The Modern Doctor-Patient Intake form

Dear Patient,

Welcome to The Modern Doctor! As a Naturopathic Doctor's office, we are determined to modernize the medical field by taking an integrative approach to provide the highest quality patient care and education. We treat a variety of conditions from acute to chronic, and everything in between. We will work with you to understand the problem at hand, and dig deeper to get to the root cause. We embrace and care for the whole family; babies, children, adults and seniors.

Please complete the following task before your appointment: fill out New Patient Paperwork found on our website, email us a copy of your insurance card (front & back), and email us a copy of your driver's license (or photo ID). You are encouraged to bring copies of medical records and lab results to your visit.

Your appointment time is reserved for you. We do not overbook appointments. If you must cancel or change this appointment, kindly notify us two days in advance.

Feel free to contact our office at 203-239-3400 with any questions. We look forward to meeting you!

Sincerely,
The Modern Doctor Staff

493 Whitney Avenue
New Haven, CT 06511
Email: themoderndoctornmd@gmail.com
Phone: (203) 239-3400 or (203) 903-2658
Fax: (203) 239-4900

This is a fill in the blanks field. Please add appropriate blank fields and text.
Patient Information
Full Name*

First NameMiddle NameLast Name
Preferred Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Preferred Primary Phone*
Secondary Phone
E-mail*
example@example.com
Would you like to receive monthly health tips from Dr. Homkovics via email?*

YesNo
Hobbies*
Occupation*
Name of Employer*
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone Number
SS#
Name of Spouse/ Partner
Phone Number
Please enter a valid phone number.
If Minor, Name of Parent/ Guardian
Phone Number
Please enter a valid phone number.
Emergency Contact*
Relationship*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
How did you find out about us?*
May we tell your doctor you are being seen at The Modern Doctor and communicate with him/her regarding your care?

YesNo
Primary Physician
Name
Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Insurance Company*
ID#
Plan name & Group #
Name of insured (if different from patient)*
Address if different

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth of insured

MonthDayYear
Date
SS#
Employer
I authorize any holder of medical information about me to release to my insurance company and its agents, or any other supplier of medical benefits, any information needed to determine those benefits, or the benefits payable for related services. I request that payment of authorized benefits be made on my behalf to Shannon Homkovics N.D. for any services furnished to me.

Office Policy
Welcome and thank you for choosing The Modern Doctor as your new home for your health care needs! We hope your time with us is all you wish it to be. We encourage your feedback! Your well-being and health is our top priority and we strive to offer the best care possible. Please read our following policies and information.

Cancellation Policy and Missed Appointments

Your scheduled appointment is a time we have reserved and prepared just for you. We try to ensure we will have sufficient time to adequately help you. We make every effort to accomodate your schedule and needs. Therefore, we ask that you help us by keeping your schedule appointment times, arriving on time, and if you are unable to do so, notifying us of the conflict at least forthy-eight (48) hours in advance. Failure to comply with this policy will necessitate the assessment of the following fee:

First Missed Appointment: Our staff will call to ensure you are alright and to reschedule your appointment. There will be no charge for this. However, if you are a new patient, never seen in the office before, and cancel the same day of, it is $60 dollars to reschedule.

Second Missed Appointment: You will be notified by staff that this is your second missed appointment and will receive a missed appointment fee of $60.

Office Hours

Monday and Thursday 9am-7pm
Friday 9am-5pm

Telephone Calls
Our staff is knowledgeable and available to help with most questions. If we are busy with patients, our telephone will be answered by an automated system. Please leave us a message and your call will be returned as soon as possible. If you are ill or in pain please say so when you leave the message/ speak to staff member so we can determine if you need to be seem immediately. Please call 911 if you are experiencing a true medical emergency.
I have read and understand the office policy

Financial Policy
We make every effort to keep down the cost of your health care. Payment is expected at the time of your visit. Any lab test and medications from our inventory that you and your doctor decide are beneficial/necessary to your health are in addition to your visits charge. They must be paid for when you receive them. We accept VISA, MasterCard, Discover, and cash or checks. There is a $25.00 fee for
returned checks.

We reserve the right to seek outside counsel for any unpaid bill.
Most insurance companies cover naturopathic medical services. If we do not participate with your insurance company, it does not necessarily mean that you are not covered. We encourage you to contact them for benefit information. If your policy covers out-of-plan providers, or is a point-of-service plan, and allows you to choose your doctor, it’s likely that you will be reimbursed by your insurance company when you send in your claims. Payment is required at the time of your visit. You may submit the receipt we give you for out-of-plan coverage, as it provides all the information your insurance company needs.

The Modern Doctor LLC is a participating provider for CT
Anthem Blue Cross/Blue Shield, Cigna, Aetna, Husky, Connecticare and United Health Care.

