9000 Bailey Cove RoadHuntsville, AL 35802o: (256) 428-4900f : (256) 428-4912

Robert Marlow, MD

Jason Kelly, MD

Courtney Fennell, DO

Tatjana Acker, PA

Brandi Harbin, CRNP

Crystal Gaskins, CRNP

Sherri Telaga Practice Administrator Huntsville Hospital Physician Care at Bailey Cove

Dear patient,

We would like to take this opportunity to thank you for choosing Huntsville Hospital Physician Care for your primary medical care and to welcome you to our office. We are pleased that you have chosen us to provide you with medical services.

Our website (huntsvillehospital.org/find-a-doctor/huntsville-hospital-physicians-offices) should help answer any questions about our office. We want you to know about our office services and what to expect at the time of your first visit.

Please call our office at the number on the left to schedule your new patient appointment prior to completing the New Patient Forms found on our website. We prefer that you mail, fax or drop off the completed forms prior to your appointment. If unable to do so, please bring the completed forms with you to your appointment. Bring your identification cards, insurance card and medication bottles, as well as your co-payments and/or deductibles the day of your visit.

We ask that all new patients arrive 30 minutes prior to your appointment time, so you can be seen by the provider at your scheduled time.

If you are unable to keep your appointment for any reason or if you are going to be 15 minutes or more late, please call our office as soon as possible. We will be happy to reschedule a more convenient time for you.

Sincerely,

Patient Date: ______________

Name: _______________________________________ Referred by:__________________________________________

Address: _____________________________________ City: _____________________ State: _____ Zip: _________

Home phone: ____________________ Cell phone: _____________________ Work phone: _____________________

DOB: ___________________________ SSN: ___________________________ Sex: M F

Email address: _____________________________________________________________________________________

Patient’s occupation: ___________________________ Employer: ___________________________________________

Employer’s address: _______________________________________________ Employer phone: __________________

Spouse’s name: _______________________________ Spouse’s DOB: ____________ Spouse’s SSN: _____________

Spouse’s occupation: __________________________ Employer: ___________________________________________

Employer’s address: _______________________________________________ Employer phone: __________________

In case of emergency, notify: _______________________________________ Relationship: _____________________

City: _______________________________________ State: _____________ Phone: __________________________

If patient is a minor, list person/s other than emergency contact above who have permission to bring child to office for treatment:

Name: ________________________________ Relationship: _____________ Phone: __________________________

Name: ________________________________ Relationship: _____________ Phone: __________________________

Name: ________________________________ Relationship: _____________ Phone: __________________________

Insurance (provide patient information unless patient is a minor, then provide guarantor’s information)

Person responsible for this account: ________________________________ Phone: __________________________

I agree payment will be made at the time of service. I agree to pay all co0pays, non-covered or routine charges, deductibles and co-insurance amounts that apply. In the event this account is turned over to a collection agency for collection, I will be responsible for all collection fees, court costs and attorney’s fees. I authorize HH Physician Care to release information to insurance carriers and for insurance carries to release information to HH Physician Care concerning my illness, treatment and payments (including workmen’s compensation) and I hereby assign to the physician all payments for medical services rendered to myself or my dependents if assignment applies.

___________________________________________________ ________________________ _______________________

Signature Date Time

Insurance name: __________________________________Relationship to patient: ________________________

Subscriber’s name: ________________________________Copay amount: _______________________________

Subscriber ID/Contract Policy #: _____________________ Group #: ____________________________________

Subscriber’s SSN: _________________________________ Subscriber’s DOB: ___________________________

Subscriber’s Employer: _____________________________ Employer’s Phone: ____________________________ PR

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Insurance name: __________________________________Relationship to patient: ________________________

Subscriber’s name: ________________________________Copay amount: _______________________________

Subscriber ID/Contract Policy #: _____________________ Group #: ____________________________________

Subscriber’s SSN: _________________________________ Subscriber’s DOB: ___________________________

Subscriber’s Employer: _____________________________ Employer’s Phone: ____________________________

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EPATIENT

INFORMATION

Date: _________________ Appointment with: __________________________

Name: __________________________________________________ Date of birth: _____________ Age: ____________

What other doctors/specialists do you see? Name/Specialty: _________________________________________________

_____________________________________________________________________________________________________

Reason for visit: _______________________________________________________________________________________

Any new or worsening problems? If yes, please describe: ____________________________________________________

