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NEW PATIENT REGISTRATIONFORM


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D*O*C*S MEDICAL PRACTICE

PATIENT INFORMATION FORM

LAST NAME___________________ FIRST______________________ MIDDLE________________________

SSN_________________ DOB______________ AGE______ SEX________ MARITAL STATUS___________________

ADDRESS__________________________________________ APT_____ CITY_____________ STATE_____ ZIP____________

COUNTRY_______________ HOME PHONE_______________ CELL PHONE__________________

DAY PHONE_________________ EXT_________ EMAIL_________________________________________

REFERRING PHYSICIAN______________________________

REFERRING PHYSICIANS ADDRESS____________________________________________________________________________

PRIMARY CARE PHYSICIANS NAME________________________________________________

EMPLOYER_________________________________________________________________________________________________

EMPLOYERS ADDRESS_________________________________________________________________________________________

DOCTOR YOU ARE HERE TO SEE_________________________________________________________________________________

LAST NAME SPOUSE/ PARENT/ LEGAL GUARDIAN_____________________ FIRST__________________ MIDDLE__________

EMPLOYER____________________________________________________________________________________________________

EMPLOYERS ADDRESS_________________________________________________________________________________________

(STREET ADDRESS) (CITY / STATE / ZIP) (PHONE

#)

PRIMARY MEDICAL INSURANCE

_______________________________________________________________________________________________________________

_

((PRIMARY INSURANCE COMPANY NAME) (ID #) (GROUP #) (EFFECTIVE DATE)

_____________________________________________________________________________________________________________________________

_

(PRIMARY INSURANCE COMPANY NAME) (STREET ADDRESS) (CITY / STATE / ZIP) (PHONE #)

_____________________________________________________________________________________________________________________________

_

(POLICY HOLDERS NAME/GAURANTOR) (ID#) (SS#) (D.O.B) (EMPLOYER)

_____________________________________________________________________________________________________________________________ _

(POLICY HOLDER) (STREET ADDRESS) (CITY / STATE / ZIP) (PHONE #)

SECONDARY MEDICAL INSURANCE

_______________________________________________________________________________________________________________

_

((PRIMARY INSURANCE COMPANY NAME) (ID #) (GROUP #) (EFFECTIVE DATE)

_____________________________________________________________________________________________________________________________

_

(PRIMARY INSURANCE COMPANY NAME) (STREET ADDRESS) (CITY / STATE / ZIP) (PHONE #)

_____________________________________________________________________________________________________________________________

_

(POLICY HOLDERS NAME/GAURANTOR) (ID#) (SS#) (D.O.B) (EMPLOYER)

_____________________________________________________________________________________________________________________________

_

(POLICY HOLDER) (STREET ADDRESS) (CITY / STATE / ZIP) (PHONE #)

IS THIS VISIT COVERED BY WORKERS COMP? ______________________________

FAULT _________________________________

IN EMERGENCY WHOM MAY WE CONTACT ________________________________ PHONE # _____________________________

PHARMACY NAME___________________________ PHONE ___________________________ FAX ___________________________

I WILL BE PAYING BY CASH___________ CREDIT CARD __________


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I CERTIFY THIS INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I WILL NOTIFY YOU OF

ANY CHANGES IN THE ABOVE INFORMATION. I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION

NECESSARY TO PROCESS AN INSURANCE CLAIM AND REQUEST THAT PAYMENT OF BENFITS BE MADE TO THE

PHYSICIAN UNLESS MY ACCOUNT HAS BEEN PAID IN FULL.

PATIENT SIGNATURE DATE:


MEDICAL HISTORY

DATE:

NAME: M OR F MARITAL STS DOB

OCCUPATION/EMPLOYER:

FAMILY HISTORY- If any blood relative has suffered any of the following- Please circle the number & indicate which relative

