Patient Intake Form

Patient Intake Form

Premier Health & Wellness Clinic
Today's Date:

MonthDayYear
Date
Date of Birth:

MonthDayYear
DOB
Patient's Name:

First NameLast Name
SSN:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Contact Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Employer:
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Gender:
Martial Status:
Spouse Name:
Phone Number:
Responsible Party:
Pharmacy:
If minor, responsible parent:
Phone:
Most Recent Doctor:
Phone:
Date of Last Exam:

Is this work related?
Is this accident related?
If yes, give brief details
Insurance Information

Please present insurance cards for copying and complete all requested information
Insurance Company #1:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Primary Insured's Name:
Date of Birth:

MonthDayYear
Date
Policy Number :
Group Number :
I hereby authorize the payment of medical benefits to Nurse Practitioner Raven Campbell-Smith for services rendered. I understand that I am financially responsible for any services not covered by my insurance carrier. I further agree to pay all collections cost, attorney fees, and other collection cost incurred to enforce the collection of any amounts outstanding. I hereby authorize RN Raven Campbell- Smith to release any medical information necessary to complete and process my insurance claims. I authorize NP Raven Campbell-Smith to treat me and use personal health information for health care purposes.
Signature
Date

MonthDayYear
Date

Do you live at home alone? If not, who lives at home with you?
Medical History

Please check conditions you have now or have had in the past
Medical History Options
Hospitalization

List all the times you have went to the hospital, for illness and / or surgery.
Date/Hospital/Physician
Medications, Vitamins, Supplements
Please list all medications, vitamins, and/or supplements
Allergies
List any allergies.
Lifestyle Affecting Health: Please answer all questions
Tobacco
Alcohol
I,_________________________ answered all the above listed questions to the best of my knowledge in reference to my health history.
Patient or Insured Signature :
Date:

MonthDayYear
Date

Premier Health & Wellness Clinic - No Show Policy

No Show: Failure to cancel a scheduled appointment within twenty-four (24) hours of scheduled time, will result in a $25.00 fine charged to you. You will be responsible for this payment due before your next appointment.
3 “No Shows” Will Result in Dismissal from this Clinic

You will have thirty (30) days to find a new provider; after thirty (30) days, there will be no more refills. If you feel like you have ‘just’ reason for (3) no shows, you have the right to appeal to the office manger by calling within the thirty (30) days to present your case.
I,____________________________ have read this and hereby agree to this policy and understand that from this date on, it will be in effect as long as I am a patient of NP Raven-Campbell-Smith, FNP-C.
Patient or Insured Signature:
Date:

MonthDayYear
Date

Patient's Full Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:

MonthDayYear
Date
Premier Health & Wellness Clinic is authorized to furnish to and receive from:
Recipient/Disclosure:
For the Purpose of :
I AUTHORIZE RELEASE OF THE FOLLOWING MEDICAL RECORDS:
GIVE PERMISSION TO RELEASE ALL 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 SENSITTIVE 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:
I release Premier Health & Wellness, the Recipient/Disclosure listed above, and 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 Premier Health & Wellness, provided that I do so in writing and to the extent that you have already disclosed the information in reliance on this authorization.
Patient or Insured Signature
Witness Signature
Date

MonthDayYear
Date
Date

MonthDayYear
Date

PATIENT CONSENT FOR USE AND DISCLOUSRE OF PROTECTED HEALTH INFORMATION
I hereby give my consent for Premier Health & Wellness Clinic to use and disclose protected health information (PHI) about me to carry out treatment, payment, and health care operations.
I have the right to review the Notice of Privacy Practices prior to sign consent, Premier Health & Wellness Clinic reserves the right to revise its Notice of Privacy Practices at any time.
With consent, Premier Health & Wellness Clinic may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS, such as an appointment reminder, insurance items, and any calls pertaining to my clinical care, including laboratory test results, among others.
With this consent, Premier Health and Wellness Clinic may mail to my home or any alternative location any items that assist the practice in carrying out TREATMENT, PAYMENTS, AND HELATH CARE OPERATIONS, such as appointment reminder cards, and patient statements,
With this consent, Premier, Health & Wellness Clinic may e-mail to my home or other alternative location any items that assist in the practice in the carrying out TREATMENT, PAYMENT, and HEALTH CARE OPERATIONS, such as appointment reminder cards and patient statements. I have the right to request that Premier Health & Wellness Clinic restrict how it uses and discloses my PHI To carry out TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS. The practice is not required to agree to my request restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to allow Premier Health & Wellness Clinic to use and disclose my PHI to carry out TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Premier Health & Wellness Clinic may decline to provide treatment to me.
Signature

PREMIER HEALTH & WELLNESS PERFUME & COLOGNE POLICY
Due to other patients and staff having severe allergy and asthma reactions to people wearing cologne or perfume, we ask you not to wear either on the day of your appointment.
Deodorant is acceptable.
If you have perfume or cologne on when you show up for your appointment, we may have to ask you to reschedule for another day.
I have read and agree to the above asking me no to wear perfume or cologne when I show up for an appointment.
Signature
Date

MonthDayYear
Date

INFORMED CONSENT FOR TELEMEDICINE SERVICES
POSSIBLE RISKS
• With any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but no limited to:
• In rare cases, information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s)
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reaction or other judgement error
EXPECTED BENEFITS
• Improved access to medical care by enabling a patient to remain in his/her office (or a remote site) while the physician obtains test results and consults form healthcare practitioners at distant/ other sites
• More efficient medical evaluation and management
• Obtaining expertise of a distant specialist
POSSIBLE RISKS
• With any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but no limited to:
• In rare cases, information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s)
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reaction or other judgement error
Please initial after reading this page:
Signature
Date

MonthDayYear
Date

PATIENT CONSENT TO THE USE OF TELEMEDICINE

I have read and understood the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction, I hereby give my informed consent for the use if telemedicine in my medical care.
I hereby authorize Raven Campbell-Smith, FNP-C to use telemedicine in the course of my diagnosis and treatment.
Patient's Signature
Authorized Signer, Relationship to Patient
Physician's Signature
Date

MonthDayYear
Date
Should be Empty:

Patient Intake Form

Insurance Information

Medical History

Hospitalization

Medications, Vitamins, Supplements

Allergies

Lifestyle Affecting Health: Please answer all questions

I,_________________________ answered all the above listed questions to the best of my knowledge in reference to my health history.

Premier Health & Wellness Clinic - No Show Policy

3 “No Shows” Will Result in Dismissal from this Clinic

Premier Health & Wellness Clinic is authorized to furnish to and receive from:

I AUTHORIZE RELEASE OF THE FOLLOWING MEDICAL RECORDS:

PATIENT CONSENT FOR USE AND DISCLOUSRE OF PROTECTED HEALTH INFORMATION

PREMIER HEALTH & WELLNESS PERFUME & COLOGNE POLICY

INFORMED CONSENT FOR TELEMEDICINE SERVICES

PATIENT CONSENT TO THE USE OF TELEMEDICINE