lakehealthcarecenter.com - New Patient Health History Form

New Patient Health History Form
Name:

First NameMiddle NameLast Name
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Out of State Mailing Address
SSN #:
Gender:

MaleFemale
DOB:

MonthDayYear
Date
Age:
Primary Phone # :
Please enter a valid phone number.
Secondary Phone # :
Please enter a valid phone number.
Primary Insurance:
Secondary Insurance:
Email Address:
Marital Status:

SingleMarriedDivorcedWidowedSeparated
Spouses Name:
Children:

YesNo
# of children?
Employer:
Occupation:
Work #:
Please enter a valid phone number.
In an Emergency Contact:
Phone Number:
Please enter a valid phone number.
The present illness/complaint/health problem that brought you in the office today is:
How and when did the main complaint or health problem start?
If auto accident, list date:
What treatment have you had for this complaint or health problem?

MedicationX-RaysPhysical TherapyInjectionsBlood TestsUrine TestStool TestPap SmearMRICTNCV/EMGHospitalization
Past History:

Please list the following:
Doctors:
Hospitalizations:
Prior surgeries:
Current medications:
All illnesses:
Which pharmacy do you use?
Phone Number:
Please enter a valid phone number.
Have you had any bad reactions to any medications or treatment in the past?

YesNo
Please list any Allergies:
Family History:

(Please list any major illness, disease or cause of death of any family members.)

Rows	Major illness	Disease or Cause of Death
Mother
Father
Sister 1
Sister 2
Sister 3
Sister 4
Brother 1
Brother 2
Brother 3
Brother 4

Social History:
Have you ever been treated for an on the job injury?

YesNo
Year of Injury:
Do you:

SmokeChew TobaccoDrugsDrink CoffeeDrink TeaDrink AlcoholExercise
Signature:

Clear
Date:

MonthDayYear
Date

Direct Payment Authorization with Assignment of Benefits & Policy Rights
The undersigned Type a label, by way of original or copy hereof, hereby assigns the benefits of insurance with Type a label("Insurer") to make payments directly to Lake Health Care Center, Inc. (LHCC) for services rendered to the patient by LHCC, which were necessitated by illness or medical conditions requiring treatment. The undersigned authorizes and directs Insurer to make any and all benefits payment for services rendered by LHCC only, and to forward the same to LHCC’s place of business, being 910 Mt. Homer Road Eustis, FL 32726. The undersigned has read the information herein and it is true to the best of his or her knowledge and belief.

This assignment includes, but is not limited to, all rights to collect benefits directly from Insurer for services that the undersigned has received and all rights to proceed against Insurer in any action, including legal suit, if for any reason Insurer fails to make payments of benefits due to the undersigned or his or her assignee.

As part of this assignment of rights and benefits, which becomes binding upon Insurer upon receipt of said assignment, I hereby instruct Insurer that, in the event of dispute of medical benefits for any reason, including medical reasonableness and / or necessity, that the amount of benefits claimed by LHCC is to he held in abeyance and not disbursed until the resolution of any legal proceedings brought by LHCC.

The undersigned agrees to pay, in a current manner, any applicable deductible, co-payment or professional service charges over and above this insurance payment that is not covered by the Insurer.

The undersigned has assured his or her physician at LHCC that Insurer is the ONLY third party or payer he or she is authorizing to review his or her claims for payment. DO NOT send the undersigned's insurance assignment or bills to other networks, brokers, reprising groups or enter him or her into a “silence PPO” chain or blind / non-directed PPO. The undersigned's physician has accepted me for treatment on this basis only.
Signature:

Clear
Date:

MonthDayYear
Date
Name of Insurance Company:
Claim #:
Address:
Fax #:
Policy #:
Group #:
Deductible $:
Copay: $
Termination Date:

MonthDayYear
Date
Effective Date:

MonthDayYear
Date
Coinsurance:
Name of Adjuster:
Phone Number:
Please enter a valid phone number.
The undersigned hereby accepts assignment of the insurance benefits for the services rendered to the above named patient and to be paid directly to LHCC under the above named insurance coverage in accordance with Florida Statutes. The undersigned understands that any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement containing false, incomplete or misleading information is guilty of a felony of the third degree. The undersigned has read the information herein and it is true to the best of his or her knowledge and belief.
By:

Clear
Date:

