Medical Form Pancare of Florida

Patient Medical Intake Form

PATIENT INFORMATION

Last Name: First Name: Middle Initial:

Social Security Number: Date of Birth: U.S. Military Service: None Currently Serving Discharged

Address: City: State: Zip Code: County:

Home Phone: Work Phone: Cell Phone:

Sex: Female Male   Marital Status: Single Married Widowed Separated Divorced

Primary Language Spoken: Patient’s relationship to responsible party: Self Spouse Natural Child Parent Foster Child Foster Parent

Race: American Indian/Alaska Native Black Asian White Native Hawaiian Latino Asian Pacific Islander Other Pacific Islander Undocumented

Ethnicity: Hispanic Non-Hispanic

Migrant worker or family member of migrant worker? Yes No

Emergency Contact: Phone: Relationship to Patient:

RESPONSIBLE PARTY INFORMATION

Last Name: First Name: Middle Initial:

Street Address: City: State: Zip Code: County:

Mailing Address: City: State: Zip Code: County:

Home Phone: Work Phone: Income: $ Per: Week Bi-Weekly Month Year

Employer Name: Employer Address:

Social Security Number: Birth Date: Sex: F M   Marital Status: Single Married Widowed Separated Divorced

INSURANCE COMPANY – INCLUDING MEDICAID

Primary Insurance: ID#: Group #: Insurance Company Address:

Name of Insured: Date of Birth: Insured’s Employer:

Relationship to Responsible Party: Self Spouse Natural Child Step Child Parent Foster Child Foster Parent

Secondary Insurance: ID#: Group #: Insurance Company Address:

Name of Insured: Date of Birth: Insured’s Employer:

Relationship to Responsible Party: Self Spouse Natural Child Step Child Parent Foster Child Foster Parent

Assignment and Release: I authorize my insurance benefits to be paid directly to the Community Health Center. I also authorize the Community Health Center to release any information required to process this claim.

HEALTH INFORMATION

Date of Last Medical Visit: Reason for Today’s Visit:

Check all that apply to you:

Alcohol use Diabetes High Blood Pressure Shortness of Breath

Anxiety Diarrhea HIV/AIDS Skin Cancers

Asthma Drug Addictions HIV/AIDS Risk or Exposure Sleeping Difficulties

Blood in Stools Ear Discharge Injuries Smoker

Blood in Urine Earache Irregular Heart Beat Stroke

Bowel Changes Ecstasy use Jaundice Suicide Attempt

Cancer History Emphysema Kidney Stones Thyroid Disease

Changing Moles Fainting Liver Disease Thyroid Problems

Chest Pain Fractures Marijuana use Tobacco use

Cholesterol (high) Gallbladder Disease Marital Problems Transfusion

Chronic Cough Gout Osteoarthritis When:

Cocaine use Hay Fever Pneumonia Venereal Disease

Constipation Head Injury Prostate Problems Wheezing

Coughing Up Blood Heart Attack Rectal Bleeding Allergies

Crystal Meth use Heart Catheterization Rheumatoid Arthritis

Dark or Black Stools Heart Disease Seizures

Depression Hepatitis Sexual Difficulties

Hospitalization/Surgeries:

Medications:

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have a change in my health, I will inform the doctors at the next appointment without fail.

FAMILY HISTORY

Check all that apply to you:

Alcohol Abuse Depression Heart Disease

Asthma Diabetes Hypertension or High Blood Pressure

Cancer Glaucoma

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have a change in my health, I will inform the doctors at the next appointment without fail.

NOTICE OF PRIVACY PRACTICES

I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this organization’s Notice of Privacy Practices provides a complete description of the uses and disclosures of my health information. I also understand that the Patient Rights and Responsibilities.

I understand that:

I have the right to review this organization’s Notice of Privacy Practices prior to signing this acknowledgement; I have the right to review the Patient Rights and Responsibilities prior to signing this acknowledgement; This organization reserves the right to change these documents and that they are available to me upon request, at my next visit, and on the organizations web site.

Signature of Patient or Legal Representative:

Printed Name of Patient or Legal Representative:

Date:

CONSENT TO OBTAIN PROTECTED HEALTH INFORMATION

Patient’s Name: Date of Birth:

I give my permission for to release all protected health information to Community Health Center for the purpose of treatment and payment activities.

Health Care Provider/Facility:

Address:

Phone: Fax:

CONSENT FOR MEDICAL TREATMENT

I hereby authorize PanCare of Florida, Inc., Community Health Center, its facilities or treatment centers, its affiliated physicians, ARNPs, physician assistants and other medical personnel to administer examinations and treatments as deemed medically necessary.

Parents with Minor Children: I understand that in order for my child to be seen by one of the medical professionals, a parent or legal guardian must be present.

BROKEN APPOINTMENT POLICY AGREEMENT

I have read and understand the above statement. By signing below, I acknowledge that I will make every effort to notify the medical staff at least 24 hours in advance if I will not be able to make my scheduled appointment.

DESIGNATION FOR RELEASE OF MEDICAL/DENTAL INFORMATION

To Family Member, Friend, or Legal Representative

I authorize PanCare of Florida, Inc. to release my medical/dental and/or billing information to the following individual(s):

Name: Relationship to Patient:

Name: Relationship to Patient:

Name: Relationship to Patient:

Patient Name:

SLIDING FEE APPLICATION FORM

I, , am requesting to be considered for the sliding fee scale discount offered by PanCare of Florida, Inc.

Current Income

Please provide ALL requested income verification for ALL household members with your paperwork. Your appointment will need to be rescheduled if you do not provide it with your packet.

Employer:

Employer’s Phone Number:

Monthly Income:

Spouse/Significant Other’s Employer:

Monthly Income:

Any other income, including any other working adults that live in the home:

List all people (including children) in your household:

Attach

A copy of your CURRENT tax return

A copy of a pay stub for the last month for all working adults in the household

SSI/Disability proof of benefits

Child Support