of my insurance benefits be made on my behalf to St. Joseph’s CHI St. Vincent Clinic for any services furnished me by that group of physicians. I authorize any of my medical information to be released, if needed to determine these benefits. I understand I am financially responsible for any balance not covered by my insurance carrier.

Signature of Patient: Date:

PHI Communication Resource Tool

Please print below information

I, hereby authorize release of my Protected Health Information for discussion of my care or treatment to the person(s) specified below

Authorized family member or person to receive verbal information for the above named patient's care:

Name of Central Contact (other than patient) Relationship to Patient Phone

Others authorized to receive my verbal information (please list names and relationship):

Print Name Relationship to Patient Phone

Print Name Relationship to Patient Phone

sNote: This form does not give the above referenced persons permission to make health care decisions for the patient or entitle them to paper or electronic copies of the patient's medical record. We will not release via the telephone or any other means of communication any information to any friends or family members not listed above unless the patient has an opportunity to object and does not (documented) or if it is reasonable to infer that the patient does not object such as when a patient brings a spouse into the room when treatment is being discussed. Exception: if the release is needed in emergency situations.

¨  Leave message on answering machine? ❑ Yes ❑ No

(Example: We may leave message reminders, scheduling changes or notices that lab results are in on your answering machine. Would this process be acceptable, yes or no.)?

¨  Leave message for patient to return call? ❑ Yes , ❑ No

(Example: We may leave a message regarding appointment reminders, scheduling changes or

notices that lab results are in with an individual who answers the phone. Would this process be

acceptable, yes or no?)

¨  Acknowledgement Statement:

I have been offered a copy of the Notice of Privacy Practices and received a copy ❑

I have been offered a copy of the Notice of Privacy Practices and declined a copy ❑

Patient or Legal Personal Representative: Date:

(SIGNATURE)

Patient or Legal Personal Representative: Relationship to Patient

(PRINTED NAME)

Note: Except to the extent that action has already been taken in reliance on this PHI Communication Resource Tool, at any time I can revoke this PHI Communication Resource Tool by submitting a notice in writing to the Privacy Site Coordinator or Privacy Site Designee

Consent and Agreement

Physician Services and Hospital Services

1.  Annual Consent for Services: I consent to the services that may be performed by a CHI St. Vincent Health “CHI St. Vincent”) physician or non-physician provider (“provider") or facility. I understand I can withdraw this consent at any time. This consent and agreement applies to any provider services I may obtain from CHI St. Vincent providers at a clinic or physician's office and any hospital services I may obtain at a CHI St. Vincent hospital or from a hospital-based clinic location.

2.  Financial Agreement: I guarantee and agree to pay for all goods and services provided to me or the patient named below at the rates listed in CHI St. Vincent’s Charge Description Master as of the date of treatment, unless I am entitled to pay a different amount under my (or the patient's) health insurance plan or my (or the patient’s) status as a Medicare or Medicaid beneficiary. Should an account be referred to an attorney or collection agency for collection, I will pay attorney’s fees and collection expenses. CHI St. Vincent will provide a medical screening exam to anyone in need of emergency medical treatment regardless of ability to pay.

3.  Assignment of Insurance Benefits: I assign my (or the patient's) rights under all insurance and benefit plan documents and authorize direct payment to CHI St. Vincent of all Insurance and plan benefits payments for services provided by CHI St. Vincent. By paying CHI St. Vincent, my insurance company or employer is fulfilling its obligations to me (or the patient) under the health insurance policy, or the employer is fulfilling its obligations as required by law. I also agree that I (or the patient) am financially responsible for charges not paid according to this assignment.

4.  Medicare Assignment: I certify that the information given by me in applying for payment from any third party payor, including payment under Title XVIII of the Social Security Act, is correct: I request that payment of authorized benefits be made in my (or the patient's) behalf, and I authorize the Social Security Administration Office of the Department of Health and Human Services to release information regarding my (or the patient’s) eligibility for coverage under Medicare Part A and Part B. including but not limited to the effective date of such coverage. I also authorize CHI St. Vincent to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim.

5.  Legal Relationship between Hospital and Provider: I understand, that when I am hospitalized, I am under the care and supervision of my attending provider, and it is the responsibility of the hospital and nursing staff to carry out his/her instructions. It is the responsibility of my provider or surgeon to obtain my informed consent, when required, for specific medical or surgical treatment, special diagnostic or therapeutic procedures, or hospital services provided to me under instruction of the provider.

6.  Clinic and Hospital Rules: I understand that my visitors and I must obey all CHI St. Vincent clinic and hospital rules. I understand that if I or my visitors do not follow the rules, CHI St. Vincent may pursue corrective action.

7.  Notice of Privacy Practices: I acknowledge that I have received a copy of the Notice of Privacy Practices (NOPP), which describes when CHI St. Vincent may use or disclose information for treatment, payment and health care operations. The NOPP is considered part of this Consent and Agreement by this reference. I understand that the NOPP is only provided the first time I receive services from the hospital and is otherwise available upon request and on CHI St. Vincent's website.

Consent & Agreement Page 2

8.  Personal Valuables: I understand that as a patient, I am encouraged to leave valuable personal items at home, While CHI St. Vincent may maintain a safe for small personal items of unusual value, CHI St. Vincent is not responsible for the loss or damage to these items.

9.  Demographic Information: I have reviewed the demographic information listed for me and confirm that it is correct. I am aware that I need to inform CHI St. Vincent of any changes as soon as possible.

