Intake and Consent Form

Medical History
Today's Date:*

MonthDayYear
Name:*

First NameLast Name
Parent or guardian (if applicable) / relation to patient:
Date of birth:*

MonthDayYear
Age:*
Email:*
example@example.com
US Phone Number:
Alternate or Non-US number:
Home Address:*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Are you a Summit County resident?

noyes
Hotel if applicable:
Room #:
Address of place of lodging including room # (if applicable) if not listed above

Street Address

CityState / Province

Postal / Zip Code
Date of arrival:*

MonthDayYear
Date leaving:*

MonthDayYear
Gender:*

FemaleMale
First day of last menstrual period if applicable:

MonthDayYear
Are you pregnant:

YesNoMaybe
Height:*
Please specify inches or cm
Weight:*
Please specify lb or kg
Primary health concern/ symptoms today:
Allergies to Medications?*

NONEYes - Please List
Current Medications*

NONEYes - Please List
Past or Present Medical Conditions:*

NONEHeart problemsLung problemsDiabetesHigh Blood PressureHistory of Altitude SicknessThyroid diseaseHistory of High-Altitude Pulmonary EdemaOther (Please List)
Surgeries*

NONEYes (please list)
Family Medical History*

NONEYes (please list)
Social History:
Smoke Cigarettes*

NONEYes (please list # per day)
Drink Alcohol*

NONEYes (please list # of drinks per week)
Recreational Drug Use*

NONEYes (please list type and frequency)
PATIENT HIPAA ACKNOWLEDGEMENT AND CONSENT FORM
RELEASE OF INFORMATION

I hereby permit the medical providers or other health professionals involved in the outpatient care to release healthcare information for purposes of treatment, or healthcare operations.
Initials (draw or use mouse)*

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NOTICE OF PRIVACY PRACTICES

I acknowledge that I have been offered a copy of the practice’s Notice of Privacy Practices, which describes the ways in which the practice may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures.

I understand that I may contact the Office Manager if I have a question or complaint.

I understand that this information may be disclosed electronically by the Provider and/or the Provider’s business associates. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice’s Notice of Privacy Practices.

Notice of Privacy Practices
Initials (draw or use mouse)*

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CONSENT TO EMAIL OR TEXT USAGE HEALTHCARE COMMUNICATIONS

I consent to receive text messages from the practice at my cell phone and any number forwarded or transferred to that number AND/OR emails to receive communication.

I understand that security of information sent, cannot be guaranteed.

The practice does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan (contact your carrier for pricing plans and details).

Revocation of the permission to use text and/or email may be done in writing at any time.
Initials (draw or use mouse)

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My medical information may be shared with (ie: spouse, parent, provider etc):
TREATMENT CONSENT AND DISCLOSURE

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment.

By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment through this practice. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your provider about the purpose, potential risks and benefits of any treatment ordered for you. If you have any concerns regarding any treatment recommend by your health care provider, we encourage you to ask questions. I voluntarily request a Medical Provider (may be a Physician or Nurse Practitioner) or the certified medical designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care with this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

FINANCIAL AGREEMENT

I understand that payment is due at the time of service. I acknowledgment that High Altitude Mobile Physicians does not accept any insurance plans including Medicare and will not bill the insurance company directly. Due to the nature of the service, there are no refunds.

I, , agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.
Signature*

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Informed Consent for Skin Laceration / Wound Repair

ALTERNATIVE TREATMENTS

Alternative forms of treatment consist of not treating the skin laceration or wound. Risks and potential complications are associated with alternative forms of treatment.

RISKS of Skin Laceration / Wound Repair

Infection- Likelihood of infection is high after accidents, animal or human bites, and in dirty injuries specifically. Should an infection occur, additional treatment including antibiotics may be necessary.

Scarring- Any laceration or wound to the skin will most likely leave a scar. The goal in suturing is to decrease the severity of the scar. Sutures and/or staples used to close the wound may leave visible marks. There is the possibility that scars may limit motion and function.

Damage to deeper structures- Deeper structures such as nerves, blood vessels and muscles may be damaged from the accident or during the laceration repair. The potential for this to occur varies according to where on the body the injury is located. Injury to deeper structures may be temporary or permanent. If nerves are damaged repair may not be successful. Facial nerve injury may cause permanent cosmetic deformity and well as functional deformity of the face.

Wound disruption- Until wound healing is complete; it is possible to split open the wound where the skin laceration / wound repair was performed. Wound disruption can produce scarring. If this occurs, additional treatment may be necessary.

Allergic reactions- In rare cases, local allergies to tape, suture material, or topical preparations have been reported. Allergic reactions may require additional treatment.