MonthDayYear
Date
Name:
Please confirm the above patient's coverage by faxing to LHCC ASAP. *If receiving this by fax, Lake Health Care Center certifies that an original of this document is on file with the patient's signature

Consent for Treatment
I am giving general consent to be seen by a physician(s) at Lake Health Care Center. The physician I am seeing will explain the diagnosis, prognosis, nature, purpose and description of the proposed treatment and procedures; he or she will explain the risks and benefits of the proposed treatment or procedure, including the likelihood of success, as well as any alternatives; he or she will provide these explanations regardless of the cost of the treatment options or the extent of which they are covered by health insurance; he or she will also discuss the risks and benefits of NOT receiving or undergoing treatment or procedure.
Signature:

Clear
Date:

MonthDayYear
Date
Patient Self Determination Act

In order to comply with the Omnibus Budget Reconciliation Act of 1990 and Chapter 745, Floridastatutes, please answer the following questions.
Declaration to Decline Life-prolonging Procedures (Living Will)

I have made such declarations.I have NOT made such declarations
Health Care Surrogate

I have designated a health care surrogate.I have NOT designated a health care surrogate.
Durable Power of Attorney

I have appointed a durable power of attorney (POA) for health care decisions.I have NOT appointed a durable power of attorney (POA) for health care decisions.
Signature:

Clear
Date:

MonthDayYear
Date

Consent to Use & Disclose Information for Treatment, Payment or Health Care Operations
The Patient hereby consents to the use and disclosure of his or her protected health information ("PHI","medical records") by Lake Health Care Center (LHCC) in order to carry out treatment, payment, or health care operations. The Patient should review the LHCC's Notice of Privacy Practices for a more complete description of the potential uses and disclosures of such information, and the Patient has the right to review such Notice prior to signing this consent form.

LHCC reserves the right to change the terms of its Notice of Privacy Practices at any time. If LHCC does change the terms of its Notice of Privacy Practices, the Patient may obtain a copy of the revised Notice.

The Patient retains the right to request that LHCC further restrict how his or her PHI is used and disclosed to carry out treatment, payment, or health care operations. LHCC is not required to agree to such requested restrictions; however, if LHCC does agree to the Patient’s requested restriction(s), such restrictions are then binding on the practice.

The Patient acknowledges and agrees that LHCC may disclose his or her PHI to the following individuals who are either his or her family members, legal representatives, guardians, health care surrogates, or have power of attorney on behalf of the Patient:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
The Patient agrees that LHCC MAY NOT disclose the following types of information contained in the Patient’s medical records (please initial the appropriate categories listed below):

Initial : HIV / AIDS Information
Initial: Mental Health Information
Initial: Substance Abuse Information
Initial: Sexually Transmitted Disease Information
Initial: If the Patient is under the age of eighteen, Pregnancy Information

The Patient agrees and consents to LHCC releasing information to him or her in the following alternative manners (please initial the appropriate spaces below):
InitialVia Regular Mail with the envelopes being marked personal and confidential addressed to the Patient.
InitialVia Telephone, if the Patient contacts LHCC and provides the appropriate information (including his or her name, social security number and unique personal identifier).
Initial Appointment reminders and messages to contact the office due to test results.
At all times, the Patient retains the right to revoke this consent. Such revocation must be submitted to LHCC in writing. The revocation shall be effective except to the extent that the practice has already taken action through prior consent.

LHCC may refuse to treat the Patient if he or she (or an authorized representative) does not sign this consent form. If the Patient (or authorized representative) signs this consent and then revokes it, LHCC has the right to refuse to provide further treatment to him or her as of the time of revocation (except to the extent that the practice is required by law to treat individuals).

I have read and understand the information in this consent. I have received a copy of this consent, and I am the Patient or am authorized to act on behalf of the Patient to sign this sealed document verifying consent to the above stated terms.
Signature of Patient (or Authorized Representative)

Clear
Date

MonthDayYear
Date
Should be Empty:

New Patient Health History Form

Past History:

Family History:

Social History:

Review of Health Systems

Direct Payment Authorization with Assignment of Benefits & Policy Rights

Consent for Treatment

Patient Self Determination Act

Consent to Use & Disclose Information for Treatment, Payment or Health Care Operations

The Patient agrees and consents to LHCC releasing information to him or her in the following alternative manners (please initial the appropriate spaces below):