*** This is NOT iphone/ipad/notepad compatible, yet. ------ It is android phone compatible. ------ Please answer ALL questions, especially required fields: medication list, allergies, family and your health condition. ------ You can type in "na" for none applicable or "NONE" ***
Note: We require current vaccine record for children's visit. Physical are morning appointment because of fasting. *** Fasting mean NO FOOD and drink after midnight. WATER IS ALLOWED. No "black" coffee. Take your medication with water. Medication which require food, take those meds after doctor's visit and labs.
We may need to contact you regarding your medical care. Please let us know in writing which phone # you wish for us NOT to leave a general message.
Primary CONTACT phone #. May leave messages.
Address and Apt#, City, State, Zip code
If mail to PO Box then also include physical address, too.
If policy holder "insurer" is different from the patient then enter insurer's name & birthdate information. ie Patient is the child. Insurer is the dad.
ie Medicare, BCBS, UHC, Aetna, Cigna...
Primary insurance member ID / policy #.
Primary insurance Claim Billing address and provider service phone
Name of your Secondary Insurance (ins2). Enter NONE if none.
Secondary insurance Claim Billing address and provider service phone
Ethnicity (required by insurance)
Note: ie. English, Chinese, Spanish, Vietnamese, Refused, Other ...
Note: Name, relationship to patient, Cell #, Home phone #
Note: A friend, A family, hospital, newspaper, Online web, Insurance.
Note: include estimate Year, Hospital, Reason & Outcome
smoked > 100 cigarettes/lifetime... or smokes > 10 cigarettes/day or equivalent cigar or pipe smoke...
number of packs, cigarettes, cigar, pipe, etc PER DAY, number of years, Date started, Date Stopped.
Enter "NONE" if not use.
Note: REQUIRED. Dad's and Mom's health status (good, fair, bad, decease include cause) and health condition. (Arthritis , Diabetes, Gout, Heart Disease, Asthma, Strokes, Hay Fever, High Blood Pressure, Cancer, Kidney disease, Chemical Dependency, Tuberculosis, Other ____) ie dad 87 bad cancer, mom healthy good
*** DO NOT skip *** REQUIRED. Each sibling's health status (good, fair, bad, decease include cause) and health condition . (Arthritis , Diabetes, Gout, Heart Disease, Asthma, Strokes, Hay Fever, High Blood Pressure, Cancer, Kidney disease, Chemical Dependency, Tuberculosis, Other ____) ie bro 44 good, sis 32 fair, hi blood pressure
Note: *** Required field *** If not taking any medication, vitamin, including over-the-counter, type "NONE". *** It is very important for us to have a list of all medications that you are taking. *** Specify Dosage, Frequency, Reason, and Last Prescribing Doctor. ie: 1) Lisinopril 10mg once daily for BP by Dr Jones, 2) Adderall 10MG -1 tab twice a day in morning for ADHD by Dr Smith, 3) Estradiol 1mg @PM for hormone replace - Dr Mike Nguyen
Note: *** required field *** If any allergies to medication, x-ray dyes, or food. Else no allergies, then type "NONE".
Note: *** Required field *** If no health condition applied then type "Good Health". --- AIDS , Alcoholism , Anemia , Anorexia , Appendicitis , Arthritis , Asthma , Bleeding disorders , Breast lump , Bronchitis , Bulimia , Cancer , Cataracts , Chemical dependency , Chicken Pox , Diabetes , Down syndrome , Emphysema , Epilepsy , Glaucoma , Goiter , Gonorrhea , Gout , Heart disease , Hepatitis , Hernia , Herpes , High cholesterol , HIV positive , Kidney disease , Liver disease , Measles , Migraine headaches , Miscarriage , Mononucleosis , Multiple sclerosis , Mumps , Pacemaker , Pneumonia , Polio , Prostate problem , Psychiatric Care , Rheumatic fever , Stroke , Scarlet fever , Suicide attempt , Thyroid problems , Tonsillitis , Tuberculosis , Typhoid fever , Ulcers , Vaginal infections , Venereal disease, None ____
Note: ie. Abnormal Pap Smear , Bleeding between periods , Breast lump , Hot flashes , Extreme menstrual pain , Nipple discharge , Painful intercourse , Vaginal discharge , Other_____
Date Last menstrual period
Date Last Pap Smear
Date Last mammogram
39f. List number of children. List each child year of birth, Sex of birth and Complications if any (ie 2000 boy normal, 2004 girl c-section)
Note: ie. Breast lump, Erection difficulties, Lump in testicles, Penis discharge, Sore on penis, Other ______
41a. Specific and UP Front. ie How long have you been experiencing these symptoms? (hrs, days, or wks).
44. *** Authorize St. Michael Medical Clinic to release to. TYPE NAME of person and relationship i.e. spouse/parent/grandparent... etc.
45. I understand that I may revoke this authorization in writing at any time, except to the extent that caption has been taken in alliance on it. I understand that if the recipient authorized to receive the information is not a covered entity, e.g. insurance company or non-healthcare provider; the release information may no longer be protected by federal or state privacy regulations.
46. Please call us if you are unable to make the appt to avoid the $30 NO-SHOW fee.
47. I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.
**** 1) You are ultimately responsible for knowing what your plan does and does not cover and the administrative rules. (i.e. in-network / out-network; out-of-pocket balance, copayment, coinsurance, deductible , Health-Saving-Account balance; Labs/Radiology/EKG; authorizations and referrals) **** 2) As a courtesy, we will verify your insurance eligibility and benefits. However, we cannot guarantee that the information received, is accurate due to insurance policy changes and real-time/up-to-date system information. We will bill your insurance company with whom we have a contract agreement with.**** 3) Once your insurance company has processed a claim, any balance as determined by your insurance plan to be "patient's responsibility" and/or "non-covered service", will be your responsibility. ie. any copays, coinsurance, deductible, and fees. **** 4) If you disagree with the "patient responsibility" amounts due to our office per your insurance's Explanation-of-Benefits(EOB), please immediately call your insurance company and our office for further explanation. **** 5) Failure to provide current insurance information to our office and/or reply back to insurance's request for additional information may result in the entire bill being your responsibility.
If you have Medicare, then you will also need to fill-out the Medicare Annual PQRS forms, too.
NOTE: Once you are done, click submit and you should see a green messages "... successfully submitted". *** A RED messages is an error. You need to correct and then click submit. THANK YOU