HOSPITAL

ADMISSIONS

Not Including

pregnancies

YEAR ILLNESS OR

OPERATION

YEAR ILLNESS OR OPERATION

MAIN PROBLEM

1. Epilepsy 6. Hay Fever 11. Arthritis 16. Hepatitis

2. Migraine 7. Asthma 12. Heart Disease 17. Cancer

3. Diabetes 8.Anemia 13. Stroke 18..Depression

4. Glaucoma 9. Bleeding Disorder 14. Hypertension 19. Alcoholism

5. Thyroid Disease 10. Osteoporosis 15. Lipid Disorder 20. Mental Illness

LIST ALL MEDICATIONS YOU ARE TAKING NOW ALLERGIESVACCINE Y.R OF

LAST

VACCINE Y.R OF

LAST

SUPPLIMENTS


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[ ] HEARING PROBLEMS

[ ] DIZZY SPELLS

[ ] RINGING IN EAR

[ ] FAINTING SPELLS

[ ] VISION PROBLEMS

[ ] EYE PAIN

[ ] NOSE BLEED

[ ]SINUS TROUBLE

[ ] SORE THROAT

[ ] HOARSENESS

[ ]HAY FEVER/ ALLERGIES[ ] PNEUMONIA/ PLEURISY

[ ] BRONCHITIS/ CHRONIC COUGH

[ ] ASTHMA/ WHEEZING

Date of last TB test-

[ ] SHORTNESS OF BREATH:

On exertion___ Laying Flat_____

In the past week_____

Affects work lifestyle_______

[ ] CHEST PAIN

[ ] HIGH BLOOD PRESSURE

[ ] HEART MURMUR [ ] IRREGULAR PULSE

[ ] LEG PAIN

[ ] COLD NUMB FEET

[ ] VARICOSE WEINS/ PHLEBITIS

[ ] DIFFICULTY SWALLOWING

[ ] HEARTBURN

[ ] PEPTIC ULCER

[ ] PAIN PILLS

[ ] NAUSEA/ VOMITING

[ ] GALLBLADDER DISEASE

[ ] JAUNDICS/ HEPATITIS

[ ] DIARRHEA

[ ] CONSTIPATION

[ ] DIVERTICULOSIS

[ ] CROHNS/ COLITIS[ ] BLOODY OR TARRY STOOLS

[ ] HEMORRHOIDS

[ ] HERNA

[ ] ANY URINATING PROBLEM

[ ] KIDNEY STONES

[ ] URINE INFECTIONS

[ ] PROSTATE PROB

[ ] BED WETTING

[ ] WEIGHT LOSS

[ ] ANEMIA

[ ] CANCER

[ ] DIABETES

[ ] THYROID DISEASE

[ ] ARTHRITI [ ] BACK PAIN

[ ] BONE FRACTURE/ JOINT INJURY

[ ] OSTEOPOROSIS [ ] GOUT

[ ] RASHES [ ] HIVES

[ ] PSORIASIS [ ] ECZEMA

[ ] SEIZURES [ ] STROKE

[ ] TREMOR//HANDS

[ ] NUMBNESS

[ ] HEADACHES

[ ] MEMORY LOSS

[ ] DEPRESSION

[ ] DECREASED LIFE ENJOYMENT

[ ] DEREASED WORK PERFORMANCE[ ] SLEEP PROBLEMS

[ ] MENTAL ILLNESS

[ ] CONCENTRATION PROBLEM

[ ] PHOBIAS

[ ] SEXUAL PROBLEMS

[ ] RHEUMATIC FEVER

[ ] MEASLES

[ ] CHICKEN POX

[ ] POLIO [ ] MUMPS

[ ] THOUGHTS OF DEATH

[ ] ANXIETY

[ ] TUBERCULOSIS

[ ] GERMAN MEASLES

[ ] HERPES [ ] HIV/AIDS

[ ] MOOD SWINGS

[ ] ALCOHOL__________ OZ. PER WEEK

[ ] COFFEE/ TEA_______ CUPS PER WK

[ ] SMOKING- CIG/DAY

[ ] HAIR LOSS

[ ] EXERCISE_________

[ ] STREET DRUGS

FEMALE PLEASE COMPLETE:

MENSTRUAL FLOW:

[ ] REG [ ] IRREG [ ] PAIN/ CRAMPS

-DAYS OF FLOW______ -LENGTH OF CYCLE_____

- DATE 1 ST DAY OF LAST PERIOD

[ ] PAIN/BLEEDING DURING OR AFTER

SEX

NUMBER OF:

PREGNANCIES______ ABORTIONS_____

MISCARRIAGE______ LIVE BIRTHS_____

BIRTH CONTROL METHOD

________________

[ ] FLUSING/ MENOPAUSE

Date of last PAP test___________

[ ] NORMAL [ ] ABNORMAL

Date of last MAMMOGRAM

[ ] NORMAL [ ] ABNORMAL


MANAGED CARE BILLS OF RIGHTS

Article 44 of the New York State Public Health Law gives these rights to enrollees of managed care organizations.

