United Medical House Calls
Narcotic/ Scheduled Medication Consent Form
I hereby consent to the use of Narcotic/ scheduled medications prescribed to me for the
means of achieving a higher level of daily functioning. I agree to be open, honest and
have regular communication with my provider to monitor my use of scheduled/
controlled medication
The potential risks of narcotic/scheduled medication include, but are not limited to
Addiction
Interference with Physical and/or Mental Functioning
Narcotics/ scheduled medications may interfere with driving, operating machinery or other
requirements of my job. I understand it is my responsibility to avoid these risks
Physical Dependence
I understand that abrupt discontinuation of a narcotic/ scheduled medication drug may cause
nausea, vomiting, suicidal thoughts and sweating
Tolerance
I understand that in the future, narcotics/ scheduled medications may no longer work to
manage my symptoms. It will be necessary to slowly taper from the medication and to develop
other behaviors for management (e.g., exercise, healthy diet, stress management, etc.)
Pregnancy Risk
I understand that narcotic/ scheduled drugs affect a developing fetus and may result in birth
defects. I agree to inform my provider if I am currently pregnant or should become pregnant
during the course of my treatment
Patient Agreement
1. I agree not to take scheduled medications from any other source, unless approved
2. I agree to inform my provider of any other medications I take during this time
3.1 agree to allow my provider to set the interval at which I may request narcotic/ scheduled
prescriptions
4.1 agree to practice pain management behaviors regularly.
5.1 agree to provide a urine sample for drug screening, upon request
6. I will not alter my prescription in any way
my prescription through one pharmacy, and will notify my doctor and both
pharmacies of any change
8.1 understand that prescriptions will be processed within 24- -48 hours
9.1 agree that I have been instructed to go to pain management but have states I am home
bound and unable to get to pain management for treatment
10. I understand that I am being treated with pain medication because I am home bound and
that if I become able to leave my home (FOR ANY REASON), I will start a pain management
program
11. 1 understand that I can be refused scheduled medications at any time
12. Iunderstand that violation of any of the above may result in the termination of my doctor/
patient relationship
13. I understand that stolen pills will require a police report, should any future refills be given. I
understand there is no guarantee they will be refiled and that lost pills will not be refilled
There may be specific risks that pertain to my illness. There is a small chance these risks have
gone undiagnosed. I have been given the opportunity to explore alternative methods for
evaluation and pain management. I have been allowed to ask any questions regarding my pain
control
I hereby give my consent freely, voluntarily and without reservation
HCP (If Applicable) Patients Name
Patient Signature Date
Witness Signature Date
Pharmacy Name and Address
Robert Bramante, MD Steven Templeton, MS PA-C
Gary Despres, DPT Steven Sattler, DO
United Philease Martin, MS PA-C Kimberly Schmidt, PA-C Medical House Calls Laura McDermott, FNP Danielle Willsey, MS PA-C
Kimberley Levy, PA-C Melissa Clem mens, FNP 9
Jessica Graff, PA-C Angela Baily- -Hardy, PT
Suffolk: 631- -626-1006 www. medicalhousecalls .com
Central New York: 607-222- -0628/315- -715-1698 Nassau: 516-736- -1510
info@medicalhousecalls .com Fax: 631 -477-6219
CO MPREH ENSIVE PATIENT INFORMATION Delivering medical care to patients in their home saves money, avoids unnecessary ambulance
trips, emergency department visits, hospitalizations and premature nursing home placement for
our elderly patients. Medical House Calls works closely with home health companies, nurses
and medical equipment companies, mobile imaging companies and pharmacies to assure that
care is coordinated and timely
Office Staff
Our providers are usually on seeing patients but our reception staff is always available
and look forward to assisting you in
Scheduling
Assisting with urgent matters
Prescription refills
Ordering Medical Equipment and Supplies
Any other questions you may have
