Gestational Diabetes New Patient Packet

ERIC HORST, MD • MARJAN KAREGAR, MD • LAURA LABOONE, MD • JANELLE HINSON, PA-C • MEREDITH EVERETT, FNP • GINA MCKELVEY, FNP
GESTATIONAL DIABETES NEW PATIENT PACKET
Patient Information
Reason for Consult*
Date

MonthDayYear
Date
Account Number
Patient Name*
Date of Birth*

MonthDayYear
Date
Age*
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Work Phone*
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Emergency Contact*
Phone Number*
Please enter a valid phone number.
Patient's SSN*
Referring Physician*
Employer*
Your Email*
example@example.com
Pharmacy*
Pharmacy Phone Number*
Please enter a valid phone number.
Pharmacy Address*
Primary Insurance Co*
Policy ID #*
Name of Insured*
Insured Date of Birth*

MonthDayYear
Date
Relation to Patient*
Insured SSN*
Secondary Insurance Co
Policy ID #
Name of Insured
Insured Date of Birth

MonthDayYear
Date
Relation to Patient
Insured SSN
Employer
Group Number
AUTHORIZATION OF RELEASE OF MEDICAL INFORMATION TO: LAUREL ENDOCRINE AND THYROID SPECIALISTS, P.A.

Eric Horst, Md; Marjan Karegar, MD; Laura LaBoone, MD; Janelle Hinson, PA; Meredith Everett, FNP; Gina McKelvey, FNP
I authorize Laurel Endocrine and Thyroid Specialists, P.A. to obtain any medical information needed from any physician or hospital.
Patient Signature*

Clear
ASSIGNMENT OF INSURANCE BENEFITS
I request payment of medical benefits be made to Laurel Endocrine and Thyroid Specialists, P.A. or their physicians for services rendered to me.

I UNDERSTAND THAT IN THE EVENT MY INSURANCE DOES NOT PAY, I AM RESPONSIBLE FOR PAYMENT IN FULL. I AUTHORIZE LAUREL ENDOCRINE AND THYROID SPECIALISTS, P.A. TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION OR ITS INTERMEDIARIES ANY INFORMATION NEEDED FOR THIS CLAIM OR A RELATED MEDICARE/INSURANCE CLAIM. I permit this authorization or a photostatic copy of the original to be used and request payment of medical benefits be made to Laurel Endocrine and Thyroid Specialists, P.A.
Signature*

Clear
Date*

MonthDayYear
Date

The following policies have been adopted to give each patient our most effective care and treatment. We ask for your understanding of the policies

PRACTICE POLICIES
1. Please have your updated demographics and complete medication list each visit.
2. Please let us know at check-in of any lab work performed at another location.
3. You will need to be up to date on your appointments in order to receive refills between appointments. Otherwise, you may need to wait until your next appointment or make a new appointment.
4. Our providers do not accept refill requests from pharmacies. Please contact your provider directly.
5. MyChart messages are checked on the days that the office is open. You should receive a response in 1-2 business days, however certain messages or questions may require an appointment.
6. It is not always possible for the provider or medical assistant to speak with you immediately. Your call will be returned within 1-2 business days, or as the schedule permits.
7. If it is an emergency, please go to the emergency room or call 911 for immediate care.
8. No lab specimens or glucometers can be accepted by our front office staff. Please notify the receptionists and a clinical staff member will be called to assist you.
9. There will be a $25 charge per form for the completion of any forms (e.g. pregnancy, FMLA, CDL, or physician exam forms
FINANCIAL POLICIES
1. All copays, coinsurances, and previous balances are due at check-in. Failure to pay in full will result in a $15 service charge being added to your account and you may have to reschedule for a future date.
2. We require a 48-hour notice for any appointment. Any consultation, visit, or in-office procedure not cancelled or rescheduled in that time will be charged a $100 fee. You must pay all fees before rescheduling an appointment.
3. If you are more than 15 minutes late to your appointment, you may be considered a "no-show," which means that you will not be seen for your appointment and you will be charged the $100 fee.
4. If you are unable to make the payment in full, please contact our billing office to make financial arrangements.
5. Failure to pay your balance could result in your care being transferred back to your referring provider.
6. Please bring your insurance card with you to each visit. Insurance is filed as a courtesy to our patients. If you have insurance, but cannot produce a valid card, you will be considered "self-pay" and payment in full will be expected at each visit until we can verify your insurance. No insurance will be filed on services over 45 days old.
PLEASE SIGN AND DATE BELOW INDICATING YOUR UNDERSTANDING OF THE ABOVE POLICIES
Signature*