We will submit your insurance claims and accept the amount allowed by your insurance company for covered services. Should any of the services be denied by your insurance company, we will make every effort to appeal your claim on your behalf. Please understand any deductibles, co-pay/co-insurances, and non-covered
services are your responsibility. It is also your responsibility to know your insurance coverage; we encourage you to call your insurance company with any benefit questions. Usually, the insurances that we participate with will cover in full excluding your copayment. Blue Cross/Blue Shield policies differ from state to state, so it is extremely important to check your policy. Please note that any service not reimbursed from individual insurance companies must be paid in full within 15 business days or you are subject to a 15% increase for each missed payment.
“I have read and understood the information provided above. I hereby authorize Dr. Shannon Homkovics and designated assistants to examine and treat me. I understand and agree that I am responsible for payment in full on my account.”

HIPAA Policy
Your health care information is confidential and access is limited. We use your health care information about you for diagnosis and treatment, to consult with other health care practitioners when necessary and with your permission, to obtain payment for treatment, for administrative services, and to evaluate the quality of care you receive. We will not disclose health information for other reasons without your signed permission unless it is required by law. You have the right to examine your records and to have copies for a reasonable fee. You may request a change in your records if you believe they are incomplete or incorrect. If you are concerned we have violated your privacy rights you may complain to us or directly to the US Department of Health and Human Services. We are required by law to protect the privacy of your information and to provide you with this information. More complete rules and regulations are available on request.
I understand my rights under the Health Insurance Portability and Accountability Act of 1996.Other
Should be Empty:

	NOW	PAST	More	N/A
tired, weak, lack of energy
depression, melancholy, moody
worry, anxiety, nervousness, irritable
sleeplessness or sleep too much
frequent colds or other illness
headaches
don't sweat enough
sweat too much
night sweats
loss or gain of weight

	NOW	PAST	More	N/A
skin rashes
acne or pimples
hives
face flushes
stretch marks
athletes foot
skin ulcers or sores
moles, warts or skin tags
hair loss or thinning
sunburn easily
cuts heal slowly or scar badly
hands or feet numb/tingling
dryness, roughness or scaling skin
nails weak, rigid, or split easily
brown spots or bronzing on skin

	NOW	PAST	More	N/A
near/far sightedness
blurry or failing vision
eyes water excessively
bloodshot or puffy eyes
eyes sensitive to light
night blindedness

	NOW	PAST	More
earaches
lots of wax
noises or ringing in ears
loss of hearing
ear discharges

	NOW	PAST	More	N/A
sinusitis, runny nose
nosebleeds
dry mouth or nose
sore throats, tonsillitis
dry or chapped lips
cracks in corners of mouth
cold sores or herpse
inability to smell or taste
lots of cavities
hoarseness
bleeding gums

Patient Information

Symptoms

Survey

Diet, Exercise, Medication, Allergies, Family History

Office Policy

Financial Policy

HIPAA Policy

	NOW	PAST	More	N/A
loss of appetite
bloating
constipation
gagging, difficulty swallowing
nausea or vomiting
can't eat fats
bad breath
food cravings
metallic or bitter taste
heartburn
indigestion
heaviness after eating
belching or gas
symptoms relieved by eating
symptoms worse after eating
headache, dizzy or irritable if meal skipped
diarrhea or loose stools
change in bowel movements
light or greasy stools
dark stools or blood in stool
feeling of incomplete evacuation
undigested food in stool
foul odor of stool or gas
hemorrhoids

	NOW	PAST	More	N/A
difficulty urinating
urinate frequently at night
bedwetting
incomplete urination/dribbling
pain while urinating
bladder infections
lower back pain
kidney stones

	NOW	PAST	More	N/A
prostate problems
difficult/ unusual urination
pain or discomfort in genital area
low sex drive/ uninterested
excessive sexual desire
difficulty maintaining erection

	NOW	PAST	More	N/A
cough frequently
asthma
spitting up blood/ mucus
difficulty breathing
chest pains

	NOW	PAST	More	N/A
Muscle pain/ stiffness
swollen/ pained joints
bone pains
painful feet, ankles, calves
tremors/ twitches
loss of strength
hernia
muscle wasting

	NOW	PASTPast	More	N/A
Varicose veins
fast heartbeat/ irregular
discomfort at high altitude
chest tightness
low blood pressure
high blood pressure
dizzy/ weak upon standing
leg pain while walking
tendency to anemia
swollen feet, legs, ankles
cold hands/feet
hands or feet turn blue
blue fingernails

	NOW	PAST	More	N/A
irregular menstruation
pain before or with periods
depressed, tense or irritable around periods
hot flashes
diminished sexual desire
excessive sexual desire
painful or swollen breasts
lumps in breasts
difficulty having orgasms
vaginal discharge
inability to conceive
discharge from breast(s)
pain, itching or discomfort in genital area
symptoms occur in monthly pattern

	Self	Mother/Father	Sibling	Children	Grandparents/ Relatives	N/A
Thryoid issues
Diabetes
Tuburculosis
Hypoglycemia
Stroke
Heart Attack
Epilepsy
Cancer
Asthma
Allergies
Migraines
Mental Illness
Hepatitis
Heart Disease
Birth defects
High BP
Gallbladder disease
Alcoholism/Addiction
Arthritis