Practitioners are easily reached by our office staff during operating hours for your
convenience
Fees, Billing and Co-Pays
We will gladly bill your insurance company for your house call visit and any associated charges
Your insurance coverage is an arrangement bet ween you and your unsurance company and, as
with most health policies, payment (including any deducibles or other balances not covered by
your insurance) is your responsibility. Your cooperation with co- -pays and any associated
insurance questions is greatly appreciated. Please contact our office immediately if your
insurance carrier changes at any ume. We follow Medicare Guidelines for visits. testing and
treatments. Patients with Private Insurance are responsible for any fees not covered by their plan
We do our best to keep any additional costs down
Patient Scheduling
Patients can contact our office for all scheduling matters. We do our best to see you in a fast
timely manner. Routine follow ups are scheduled according to the frequency dictated by the
provider. Other appointments are scheduled based on urgency. The scheduling department will
call with the approximate window of arrival via confirmation call the day before that
appointment. Please call back to confirn the appointment before 9: :00 AM otherwise we will
reschedule the appointment for a later date. Requested time slots may not be available due to
other appointments, and/or Continuing Medical Education (CME) for our Practitioners. We
thank you in advance for you understanding and cooperation In this manner
Page 1
Robert Bramante, MD Steven Templeton, MS PA-C
Gary Despres, DPT Steven Sattler, DO
United Philease Martin, MS PA-C Kimberly Schmidt, PA-C Medical House Calls Laura McDermott, FNP Danielle Willsey, MS PA-C
Kimberley Levy, PA-C Melissa Clem mens, FNP
Jessica Graff, PA-C Angela Baily- -Hardy, PT
Sutfolk: 631- -626-1006 www. medicalhousecalls .com
Nassau: 516-736- -1510 Central New York: 607-222- -0628/315- -715-1698
Fax: 631-477- -6219 info@medicalhousecalls .com
On the First Visit
Please have the following information readily available
A list of prescription medications, over-the- -counter medications, and herbal or nutritional
supplements you are currently taking. Please also have all the bottles out
Immunization records (Last Pneumococcal (Pneumonia) vaccination, Flu shot and
Tetanus shot)
Insurance cards for verification (We will need a copy of both the front and back of your
insurance cards)
A list of all physicians along with their phone/fax numbers and address involved with
your care
A list of all medical equipment companies along with their phone/fax numbers and
address
Canceling an Appointment
Our physicians and staff are on the road" during regular business hours. Therefore a last minute (
cancellation means that a patient who could have been seen may not have that opportunity due to
prior scheduling
If you do need to cancel an appointment, please contact us 24 hours prior to your scheduled visit
This allows us to offer the time to another patient
*** appointment is not cancelled24 hours prior to scheduled visit a $50 fee may be charged**
Nursing Staff:
Nurses coordinate all the behind the scenes" activities that allow our Providers to see you! They
answer the phones, manage patient charts and medical records, schedule patient visits, and
perform numerous other activities that keep things running smoothly
Follows care plans designed and approved by the Practitioners
May set up home health or a physician house call in discussion with the physician
Coordinate orders for medical equipment, oxygen, diabetes supplies, etc
Order and facilitate outpatient testing
Conduct Annual Wellness Visits as well as Telephone counseling
Perform EKG Lab draws, collects urine specimen
Assist Practitioner with procedures
Ph Physical Therapists:
Page 2
Robert Bramante, MD Steven Templeton, MS PA-C
Gary Despres, DPT Steven Sattler, DO
United Philease Martin, MS PA-C Kimberly Schmidt, PA-C Medical House Calls Laura McDermott, FNP Danielle Willsey, MS PA-C
(
Kimberley Levy, PA-C Melissa Clem mens, FNP
Jessica Graff, PA-C Angela Baily- -Hardy, PT
Suffolk: 631- -626-1006 www. medicalhousecalls. .com
Central New York: 607-222- -0628/315- -715-1698 Nassau: 516-736- -1510
info@medicalhousecalls .com Fax: 631 -477-6219
See patients both in home and at our facility
Work closely with your provider to tailor a regimen for you