Delayed healing- Wound disruption or delayed wound healing is possible. Some areas of the skin may not heal normally and may take a long time to heal. It is even possible to have loss of skin or deeper tissue. This may require frequent dressing changes or further procedures to remove the non-healed tissue. Smokers have a greater risk of wound healing complications.

Retained Foreign Debris/Materials- You may require removal of tiny residual fragments of glass, metal, wood, plastic, rocks, dirt and/ or other materials from the area of injury/accident in the future. Due to the nature of accidents, although all visible and palpable glass, metal and debris is attempted to be removed during your initial repair, some fragments of material still always remain. Residual foreign material is common after injuries and accidents. These materials and debris may need to be removed in the future.

I have read and understand the following Informed Consent Material for my specific procedure. The risks, benefits, and alternatives of the procedure was explained to me. I understand the specific risks in the consent material for my procedure. I agree to follow all instructions, to follow up as directed, and to follow up with a medical professional if any problems or questions arise.
Signature of Patient or Guardian:*

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MEDICARE OPT OUT PRIVATE CONTRACT

• I, Leslie Shook and Danielle Shook (High Altitude Mobile Physicians), have been excluded from Medicare under §§1128, 1156 or 1892 of the Act.
• I, the beneficiary or the beneficiary’s legal representative accepts full responsibility for payment of the physician’s or practitioner’s charge for all services furnished by the physician/practitioner.
• I, the beneficiary or the beneficiary’s legal representative understands that Medicare limits do not apply to what the physician/practitioner may charge for items or services furnished by the physician/practitioner.
• I, the beneficiary or the beneficiary’s legal representative agrees not to submit a claim to Medicare or to ask the physician/practitioner to submit a claim to Medicare.
• I, the beneficiary or the beneficiary’s legal representative understands that Medicare payment will not be made for any items or services furnished by the physician/practitioner that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
• I, the beneficiary or the beneficiary’s legal representative enters into the contract with the knowledge that the beneficiary has the right to obtain Medicare covered items and services from physicians and practitioners who have not opted out of Medicare, and that the beneficiary is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted out.
• The expected or known effective date and expected or known expiration date of the opt-out period is April 1, 2018 through April 1, 2026.
• I, the beneficiary or the beneficiary’s legal representative understands that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
• This contract cannot be entered into by the beneficiary or by the beneficiary’s legal representative during a time when the beneficiary requires emergency care services or urgent care services. (However, a physician/practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance with §40.28;)
• I, the beneficiary or the beneficiary’s legal representative will receive or have received a copy (a photocopy permissible) of this contract, before items or services are furnished to me under the terms of this contract.
Patient Signature:

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YOUR MEDICAL PROVIDER WILL COMPLETE BELOW. PLEASE CLICK SUBMIT NOW.

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Provider:
Time

Hour Minutes
ASSESSMENT AND DIAGNOSIS
Chief Complaint:
History of Present Illness:
ROS:

All systems negative except HPIOther
Vitals:
BP:
Temp:
O2sat (RA):
HR (RA):
RR (RA):
GENERAL APPEARANCE

Alert, no acute distressIll appearingToxic appearingAnxious appearingOther
SKIN

Color normal, warm and dry, no rashesOther
HEENT:

Head: Normocephalic, atraumatic, no visible or palpable masses, depressions, or scaring.Eyes: Conjunctiva clear, EOM intact, PERRLA, no exudates, patient denies visual abnormality.Ears: EACs clear, TMs translucent & mobile, hearing intact.Nose: No external lesions, mucosa non-inflamed, septum and turbinates normalPharynx: Mucosa non-inflamed, no tonsillar hypertrophy or exudate, mucous membranes moist, no mucosal lesions.Other
NECK:

Neck normal appearance, supple, full range of motion.LymphadenopathyOther
RESPIRATORY:

No respiratory distressEasy unlabored breathingBreath sounds normal bilaterallyRalesRhonchiOther
CVS:

Regular rhythmtachycardiaRegular ratemurmurno murmur, gallop or rubOther
ABDOMEN:

Non-tendertenderbowel sounds active x 4hypoactiveno distentionhyperactiveOther
BACK:

normal inspectionno CVA tendernessfull ROMtenderOther
EXTREMITIES:

non-tenderpainfull ROMinjuryOther
NEURO/PSYCH:

oriented x 3appropriate for agenormal sensationcranial nerve assessment normal (2-12)normal motorOther
Procedure Note:
Patient sustained a cm laceration to
LACERATION REPAIR:

Informed consent was obtained before procedure started.
The appropriate timeout was taken.
The area was prepped and draped in the usual sterile fashion.
The wound was copiously irrigated. No foreign body visualized.
Local anesthesia was achieved using mL of Lidocaine 1% without epinephrine
# .0 prolene sutures/staples were placed.
Estimated blood loss was less than 0.5 mL. A dressing was applied to the area.
The patient tolerated the procedure well without complications.
INCISION AND DRAINAGE:

