medi care clinics, pllc care clinics, pllc philip b. hamby, msn, aprn, fnp-c 2601 scripture st....

MEDI Care Clinics, PLLC Philip B. Hamby, MSN, APRN, FNP-c 2601 Scripture St. Suite 102 | Denton, TX 76201 (940) 799-9008 direct | (817) 841-8242 fax

www.mymedicareclinic.com New Patient Packet Page | 1

(Please Print)

Today’s date: PCP:

PATIENT INFORMATION Patient’s last name: First: Middle: q Mr.

q Mrs. q Miss q Ms.

Marital status (circle one)

Single / Mar / Div / Sep / Wid

Email Address: May we contact you by email: YES | NO

Preferred Language Race/Ethnicity Gender Birth date: Age:

Male | Female / /

Street address: City / State: ZIP Code:

Home Phone: Cell Phone: Social Security no:

( )

Occupation: Employer: Employer phone no.:

( )

Other family members seen here:

INSURANCE INFORMATION (Please give your insurance card to the receptionist.)

Person responsible for bill: Birth date: Address (if different): Home phone no.:

/ / ( )

Occupation: Employer: Employer address: Employer phone no.:

/ / ( )

Primary insurance: Address: City/State/ZIP:

Subscriber’s name: Subscriber’s S.S. no.: Birth date: Group no.: Policy no.: Co-payment:

/ / $

Patient’s relationship to subscriber: q Self q Spouse q Child q Other Secondary insurance: Address: City/State/ZIP:

Subscriber’s name: Subscriber’s S.S. no.: Birth date: Group no.: Policy no.: Co-payment:

/ / $

Patient’s relationship to subscriber: q Self q Spouse q Child q Other

IN CASE OF EMERGENCY Local friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.:

( ) ( )

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Medi Care Clinics, PLLC./Philip Hamby MSN, APRN, FNP-c. or insurance company to release any information required to process my claims.

Patient/Guardian signature: Date:



HEALTH AND HISTORY

Patient’s last name: DOB: AGE:

What doctor or clinic has been provided you care? MEDICATION INFORMATION

MEDICATION DOSE / HOW OFTEN MEDICATION DOSE / HOW OFTEN

MEDICAL HISTORY ( ) Heart Attack ( ) High Cholesterol ( ) Tuberculosis ( ) Diabetes ( ) Liver Disease ( ) Weakness

( ) Heart Failure ( ) Emphysema ( ) Thyroid Problem ( ) Rheumatic Fever ( ) Shingles ( ) Epilepsy

( ) Heart Murmur ( ) Asthma ( ) Arthritis ( ) Stomach Problems ( ) Ulcers ( ) Stroke

( ) Pneumonia ( ) High Blood Pressure ( ) Cancer (specify)___________________ ( ) Swelling ( ) Varicose Veins ( ) HIV or STDs (specify)______________

Do you have any allergies? List any Surgical History: SOCIAL HISTORY

Do you smoke? Have you ever smoked? Do you consume Alcohol? Do you use drugs? Have you ever used drugs?

YES YES YES YES YES

NO NO NO NO NO

If yes, how much & how long? If yes, how much & how long? If yes, how much & how long? If yes, how much & how long? If yes, how much & how long?

________________________________________________________________________________________________________________________________________________________________

REVIEW OF SYSTEMS General: ( ) Lost Weight

( ) Fever ( ) Headaches

( ) Gained Weight ( ) Chills ( ) Itchy Skin

How much in the last 3 Months? ________________________ lbs. ( ) Night Sweats ( ) Insomnia

( ) Constant Fatigue ( ) Hair Changes

( ) Weakness ( ) Mood Changes

Respiratory: ( ) Head Colds ( )Sore Throat

( ) Runny Nose ( ) Hoarseness

( ) Post Nasal Drip ( ) Wheezing

( ) Nasal Blockage ( ) Chronic Cough

( ) Sinus Problems ( ) Bloody Sputum

Cardiovascular: ( ) Shortness of breath with activity ( ) Shortness of breath while sleeping ( ) Shortness of breath while laying down

( ) Chest Pain ( ) Fast heat beat ( ) Slow heart beat

( ) Leg swelling ( ) Ankle swelling ( ) Edema

( ) Palpitations ( ) Eye pain

Vision: ( ) Glasses ( ) Cataracts

( ) Contact Lenses ( ) Floaters in eye

( ) Eye pain ( ) Double Vision ( ) Glaucoma ( ) Have you ever had eye surgery? _________________________

GI: ( ) Diarrhea ( ) Bloody Stools ( ) N/V Indigestion ( ) Constipation ( ) Pain Genitourinary: ( ) Hematuria ( ) Dysuria ( ) Urgency ( ) Frequency ( ) Incontinence M/S-Neuro: ( ) Syncope ( ) Seizures ( ) Numbness ( ) Trouble Walking

( ) Broken Bones ( ) Memory Loss ( ) Loss of Balance Joint & Muscle( )Weakness( ) pain/welling ( ) Dizziness

Endocrine: ( ) Heat/Cold intolerance ( ) Hypothyroid ( ) Hot Flashes ( ) Hair Loss ( ) Diabetes

Hematologic: ( ) Bruises ( ) Bleeding Lymphatic: ( ) Adenopathy (enlarged glands) Women: Are you still menstruating? YES | NO Last Period: ___ / ___ / ___ Last pap smear: ____ / ____ / ____ Number of: Pregnancies: Births: Abortions: Miscarriages: Family Medical History: ( M = Mother, F = Father, S = Sister, B = Brother) ( ) Heart Disease ( ) CAD ( ) Lung Disease ( ) Liver Disease

M | F | S | B M | F | S | B M | F | S | B M | F | S | B

( ) Hypertension ( ) Stroke ( ) Tuberculosis ( ) Diabetes

M | F | S | B M | F | S | B M | F | S | B M | F | S | B

( ) Cancer (specify) ________________________ ( ) Other (specify) _________________________

COMMENTS OR QUESTIONS

Patient/Guardian signature: Date:



HIPAA Information

Due to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the following information must be filled out.