Assist with choosing the proper equipment and or braces for your specific needs
Prescription Refills
Refills are generally written for a one- -month supply. If you would like a larger quantity to
decrease trips to the pharmacy please let us know (note, most insurance companies will only
cover a one month supply at a time). Please call the office during regular business hours for
preseription refills and not the doctor on call
Prior to your house call please review your medication bottles for any refills needed. The
physician will take care of the refills at the visit to ensure you do not run out of your medication
Your primary care provider must approve a prescription refill. Please allow 2 business days for
all refill requests
Please call and press the refill prompt with the following information
Name of medication
Patients Nane
Dosage
Pharmacy name and location
If mail-order pharmacy must specify
Phone Number or Insurance Change of Address
If your home or business address, telephone numbers, or insurance information changes, please
notify our reception promptly
Inclement Weather
During times of unsafe driving conditions, our providers will not be traveling. Should you need
immediate medical attention you should dial 911 during these times. If your house is inaccessible
due to snow or any other means we will reschedule your appointment until snow can be removed
or the situation remedied. There must be a clear, safe path to your home
Release of Medical Records
A signed statement is required for the release of medical records. Please allow two weeks to copy
the records. If paper copies are requested a minimal charge may be assessed for this service as
determined by state law
Page 3
United Medical House Calls
www. medicalhousecalls .com (631) 626- -1006 Suffolk
info@medicalhousecalls com (516) 736 - -1510 Nassau
FAX: (631) 477 - - 6219 Central NY: (607) 222- 0628
(315) 715- -1698
New Patient Form
Date First Visit Date
** PATIENT INFORMATION ** ** PRIMARY INSURANCE
Name Insurance Company
Street Claim Address
Facility/Complex City/state/Zip
Group #:
Town/State/Zip Policy/ 1D#
Name on Card
Date of Birth Contact Information
Soc Security #: Phone
Effective Date Email
* SECONDARY INSURANCE *
Date of Birth
Insurance Company F Sex M
Soc Security # Claim Address
City/state/Zip **
**EmergencyContact Information **
Group #
Policy/ ID# Name
Name on Card Phone
Date of Birth Relationship
Soc Security #:
Effective Date
** ** **Other Physicians** Name
Name Phone
Phone Relationship
Specialty Fax
Responsible Party Billing address
Name (If not same as above)
Phone Name
Specialty Fax Street:
Page 1
United Medical House Calls
(631) 626-1006 www. .medicalhousecalls com Suffolk
(516) 736- -1510 info@medicalhousecalls .com Nassau
Central NY: (607) 222- 0628 FAX: (631) 477 - - 6219
(315) 715-1698
Past Medical History
Have you ever been Hospitalized? If yes, why? DYes ONo
Have Have you ever been treated for Hepatitis A,B, orC OYes DNo If yes, which?
If yes, date complicated you been vaccinated for Hepatitis B? DYes ONo
If yes, date complicated DYes ONo Have you been vaccinated for Hepatitis A?
Positive ONegative Result of screening Last Tuberculosis (TB) Screening?.
Result of Chest Xray: Positive ONegative If positive TB screen, date of last chest x-ray:
Diagnosis Have you ever had a sexually Transmitted Disease? oYes oNo
Which of the following conditions are you currently being treated for or diagnosed within the past?Please
check)
DHigh blood pressure DHigh cholesterol DHeart disease / Murmur / Angina
Swollen OAnemia or blood problems Low blood pressure
DAsthma Shortness of breath OHeartburn (reflux)
Tonsillitis aSeasonal allergies DSinus problems
DEye disorder / Glaucoma DLung problems / cough DEar problems
DNeurological problems Head aches / Migraines Seizures
] Stroke DPsychiatric care Depression / Anxiety
Liver problems / Hepatitis DKidney / Bladder problems Diabetes
Ulcers/colitis Cancer OArthritis
OThyroid problems
Page 2
United Medical House Calls
www. medicalhousecalls .com (631) 626-1006 Suffolk
info@medicalhousecalls. com (516) 736 - 1510 Nassau
FAX: (631) 477 - - 6219 Central NY: (607) 222- 0628
(315) 715-1698
Please Descrlbe any current or past medlcal treatment not Ilsted above
Please list your past surgeries
Allergies
Are you Allergic to penicillin or other drugs?