Clear
Date*

MonthDayYear
Date
Print Name*
Date of Birth*

MonthDayYear
Date

Gestational Diabetes History
Patient Name*

First NameLast Name
DOB*

MonthDayYear
Date
Estimated Delivery Date*
Have you ever had high blood sugars in the past?*
If so, have you ever had diabetes education?
How many times per day do you check your sugar levels?*
Is there someone you live with who can help you in case you have a low blood sugar?*
What was your pre-pregnancy weight?*
Do you have a family history of diabetes?*
Number of previous pregnancies*
Number of live births*
What was the birth weight of each baby?
Any complications with previous pregnancies?*
Gynecologist:*
Last appointment:*
Primary Care Doctor:*
Last appointment:*
Medications
List any drug allergies:
Current prescription medications, OTC medications and supplements:

	Yes
High blood pressure
Diabetes
High cholesterol
Heart attack or stroke
Congestive heart failure
Sleep apnea
Heart disease
Seizures
Kidney disease
Gall stones
Pancreatitis
Peptic ulcer disease
Thyroid disease
Thyroid cancer
Prostate cancer
Other cancers
Low testosterone
Chronic steroid use
COPD/asthma
Kidney stones

	General
Fever/chills
Weight loss
Weight gain
Night sweats
Weakness/fatigue

	Endocrine
Cold intolerance
Heat intolerance
Excessive thirst
Excessive urination
Excessive sweating
Flushing
Tremulousness
Changes in body hair

	Skin
Rash/purple or red spots/pigment
Fingers/toes turn colors in the cold
Nail problems
Dry skin
Skin ulcers

	Neurologic
Migraines
Headaches
Numbness/tingling
Muscle weakness
Seizures
Muscle cramps
Difficulty thinking or remembering

	Scalp/Head
Hair loss
Scalp tenderness
Headache

	Eyes
Blurry vision
Double vision
Decreased peripheral vision
Eye pain
Dry eyes

	Ears/Nose/Throat
Noticeable swelling in neck
Hearing loss
Ear pain
Ringing in ears
Vertigo
Nasal congestion
Loss of sense of smell
Hoarse voice

	Musculoskeletal
Painful joints
Muscle pain
Back pain

	Mouth
Sores in mouth
Dry mouth
Dental problems
Loss of taste
Difficulty swallowing

	Allergy
Frequent sneezing
Seasonal allergies

	Respiratory
Shortness of breath
Cough
Wheezing
Chest pain with breathing

	Blood/Lymph
Easy bruising
Enlarged lymph nodes

	Gastrointestinal
Nausea/Vomiting
Constipation/diarrhea
Hemorrhoids
Change in appetite
Food intolerance
Need for antacids

	Genitourinary
Irregular menses / hot flashes
Frequent Urination
Blood in urine
Decreased urine stream
Prostate problems
Frequent urinary tract infections
Frequent yeast infections
Decreased sexual desire

	Heart
Chest pain
Stabbing chest pain/pericarditis
Irregular or rapid heart rate
Lightheadedness/passing out
Need to sit up to breathe
Leg swelling

	Psychological
Anxiety
Depression
Difficulty sleeping
High stress

	Breasts
Lumps
Pain
Discharge

HIPAA PATIENT AUTHORIZATION
Patient Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState Abbreviation (2 Characters)

Zip Code
DOB*

MonthDayYear
Date
Home Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Purpose of Request

I authorize the Practice to disclose or provide my protected health information to the following individual, who is authorized to act as my personal representative for the purposes of receiving all of my protected health information. I will inform my personal representative of the last four digits of my social security for identification purposes when inquiring about my health information. As my personal representative, they may exercise my right to inspect, copy, and request amendments to my protected health information. They may also consent or authorize the use or disclosure of my protected health information:

Personal Representative:
Name
Relationship
Phone Number
Please enter a valid phone number.
Name
Relationship
Phone Number
Please enter a valid phone number.
Name
Relationship
Phone Number
Please enter a valid phone number.
Description of Information to be Disclosed
I authorize the Practice to disclose all of my protected health information to my designated personal representative.

Expirations or Termination of Authorization
This authorization will remain in effect until terminated by you, your personal representative or another individual(s) of legal entity authorized to do so by court order or law.

Right to Revoke or Terminate
As stated in our Privacy Notice, you have the right to revoke or terminate this authorization by submitting a written request to our Privacy Manager. This can be done in-person or by mailing a request to:

Laurel Endocrine and Thyroid Specialist
Attn: Privacy Manager
1740 St. Julian Place
Columbia, SC 29204

Re-Disclosure
I understand the Practice has no control over the person(s) I have listed as my personal representative. Therefore, any protected health information disclosed under this authorization will no longer be protected by the requirements of the Privacy Rule and will no longer be the responsibility of the Practice.
Patient Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

	Yes	No	If yes, how much?
Do you smoke?
Do you drink?
Do you use recreational drugs?

GESTATIONAL DIABETES NEW PATIENT PACKET

Patient Information

AUTHORIZATION OF RELEASE OF MEDICAL INFORMATION TO: LAUREL ENDOCRINE AND THYROID SPECIALISTS, P.A.

ASSIGNMENT OF INSURANCE BENEFITS

Gestational Diabetes History

Medications

Past Medical History

Social History

Family History

Review of Systems

Signature

HIPAA PATIENT AUTHORIZATION