Date: ____________________ I, _________________________, authorize Medi Care Clinics, PLLC to release my medical information as necessary to process my medical claim and coordinate or manage my healthcare.

In the event a family member or caregiver attends my office visit and is in the exam room at the time of my evaluation or treatment, I give Medi Care Clinics, PLLC my permission to discuss freely my condition, treat, or diagnose with that person.

HOME PHONE: _____________________________ WORK PHONE: _____________________________ CELL PHONE: _____________________________

May we leave a message at one of the numbers listed above about appointments, test results, and prescriptions? YES | NO (circle)

If yes, I would prefer that the message would be left on: Home | Work | Cell (circle)

I hereby also give authorization to the authorized individual (s) named below to discuss or release information about care, treatment, or diagnosis.

Authorized Individual (s) Relationship to the patient Phone Number

Signature: _____________________________________ Date: __________________ Printed Name: _____________________________________



Office Policies Please Read Carefully Your initials in each section and your signature indicate that you have read and you acknowledged the policies listed. ______Prescriptions by telephone without an office visit are kept to a minimum for your safety. We prefer to examine you prior to prescribing medication to ensure both your safety and speedy recovery from illnesses. Should you need a refill on a prescribed medication, please call your pharmacy at least three business days in advance. Routine medication refills will be completed at follow-ups. Patients on chronic and long-term medications must be seen at a minimum of every 3 months. _____ Charges for office visits vary according to the complexity and severity of the problem being addressed. Payment for office services rendered will be invoiced via email after being processed by Medicare for patient obligation. Please render payment via the “patient portal”. ______ All patients with more than 2 (or more) chronic conditions being managed will be required to consent to enrollment to have chronic care management (CCM) services. Our goal is to provide high-quality healthcare services in a pleasant, efficient and friendly atmosphere. If you have any suggestions that you feel would improve our service, please let us hear from you. Your comments are always welcome. Signature: _____________________________________ Date: __________________

Printed Name: _____________________________________



Please Read Carefully

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY POLICY I, _________________________________, acknowledge that I have been given access to a copy of Medi Care Clinics, PLLC. privacy policy. This notice describes how Medi Care Clinics, PLLC. may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information and right I may have regarding my protected health information. Signature: _____________________________________ Date: __________________

Printed Name: _____________________________________



CONSENT AGREEMENT FOR PROVISION OF CHRONIC CARE MANAGEMENT

By signing this Agreement, you consent to _Philip B. Hamby, MSN, APRN, FNP-‐c_ (referred to as “Provider”), providing chronic care management services (referred to as “CCM Services”) to you as more fully described below:

CCM Services are available to you because you have been diagnosed with two (2) or more chronic conditions which are expected to last at least twelve (12) months and which place you at significant risk of further decline.

CCM Services include 24-‐hours-‐a-‐day, 7-‐days-‐a-‐week access to a health care provider in Provider’s practice to address acute chronic care needs; systematic assessment of your health care needs; processes to assure that you timely receive preventative care services; medication reviews and oversight; a plan of care covering your health issues; and management of care transitions among health care providers and settings. The Provider will discuss with you the specific services that will be available to you and how to access those services.

Provider’s Obligations. When providing CCM Services, the Provider must:

• Explain to you (and your caregiver, if applicable), and offer to you, all the CCM Services that are applicable to your conditions. • Provide to you a written or electronic copy of your care plan. • If you revoke this Agreement, provide you with a written confirmation of the revocation, stating the effective date of the revocation.



CONSENT AGREEMENT FOR PROVISION OF CHRONIC CARE MANAGEMENT

(continued) Beneficiary Acknowledgment and Authorization. By signing this Agreement, you agree to the following:

• You consent to the Provider providing CCM Services to you. • You authorize electronic communication of your medical information with other treating providers as part of coordination of your care. • You acknowledge that only one practitioner can furnish CCM Services to you during a calendar month. • You understand that cost-‐sharing will apply to CCM Services, so you may be billed for a portion of CCM Services even though CCM Services will not involve a face-‐to-‐face meeting with the Provider.

Beneficiary Rights. You have the following rights with respect to CCM Services:

• The Provider will provide you with a written or electronic copy of your care plan. • You have the right to stop CCM Services at any time by revoking this Agreement effective at the end of the then-‐current month. You may revoke this agreement verbally (by calling (940)799-‐9008) or in writing ([email protected]). Upon receipt of your revocation, the Provider will give you written confirmation (including the effective date) of revocation.

Beneficiary Beneficiary’s Representative and/or Caregiver (if applicable)

Signature: ___________________________ Signature: ___________________________

Print Name: __________________________ Print Name: __________________________

Date: _____________ Date: ______________

medi care clinics, pllc care clinics, pllc philip b. hamby, msn, aprn, fnp-c 2601 scripture st....

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