Please list:
Have you ever had to use an Epinephrine Pen? DYes DNo If Yes, date administered
Medications: (PLEASE LIST ALL MEDICATIONS)
Social and Preventive History
If no, have you in past? DYes DNo Do you currently smoke or chew tobacco?
If no, have you in past? dYes ONo DYes ONo Do you drink alcohol, beer, or wine?
If yes, how many cups per day? Do you currently drink coffee or tea?
Do you exercise weekly? UYes ONo DYes ONo Do you wear a helmet when riding bike?
dYes ONo Do you wear seatbelt when driving?
Page 3
United Medical House Calls
(631) 626-1006 Suffolk www. medicalhousecalls. com
(516) 736 - -1510 Nassau info@medicalhousecalls .com Central NY: (607) 222- 0628
FAX: (631) 477 - - 6219
(315) 715- -1698
List of serious illness LivingAge (or age of death) Family History
Mother DYes DNo
Father Yes ONo
Sisters
DYes ONo
Brothers
OYes DNo
Has any member of your family (including children and parents) had any of the following illness
Which family member $ llness
Anemia or blood disorder
Cancer
Diabetes
Glaucoma
Heart Disease
High Blood Pressure
HIV disease/ AIDS
Mental Status/ Depression
Stroke
Other serious illness
Do you routinely see OBGYN? Females
Date of last Pap Smear: How many times have you been pregnant?,
Diagnosis Have you had an abnormal Pap smear? DYes ONo
Mammogram results Date of last Mammogram
Biopsy results Yes ONo Have you ever had a breast biopsy?
Page 4
United Medical House Calls
www. medicalhousecalls .com (631) 626- -1006 Suffolk
info@medicalhousecalls com (516) 736- -1510 Nassau
FAX: (631) 477 - - 6219 Central NY: (607) 222- 0628
(315) 715-1698
By signing below, I certify that to the best of my knowledge all the information I have furnished on this form is
complete, true, and accurate, I hereby give consent for medical treatment. I also give consent for Clinical Care
Management conducted by nursing and provider staff. I have read the comprehensive patient information and I agree
as per company guidelines, Medical House Calls of the North Fork reserves the right to begin the immediate
discharge of any patient if any of the following occur; abuse including physical and/or verbal, sexual innuendo
threatening communications, or assault by the patient or any family members
Patient/ Legal Guardian Signature Date
PATIENT MEDICAL INFORMATION RELEASE
Patient Name DOB
Address
Medical House Calls of the North Fork Is authorized to
()Furnish ( )Receive (check which applies)
Medical records to/from any Hospital, Facility, or Doctor
OR Specific Recipient/ Discloser:
IAUTHORIZE RELEASE OF THE FOLLOWING MEDICAL RECORDS
()I GIVE PERMISSION TO THE RELEASE OF MY MEDICAL RECORDS including information and
records or copies of records relating to the history, diagnosis, treatment, or services rendered to me in
connection with any condition or disease. This includes permission to release POTENTIALLY
SENSITIVE INFORMATION which may include information concerning my treatment of mental illness
Human Immunodeficiency Virus (HIV), alcoholism, drug use/ dependency, venereal disease, sexual
assaults, abortion, illegitimacy of birth, communications to social workers and/or psychotherapies
psychologists, if any
()I GIVE PERMISSION TO RELEASE ONLY RECORDS specifically described below
Page 5
(United Medical House Calls
(631) 626- -1006 Suffolk www .medicalhousecalls. .com
(516) 736 - -1510 info@medicalhousecalls com Nassau
Central NY: (607) 222- 0628 FAX: (631) 477 - - 6219
(315) 715- -1698
I release Medical House Calls of the North Fork and the Recipient/ Discloser listed above, and any of their
providers and staff from all responsibility or liability that may arise from this authorization. I may withdraw
this authorization at any time by giving written notification to Medical House Calls of the North Fork
provided that I do so in writing and to the extent that you already disclosed the information in reliance on
this authorization
(optional) if no expiration date is given, then this authorization This authorization expires /I shall remain in effect for 12 months from date of signature
Date Patient Signature (Legal Representative)
Page 6
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