_____________________________________________________________________________________________________

AIDS/HIVAsthmaAtrial FibrillationAnemiaAnxietyAutoimmune Disease (Lupus)Biliary CirrhosisBipolar DisorderBlood TransfusionBrain TumorCirrhosisCVA/StrokeCOPD (Lung Disease)Colon CancerCoronary Heart Disease

Crohn’s DiseaseChronic Kidney DiseaseDepressionDiabetes - Type 1Diabetes - Type 2DiverticulitisDVT (Blood Clot in Legs)EczemaGI BleedGerd (Acid Reflux)HemochromatosisHigh Blood PressureHigh CholesterolHypothyroidismHyperthyroidism

GoiterHepatitis AHepatitis BHepatitis CInfertilityInsomniaKidney StonesLiver DiseaseLung CancerMI (Heart Attack)Migraine HeadachesNeurological DisorderOsteoarthritisOsteoporosisPVDPUD (Stomach Ulcers)

Rheumatoid ArthritisSeizure DisorderThyroid NoduleTuberculosisValvular Heart DiseaseUTI - RecurrentVaricose Veins/PhlebitisAbnormal Pap SmearBreast DiseaseBreast CancerCervical CancerGestational DiabetesRh SensitizedSleep ApneaUsing a CPAP? Yes / No

PAST MEDICAL HISTORY (Please check if you have any of the below.)

AmputationAV Fistula CreationAV GraftAortic Valve ReplacementAortic Valve ReplacedAppendectomyBoth Legs BypassedBack SurgeryBronchoscopy (Lung Scope)CABG (Heart Bypass)Carotid EndarterectomyCarpal Tunnel Right / Left

Cataract ExtractionColon ResectionCraniotomyGastric BypassGallbladder RemovedHemorrhoidectomyHip Replacement Right / LeftInvasive Pain ProcedureKidney Transplant Right / LeftKnee Arthroscopy Right / LeftKnee Replacement Right / Left

KyphoplastyMitral Valve ReplacedNephrectomy Right / LeftPacemaker ImplantedParathyroidectomyPneumonectomy Right / LeftPTCA (Angioplasty)Rotator Cuff Repair Right / LeftAbdominal HysterectomyOvaries Removed Yes / No

Prostate SurgeryShoulder Surgery Right / LeftSleep Apnea SurgeryThyroid SurgeryTonsil’s RemovedVascular SurgeryBreast Augmentation Right / LeftMastectomy Right / LeftLumpectomy Right / Left

Other________________________________________________________________________________________________

PAST SURGICAL HISTORY

Other________________________________________________________________________________________________

MEDICAL HISTORYWORK-UP SHEET

FAMILY HISTORY Father Mother Brother Sister Children

High Blood Pressure

Heart Artery Disease/Heart Attack

Kidney Disease (Chronic)

Diabetes

Stroke

Asthma

Arthritis

Thyroid Disorder

Cancer (Type)

SOCIAL HISTORY (Check or circle appropriate) Married Single Divorced Widowed Work Part-Time Full-Time Retired Disabled Occupation:_____________________________ Children: Yes / No Religious Affiliation ____________________________

ALLERGIES OR MEDICATION REACTIONS NO KNOWN DRUG ALLERGIES Allergic to: Reaction:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

RISK FACTORS (Check or circle appropriate) Current tobacco use Year started __________ Type of tobacco: Cigarettes / Cigars / Snuff / Vapor Former tobacco use Year quit _____________ Never smoked Second hand smoke Yes / NoDo you wear a seat belt? Yes / No

Multiple sexual partners? Yes / NoCaffeine Use Yes / No How many drinks per day _________Alcohol use Yes / No How many per day? _________ Type _________Exercise Yes / No Times per week _________ Type _________

CURRENT MEDICATIONS REFER TO LIST REFER TO BOTTLES Please include the dose and how often you take the medication. (Skip if you brought a list or bottles)

Name Dosage How many times per day? As Needed (PRN)

Pharmacy ______________________________ Phone # __________________ Location ________________________

Do we have permission to receive medication history on patient via electronic prescription? Yes / No

Signature of patient/guardian ________________________________________ Date _______________

Patient name: ________________________________ DOB ____________________

MEDICAL PROBLEMS Have you had any recent or persistent problems with the following?General

Weight Gain/Loss Fever/Chills/Fatigue Snoring Sleep Troubles Depression/Anxiety

Neuro Headache Head injury Blackouts/Dizzy Seizures/Tremors Memory Loss Numbness/Tingling Forgetfullness/ Confusion Abnormal Coordination