You may also ask the health plan for this information before you join the plan.

You have the right to know what health care must be given to you by the plan, as well as any limits on

care, and which types of health care are not covered.

You have a right to know about any treatments or health care which your plan needs to approve in

advance.

You have a right to know what step you can take if the plan will not cover a service. This includes the

toll free phone number of the person who will review the plans action, how long will it take until the

review is done, how to appeal the plans action, and how to file an independent external appeal with the

state. You also have the right to have someone speak to you in any disputes with the plan.

You have a right to know, each year, how the plan decides on how much it will pay to doctors and health

providers who belong to the plan. You have the right to know about any fees you will have to pay, any amount you have to pay yourself

before the plan will start paying, and any caps (maximums) or yearly limits on plan payments. You also

have the right to know what you will have to pay for health care not covered by plan.

You have the right to know about what will you have to pay if you go to a doctor who is not part of the

plan or if you get care that the plan has not approved in advance.

You have the right to file a grievance about any dispute between you and the plan, and you have the right

to know just how a grievance should be made.

You have the right to go to the emergency room 24 hours a day for any health problems that threatensyour life. You do not need the plan to approve this in advance.


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You have the right to a list of the plans doctors, as well as to learn which doctors are taking new

patients.

You have the right to know how you can change to new doctor within the plan.

You have the right to see a doctor outside the plan if the plan doesnt have a doctor you can meet your

heath needs, but your primary must set this up for you.

If you have a very bad health problem that requires you to be seen by a specialist doctor for a long time,

you can ask your special doctor to be your primary doctor.

If you have a very bad health problem that requires you to be seen by a special health care center for a

long time, you can ask to go where you need to without going through your primary doctor. Your plan

must tell you how to make such request.

You have the right to know how you can have input in how the plan makes its rule.

You have the right to know how the plan meets the needs of plan members who dont speak or read

English.

You have the right to know the correct mailing address and phone numbers to be used by the plan

members who need to know something or who need a plan to approve a health service.

You have the right as a female enrollee, to see a plan gynecologist or obstetrician for at least two exams

per year and for all pregnancy care, without referral from your primary doctor.

You have a right to a list that the plan updates once a year, of the name, address and phone number of

each health care provider who belongs to the plan.

If you are receiving services that are not covered by your insurance, we may bill you for them.


DISCLOSURE OF PROTECTED HEALTH INFORMATION

Use and Disclosure Of your Protected health information

Your protected information will be used by D.O.C.S or disclosed to others for the purpose of

treatment, obtaining payment, or supporting the day to day healthcare operations of the

practice.

Notice of Privacy Practice

You should review the notice of practice for a more complete description of how your protectedhealth information may be used or disclosed. You may review the notice prior signing thisconsent.

Requesting a Restriction on the Use or Disclosure of Information

You may request a restriction on the use or disclosure of your protected health information.

DOCS may or may not agree to restrict the use or disclosure of your protected healthinformation

If docs agree to your request, the restrictions will be binding to the practice. Use or disclosureof the protected information in violation of an agreed upon restriction will be a violation of the

Federal Privacy Standards.


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Revocation of Consent

You may revoke this consent to the use and disclosure of your protected health information.You must revoke this consent in writing. Any use or disclosure that has already been acquired

prior to the date on which your revocation of consent is received will not be affected.

Revocation of Right to change privacy practices

DOCS reserves the right to modify the privacy practice outlines in the notice

Signature

I have reviewed this consent form and give permission to D.O.C.S to use and disclose anyhealth information in accordance with it .

NAME OF THE PATIENT (Print):

SIGNATURE:

DATE:

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