10.  Independent Contractor/Providers: I understand that separate bills may be sent for professional services from non-CHI St. Vincent providers such as radiologists, pathologists; and anesthesiologists, in addition to the CHI St. Vincent bill.

11.  Phone Calls: .I authorize CHI St. Vincent and its collection agencies to contact me, or a representative I appoint, ______about my account, including using any contact information or cell phone numbers that I have provided or will provide, or that is available to CHI St. Vincent from third parties. I authorize contact with me by telephone or voice messages and authorize the use of automated dialing technology and pre-recorded messages, even if I am charged for the call under my phone plan, I agree such contact will not be "unsolicited" for purposes of local, state or federal law. l. agree that CHI St. Vincent and its collection agencies may monitor and/or record any communication

12.  Notice to CHI St. Vincent-Co-workers: As a co-worker employed by an entity owned or controlled by CHI St. Vincent, I agree to payment of outstanding balances(s) due for medical services rendered to me, or any dependents for whom l: am financially responsible, after all applicable insurance payments are received for such services. In the event I do not make reasonable attempts to resolve the outstanding balances, I understand CHI St. Vincent may initiate payroll deduction; in accordance with CHI St. Vincent's Co-worker Payroll Deduction Policy.

A copy of this form shall have the same force and effect as the original. The undersigned is the patient or is

duly authorized to act on behalf of the patient to sign for the patient and accept the terms written above. A signed copy of this form is available upon request.

Signature: Date: Time:

If signed by other than patient, indicate relationship:

Witness: Date: Time:

HISTORY AND PHYSICAL EXAMINATION

Patient’s Full Name: Date of Birth:

Age: Sex: Marital Status: No. of Children

Date of last complete physical exam: Date of last Pap Smear:

Date of last blood work: What test were done?

HISTORY OF PRESENT ILLNESS:

Childhood Diseases:

Adult Disease:

Yes No Date When Diagnosed:

Diabetes

High Cholesterol

Cancer

Heart Disease

High Blood Pressure

Other diseases not mentioned:

List any injuries you have had that required medical attention:

History Questionnaire (continued)

SURGERIES:

YES NO DATE
Coronary artery bypass
Gallbladder
Appendix
Hernia
Hysterectomy
Ovaries removed
Other:

List approximate dates and reasons you have been hospitalized:

Hospitalizations (X-Rays & EKG's), other than for Operations:

MENSTRUAL HISTORY
Age of first menstrual period
Number of Pregnancies
Age at menopause / Last Menstrual Period
Number of Live Births

CURRENT HABITS

Do you smoke? If so, how much do you smoke in one day? How long have you

smoked? If you smoked in the past but no longer smoke, when did you quit?

How long did you smoke?

Do you drink alcohol? How much?

Caffeine: How many cups of coffee per day do you drink?

How many glasses of tea per day do you drink?
How many soft drinks per day do you drink?

History Questionnaire (continued)

DIET HISTORY

Special diet or diet restrictions?

SOCIAL HISTORY

Retired? Yes /No

Work History (last or present job)

Martial Status: (circle one) Single Married Divorced Widowed

Do you have a Living Will? Yes / No (Do we have a copy on file? ____Yes ____No)

IMMUNIZATIONS

Last Tetanus Pneumonia Influenza

Father
Mother
Brother (s)
Sister (s)

Is there a family history of:

YES NO RELATIONSHIP
Diabetes
Cancer
Stroke
Hypertension
Arthritis
Heart Disease
Other

History Questionnaire (continued)

ALLERGIES

Drugs:

Food:

Other:

List all the medications (Prescription and OVER THE COUNTER >including Vitamins<) that you are currently taking. Include dose (mg) and how many times a day you take each one.

Medication Dose How often?

History Questionnaire (continued)

STUDY OF SYSTEMS
Check Yes or No for each item except where applies to male or female
Condition / Yes / No / Condition / Yes / No / Condition / Yes / No
Fever / Neck / Stiffness / Psychological / Is Your Life:
Chills / Swelling / Satisfactory
Bruise Easily / Lumps / Boring
Swollen Glands / Other * / Demanding
Loss of Memory / Gastrointestinal / Appetite Poor / Unsatisfactory
General Weakness / Indigestion / Heartburn / Is There Worry Over:
Aches/Pains / Nausea / Home Life
Head / Double Vision / Vomiting Blood / Marriage
Light Flashes / Abdominal Pain or Cramps / Job
Blurred Vision w/o Glasses / Abdominal Tension / Children
Halos Around lights / Diarrhea / Money
Eye Pains / Constipation / Do You:
Ear Pains / Bowel Habit Changes / Often feel Depressed
Ear Drainage / Rectum Blood Passage / Have Irrational Fears
Buzzing/Ringing in Ears / Black Tar-Type Bowel Movements / Feel Upset
Nosebleeds / Other * / Feel Things Often Go Wrong
Sinus Problems / Feel Shy
Swallowing Problems / Kidney / Up Nights to Urinate / Cry Easily
Deafness / Blood in Urine / Feel Inferior
Mouth, Tooth or Tongue Problems / Burning or Pain While Urinating / Have You:
Persistent Hoarseness / Problems Passing Urine / Attempted Suicide
Severe Headaches / Trouble Controlling Urine / Seriously Considered Suicide
Other * / Other * / Man Genitalia / Lump In Testicle
Rash / Neu. Musc. / Leg or Arm Weakness / Penis Discharge
Changing Moles / Balance Problems / Breast Lump
Pigmentation / Dizziness / Sore on Penis
Other Skin Problems * / Fainting Spells / Erection Difficulties
Chest Heart Lungs / Irregular Heartbeat / Speech Problems / Other *