Urinary Frequency Trouble starting or stopping urine stream Blood In Urine Painful Urination Urinating at Night Urine Leakage Unable to Urinate

ENT Allergies Sinus Congestion Glasses/Contacts Blurred Vision Ringing Hoarseness Runny Nose Hearing Loss Trouble Swallowing Neck Lump Swollen Glands Earache

Skin Rashes Abnormal moles Changes in Hair/ Hair Loss Wounds that will not heal Heart Chest Pain Palpitations Shortness of Breath Ankle Swelling

Lungs Persistent Cough Cough Up Blood Shortness of Breath Wheezing

Women Irregular Periods Pelvic Pain Nipple Discharge Lumps In Breasts Frequent Sweats/ Hot Flashes Vaginal Discharge

Musculoskeletal Joint Pain Gout Varicose Veins Leg Swelling Back Pain Joint Stiffness Muscle Weakness Muscle Pain Muscle Cramps

Gastrointestinal Reflux/GERD Vomiting Diarrhea Constipation Bloody/Black Stool Hemorrhoids Loss of Appetite Rectal Bleeding Abdominal Pain Sexual Problems with sex Erectile Dysfunction Painful Intercourse Decreased Sexual Desire Blood in Semen

Endocrine Excessive Thirst Excessive Urination High Blood Sugars Heat Intolerance Cold Intolerance

Please enter the most recent date and results of the following:

Date Results Performed by (who/where)

Colonoscopy _____________ _____________________ ____________________________________Pap Smear _____________ _____________________ ____________________________________Mammogram _____________ _____________________ ____________________________________

Bone Density Scan _____________ _____________________ ____________________________________Menstural Period _____________ _____________________ ____________________________________PSA (Prostate Sceen) _____________ _____________________ ____________________________________Eye Exam _____________ _____________________ ____________________________________

When was your last vaccine on the following:

Date Would you like one?

Flu Vaccine _____________ Yes / NoTetanus Vaccine _____________ Yes / NoPneumonia Vaccine _____________ Yes / NoShingles Vaccine _____________ Yes / No

Patient name: ________________________________ DOB ____________________

Patient Name: ________________________________________ Date of Birth: _______________Today’s Date:__________

Part 11. Are you receiving Black Lung Benefits? No Yes, benefit began: ______________ (date) Black Lung is Primary only for claims related to Black Lung

2. Are the services to be paid by a government program such as a research grant? No Yes If yes, STOP - Government Program will be Primary

3. Has the Department of Veteran Affairs authorized and agreed to pay for care at this facility? No Yes If yes, STOP - Department of Veteran Affairs is Primary

4. Was the illness or injury due to a work-related accident or condition? No - Go to Part 2 Yes, date of injury/illness: _________________ Go to Part 3 - Workers’ Comp is Primary

Part 21. Was illness or injury due to non-work-related

accident? No - Go to Part 3 Yes, date of accident: _________________

2. What type of accident caused the illness or injury? Automobile - STOP - Motor Vehicle Insurance is Primary Non-automobile

3. Was another party responsible for this accident? No - Go to Part 3 Yes - STOP- Liability Insurance carrier is Primary

Part 3Are you are entitled to Medicare based on: Age - Go to Part 4 Disability - Go to Part 5 Dialysis (End stage renal disease) - Go to Part 6

Part 41. Are you currently employed? No, retired: ______________________(date) Never worked Yes, employer name and address:

_______________________________________ _______________________________________2. Is your spouse currently employed? No, retired: ______________________(date) Never worked Yes, employer name & address:

_______________________________________ _______________________________________

If the answer to both questions above is no - STOP - Medicare is Primary.3. Do you have Group Health Plan coverage based on

your or your spouse’s current employment? No - STOP Yes

4. Is your spouse currently employed? No - STOP Yes - STOP, Group Health Plan is Primary

Part 51. Are you currently employed? No, retired: ______________________(date) Never worked Yes, employer name & address:

_______________________________________ _______________________________________2. Is your spouse currently employed? No, retired: ______________________(date) Never worked Yes, employer name & address:

_______________________________________ _______________________________________

If the answer to both questions above is no - STOP - Medicare is Primary.3. Do you have Group Health Plan coverage based on

your or a family member’s current employment? No - STOP Yes

4. Does the employer that sponsors the Group Health Plan have 100 or more employees? No - STOP Yes - STOP, Group Health Plan is Primary

Part 6 1. Do you have Group Health Plan Coverage? No - STOP, Medicare is Primary Yes, employer name & address:

_______________________________________ _______________________________________2. Have you received a kidney transplant? No Yes, transplant date:___________________

3. Have you received maintenance dialysis treatments? No Yes, dialysis began:______________(date)If you participated in a self-dialysis training program, training started: ____________ (date)

4. Are you within 30 month coordination period? No - STOP - Medicare is Primary Yes

5. Are you entitled to Medicare on the basis of either End Stage Renal Disease and age or End Stage Renal Disease and disability? Yes No - STOP, Group Health Plan is Primary

6. Was your initial entitlement to Medicare (including simultaneous entitlement) based on End Stage Renal Disease? No - Initial entitlement based on age or disability Yes - STOP, Group Health Plan continues to pay Primary during 30 month coordination period

7. Does the working aged or disability Medicare Second Payer apply (i.e. is the Group Health Plan Primary based on age or disability entitlement)? No - Medicare continues to pay Primary Yes - Group Health Plan continues to pay Primary during 30 month coordination period

MEDICARE SECONDARY PAYER QUESTIONNAIRE

Patient Name: _____________________________________________ SSN (opt):_______________________________

Date of Birth: _________________________________ Address:___________________________________________

Phone: ______________________ Date of Service: _____________

I authorize the use or disclosure of the above named individual’s health information as described below:• Huntsville Hospital Physician Network is authorized to make the disclosure.

• The type and amount of information to be used or disclosed is as follows: (include dates where appropriate) � All/entire record � Visit/encounter notes � Laboratory results � X-ray and imaging reports � Problem list � Medication list � Allergies list � EKG report � Pathology report

� Consultation report � Operative report � Immunization record � Drug and alcohol treatment � HIV/AIDS/STD treatment � Registration record � Other: ________________________

Records release format: (choose one)

� e-delivery (HealthPort connect)

� CD � Paper

• I understand the information in my health record may include information relating to sexually transmitted diseases, acquired immunodeficiency syndroms (AIDS) or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.

• This information may be disclosed to and used by the following individual or agency:

Name: ___________________________________ Address: ____________________________________________

for the purpose of: ______________________________________________________________________________

• I understand that I have a right to revoke this authorization at any time. I understand if I revoke this authorization, I must do so in writing and present my written revocation to the Medical Record Department. I understand the revocation will not apply to information already released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

• Unless otherwise revoked, the authorization will expire on the following date, event or condition:

______________________________________________________________________________________________ If left blank, this authorization will expire six months from the date of signing.

• I understand that once the information is disclosed pursuant to this authorization, it may be redisclosed by the recipient and the information may not be protected by federal privacy regulations.

• I understand as the recipient, I am responsible for the security of these medical record copies and the health information contained therein, whether in paper format or on CD/DVD.

• I understand I need not sign this form in order to ensure health care treatment, payment, enrollment in my health plan or eligibility for benefits. HOWEVER, I understand that if I refuse to sign this form, under specific conditions the organization can refuse treatment enrollment in the health plan and/or eligibility for benefits.

______________________________________________________________________ ______________________ ____________________ Signature Date Time

______________________________________________________________________ Relationship to patient (if signed by legal representative)

______________________________________________________________________ ______________________ ____________________ Signature of witness Date Time

Chart #: ____________________________

Provider: ___________________________

OFFICE USE ONLY: Any portion of the record request found in paper chart? � Yes � No

AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

Name of Organization/Person

Address

Fax/Phone

Huntsville Hospital requests information for the following patient:

Patient Name

SS# (Optional) Date of Birth

Address

Phone

Signature Date of Service

Patient Number

Requested information for treatment, payment or operations:

� Discharge summary

� History and physical

� Operative note

� Pathology report

� Consultation report

� EKG report

� Nurses’ notes

� Progress notes

� Physicians’ orders

� Outpatient record

� Emergency dept record

� Laboratory results

� Imaging results

� Other:

Please send to:

Airport Road Fax: (256) 265-0777

Bailey Cove Fax: (256) 428-4912

Elkton Fax: (931) 468-2103

Fayetteville Fax: (931) 438-0069

Hampton Cove Fax: (256) 265-0357

Lowell Drive Fax: (256) 265-9875

Madison, Hwy 72 Fax: (256) 265-5647

Madison, Lanier Rd. Fax: (256) 265-5971

Hazel Green Pediatrics Fax: (256) 828-0526

_______________________________________________________________________ _____________________________________ Signature Date

_______________________________________________________________________ _____________________________________ Relationship to patient Witness

Patient Number: ___________________________

132 REQUEST FOR HEALTH INFORMATION FROM HOSPITALS OR OTHER PROVIDERS

Patient information

Name: __________________________________________________________ Date of birth: ________________ Date: _____________

Reason for visit: _________________________________________________________________________________________________

Referred by:______________________________________________________ Previous family physician: ________________________

IT IS THE RESPONSIBILITY OF THE PARENTS TO PROVIDE A COPY OF THE IMMUNIZATION RECORD.

Name/s and relationship/s of those living with the child:

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Legal guardian of the child: ________________________________________________________________________________________

Please list the name/s of those who are authorized to bring the child in for medical exams, including immunizations:

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Name/s and phone number/s of those we may discuss the patient’s medical history with (phone and/or office visits):

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

The child’s parents are: Married Divorced Separated Unmarried Widowed

Is there any legal reason why we cannot discuss the child’s medical care with either parent?

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Education/Development/Social

Does the child attend daycare? No Yes

What school does the child attend? ______________________________________________________________ Grade: ______ (If homeschooled, please list)

Doe the child receive any special services such as physical therapy, speech therapy, occupational therapy or special education?

No Yes: _____________________________________________________________________________________________

Does the child have any behavioral, social or learning problems?

No Yes: _____________________________________________________________________________________________

Does the child participate in organized sports or hobbies?

No Yes: _____________________________________________________________________________________________

Are there any smokers in the house? No Yes

Family history Check any that the child has a family history of from the following:

Diabetes

High blood pressure

Childhood heart disease

Asthma

Allergies

Learning problems

Seizures

Sickle Cell Anemia

Birth defects

Sudden death

Other pertinent family medical history:

_________________________________________

Medical history Please list the child’s medical problem and check all that apply.

Asthma Allergic Rhinitis Attention Deficit Disorder (ADD) Migraines Seizures Heart Murmur

_________________________________________________________________________________________________________________

PEDIATRIC MEDICAL HISTORY

Has the child ever been hospitalized? If so, when for what?

No Yes: __________________________________________________________________________________________

Has the child ever had any surgeries? Check all that apply.

None Appendectomy Tonsillectomy Adenoidectomy Tubes in ears Gall Bladder

Orthopedic Other: ____________________________________________________________________________________

What medications does the child take?

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Does the child have any medication allergies?

No Yes, list: _______________________________________________________________________________________

Reaction:________________________________________________________________________________________

What specific health concerns do you wish to address today?

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Do you have any concern about your safety or the child’s safety? No Yes

For teen girls Have you started your period? No Yes, at age: ______ Are your period every month? No Yes

How long do they last? _________________________________ Are they painful? No Yes

Have you ever been pregnant? No Yes

For teen boys and girls Do you: smoke? No Yes Drink alcohol? No Yes Use illicit drugs? No Yes

Are you sexually active? No Yes - do you practice “safe” sex? No Yes

Have you ever had a child? No Yes

What are your long term goals for the future?

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

What talents do you have which give you joy and a sense of accomplishment?

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Dietary history (all ages) Please list everything the child has eaten or drunk in the last 24 hours:

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Name of person completing this form:______________________________________________ Relationship: _________________

LOCATIONSWhitesburg D

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700 Airport Road, Ste. F Huntsville, AL 35801(256) 265-0770

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9000 Bailey Cove Road Huntsville, AL 35802

(256) 428-4900

1446 Bryson Road Ardmore, TN 38449 (931) 468-2102

207 Elk Avenue S.Fayetteville, TN 37334

(931) 433-2551

Russell Brown Medical Park262 Sutton RoadOwens Cross Roads, AL 35763(256) 265-0350

13596 Hwy 431, Ste. 2Hazel Green, AL 35750

(256) 428-4950

401 Lowell Drive, Ste. 19 Huntsville, AL 35801(256) 265-9870

8371 Hwy 72 W, Ste. 206Madison, AL 35758(256) 817-5640

450 Lanier Rd.Madison, AL 35758

(256) 817-5970

at Airport Road

Weatherly Rd.

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Lowes

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Old B

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231431

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