Ollin Patient Intake Form - Minor

 

Personal Information

Last Name
First Name
Middle Name
Address LIne 1
Address Line 2
City
State
Zip Code
Home Phone Number
Work Phone Number
Date of Birth
Gender
Social Security #
Marital Status
Email Address
Current Occupation/Employer
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship

Insurance/Guarantor Information

Primary Insurance Information

Insurance Carrier
Insurance Phone # (Provider or Claim #)
Claim Mailing Address
Address Line 2
City
State
Zip Code
Policy/Subscriber ID #
Group #

 

Secondary Insurance Information
(if applicable)

Secondary Insurance Carrier
Secondary Insurance Phone # (Provider or Claim #)
Claim Mailing Address
Address Line 2
City
State
Zip Code
Policy/Subscriber ID #
Group #

 

Guarantor Information

(If Different from Patient)

Last Name
First Name
Middle Name
Date Of Birth
Home Phone Number
Work Phone Number
Address LIne 1
Address Line 2
City
State
Zip Code

 

Medical Health History

Todays Date
Date of Injury/Surgery
What is the reason for visit?

Please mark any of the following conditions you have.

Chest Pain Kidney Problems
Heart Problems Cancer
Change in Bowel/Bladder Hernia
Shortness of Breath Arthritis
Unusual Bleeding/Discharge Diabetes
Digestive Problems Tumor
Seizures-Convulsions Osteoporosis
Skin Problems Hepatitis
Mental Illness Asthma
Severe Headaches Tuberculosis
Stroke HIV Positive
Anemia Emphysema
Visual Disturbances Dizziness/Fainting Spells
Hearing Problems Blood Pressure Problems
Thyroid Disease Alcohol Problems
Nausea and Vomiting1 Drug Problems

 

Please list any allergies to medications and/or other substances:
Are you under the care of another doctor for this or any other condition?
Current Medications or over the counter drugs:
Past injuries/surgeries:
Do you drink alcohol?
If Yes, how many days per week.
Do you smoke cigarettes?
If Yes, how many cigarettes per day.
Approximate hours of sleep per night:
Exercise per week:

Did any of your family members have any of the following? Check all that apply.

Hypertension
Heart Attack
Diabetes
Cancer
Stroke
Please indicate/describe in detail anything else about your health history that you think would be useful or important for your practitioner to know:
WOMEN Date of last Menstrual Cycle
Men Date of last Prostate Exam

NOTICE OF PRIVACY PRACTICES

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Our practice is dedicated, and applicable federal and state laws require us to maintain the privacy of your health information. These laws also require us to provide you with this Notice of our privacy practices, and to inform you of your rights, and our obligations, concerning your health information. We are required to follow the privacy practices describe below while this Notice is in effect. This Notice is effective as of April 15, 2003, and will remain in effect until we replace it
Changes to Notice:
We reserve the right to change this Notice and the privacy practices described below at any time in accordance with applicable law. Prior to making significant changes to our privacy practices, we will alter this Notice to reflect the changes, and make the revised Notice available to you on request. Any changes we make to our privacy practices and/or this Notice may be applicable to health information created or received by us prior to the date of the changes.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
Permitted uses and disclosures of health information
A. Consent: You should be aware that during the course of our relationship with you we will likely use and disclose health information about you for treatment, payment, and healthcare operations. Examples of these activities are as follows:
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, and other business operations.
Our Therapy Center will seek to obtain Consent from you permitting us to use or disclose your health information for these activities. You should be aware that our Therapy Center does not require obtaining or confirming the existence of Consent, prior to:
a) Emergency treatment;
b) Treatment, when such treatment is required by law; or
c) Treatment of patients when communication barriers prevent obtaining Consent
You should also be aware that you have the right to revoke that Consent at any time by providing the practice with written notice.
B. Authorizations: You may specifically authorize us to use your health information for any purpose or to disclose your health information to anyone, by submitting such an authorization in writing. Upon receiving an authorization from you in writing we may use or disclose your health accordance with that authorization. You may revoke an authorization at any time by notifying us in writing. Your revocation will not affect any use or disclosures permitted by your authorization while it was.

I, ,(patients' name) acknowledge that I have received, reviewed, understand and agree to the Notice of Privacy Practices of Ollin Athletics and Sports Medicine , which describes the Practice's policies and procedures regarding the use and disclosure of any of my Protected Health Information created, received or maintained by the Practice.

Todays Date

Patients Signature
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Ollin Cancelation Policy
We realize that emergencies and other scheduling conflicts arise and are sometimes unavoidable. However, advance notice allows us to fulfill other patient’s scheduling needs and keeps the clinic operating efficiently.

Please provide our office with 24-hour notice to change or cancel an appointment. Patients who do not attend a scheduled appointment or do not provide 24-hour notice to change a scheduled appointment may be responsible for a $35.00 service charge. This charge cannot
be billed to insurance and must be paid on or before the next scheduled appointment.


Signature

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HIPPA Release of Information MEDIA RELEASE AUTHORIZAION FORM

I,  hereby authorize Ollin Athletic and Sports Medicine, its duly authorized employees or agents, to publish the following personal health information / story: (e.g., information relating to the diagnosis, treatment, and health care services provided or to be provided to me and which identifies my name, as well as other recorded media, such as photo, video and audio) to be used in print media, on the radio, TV, company website, and on the following social media platforms: Facebook, Twitter, Pinterest, Instagram, and YouTube.

The following information about me will not be disclosed:

I understand that any personal health information or other information released via the social media platform(s) above may be subject to re-disclosure by such social media platform(s) and may no longer be protected by applicable Federal and State privacy laws.

I understand that I have a right to revoke this authorization by providing written notice to Ollin Athletics and Sports Medicine. However, this authorization may not be revoked if Ollin Athletics and Sports Medicine, its employees or agents have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my eligibility for benefits or enrollment or payment for or coverage of services.

Patient Name:




CONSENT TO TREAT A MINOR

Patients Name:

I hereby request and authorize Ollin Athletics and Sports Medicine to perform diagnosis and render treatment to my minor: .

This authorization also extends to all other doctors and office staff members and is intended to include radiographic examination at the doctor’s discretion.

As of this date, I have the legal right to select and authorize health care services for the minor named above.

(If applicable) under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse / former spouse or other parent is not required. If my authority to select and authorize this care should be revoked or modified in any way, I will immediately notify this office.

Date:
Signature
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Printed Name:

Relationship to patient:

Witness
Date:
Witness Signature
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