Informed consent was obtained before procedure started.
The appropriate timeout was taken.
The area was prepped and draped in the usual sterile fashion.
The area was cleaned with disinfectant.
Local anesthesia was achieved using mL of Lidocaine 1% without epinephrine
A cm incision was made with an #11 blade scapel
Approximately mL of fluid drained.
Estimated blood loss was less than 0.5 mL. A dressing was applied to the area.
The patient tolerated the procedure well without complications.
Note:
Suture Removal: Visit set for suture removal and evaluation of the laceration in Type a labeldays.
Anticipatory guidance and post- procedure care education handout provided. Questions answered
Type a label
Plan of Care:
ICD-10 Diagnosis Codes:
Other ICD-10 code
Other ICD-10 code
Other ICD-10 code
Provider Signature:

Leslie Shook NP-C
FOLLOW UP NOTES:
Provider Signature:

Danielle Shook NP-C
Provider Signature:

Lisa Roberts NP-C
Charges:
Categories:All

All

Standard AMS visit

POC

Procedures

I.V.
prevnext( X )
99345 - Home visit for the evaluation and management of a NEW patient, requiring immediate attention Enter description
$395.00



Home visit for the evaluation and management of an ESTABLISHED patientEnter description
$295.00



99058-Visit after normal business hours
$200.00



12001-Laceration Repair < 2.5cm
$250.00



12011-Laceration Repair Face < 2.5cm
$250.00



12002-Laceration repair 2.6-7.5 cm
$250.00



12013-Laceration repair face 2.6-5 cm
$250.00



10060-INCISION AND DRAINAGE OF ABSCESS- SIMPLE OR SINGLEEG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA
$150.00



10061-INCISION AND DRAINAGE OF ABSCESS -COMPLICATED OR MULTIPLEEG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA
$250.00



G8709 - Patient prescribed or dispensed antibiotic
$30.00



S0630-Removal of sutures; by a physician other than the physician who originally closed the wound
$150.00



11740 - Evacuation of subungual hematoma
$100.00



94761- Noninvasive pulse oximetry for oxygen saturation; multiple determinations (necessary to titrate oxygen rate due to hypoxia)
$50.00



E1390-Oxygen Concentrator Rental (modifiers: RR & QF)
$150.00



Oxygen splittersplit device, extra cannula, straight tubing
$15.00 Quantity



Extra oxygen cannula
$5.00 Quantity



Oxygen CPAP adapterCPAP adapter and straight tubing
$10.00 Quantity



S0119 Ondansetron ODT 4mg
$5.00



S0119 Ondansetron ODT 8mg
$5.00



J1100-Dexamethasone IM injectionNDC# 67457-420-10
$60.00



J8540-Dexamethasone, Oral NDC# 67458-420-10NDC# 67457-420-10
$60.00



J8540-Dexamethasone 4 mg tablets
$10.00 Quantity



J2550-Promethazine HCl IM injection
$60.00



J1885-Ketorolac tromethamine IM injection
$60.00



96374-Initial IV push less than 16 minutes
$60.00



96375-IV push, each push of different drug
$60.00



96365-Initial infusion of medication up to 1 hr. (mixed in 1 Liter of Lactated Ringers)
$230.00



96361-Hydration lactated ringers (after medication infusion)
$120.00



96360-I.V. hydration; initial, 31 min to 1 hr. (Lactated Ringers-no IV medications)
$170.00



96361-I.V. Fluids 2nd liter of Lactated Ringers (no IV medications)
$120.00



87880-POC rapid strep test
$40.00



81003-POC urinalysis
$35.00



COVID-19: 87811QW; FLU A: 87804QW; FLU B: 87804QW-59 Influenza virus A and B and SARS-CoV+SARS-CoV-2 combination Ag panel
$105.00



69209-Removal impacted cerumen using irrigation/lavage
$100.00



94640 - Pressurized or non-pressurized inhalation treatment for acute airway obstruction for therapeutic purposes with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device
$150.00



94640 - Pressurized or non-pressurized inhalation treatment for acute airway obstruction for therapeutic purposes with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device- subsequent treatment MODIFIER 76
$50.00



99349-Follow up visit-established patient
$150.00



Total

$0.00
Other charges
Other:
Other:
Other Amt $:
Other Amt $:
TOTAL AMOUNT $:
Should be Empty:

Medical History

Social History:

PATIENT HIPAA ACKNOWLEDGEMENT AND CONSENT FORM

Vitals:

Procedure Note:

Provider Signature:

Provider Signature:

Provider Signature: