Received by_______ Date______Insurance Card Copied_______

EFM New Patient Process

Thank you for your interest in becoming an Evergreen patient! Please

complete this packet in full and do not leave anything blank. If there is

something that does not apply to you, please write N/A.

Once completed, your records will be requested and an appointment will

be made upon receipt of them.

Please submit a copy of your insurance card with your completed packet.

We can copy this in the office for you.

More helpful information you may want to know:

1. We will process your packet and schedule your New Patient appointment

as quickly as possible to meet your new provider. If you need to be seen

before we have received your medical records, please contact us.

2. Please contact your insurance to verify that we are in their provider

network. We hold contracts with most local insurances; Commercial,

Medicare and Medicaid, but ask our patients to communicate with their

insurance companies for their own confirmation.

Patient Name:________________________________ DOB:____________

Provider Preference: ____________________________________________

*We will attempt to accommodate your preference based on provider

availability. Not all providers have an open panel at this time.

Team 1: North Pod Team 5: Southwest Pod

Dr. Brandon Bonds & Bri Dr. Shelli Flynn & Codie

Kaitlyn Hane, PA & Jacob Cindy Maynes, FNP & Steve

Terry Bancroft, PAC & Heidi + Sara Bryan Yates, & Christy

Extra Nursing Staff: Felicia Extra Nursing Staff: Latisha

Team 2: South Pod Team 6: Family Practice West (Roseburg)

Dr. Shelley Brittain & Candy Bill Briggs, FNP & Mandy

Cindy Kusler, FNP & Charlotte Dr. Jairus Sathianathan & Marva

Amanda Rose, PA-C & Jason Extra Nursing Staff: Cindy

Extra nursing staff: Shelby

Team 7: EFM Chapman/Endocrinology (Roseburg)

Team 3: East Pod Dr. Patrick Clyde (Endocrinogist) & Cindy

Dr. Charles Hundley & Margaret Alicia Morrison, FNP (Endocrinology) & Kathy

Samanatha Griffin, FNP & Aleila

Dr. Heidi Beery & Melody Team 8: Family Practice South (Myrtle Creek)

Extra Nursing Staff: Stephanie Krissy Skinner, FNP & Whitnee

Barbara Bergeron, FNP & Shawna

Team 4: West Pod Extra Nursing Staff: Amy & Alanna

Matt Stark, PAC & Sarah

Dr. Madhu (Pediatrics) & Nicole Team 9: Care Team

Scott Goebel, PA & Clint Community Care, Population Health, Transition

Extra Nursing Staff: Crystal of Care, Care Management, & Triage

Carolyn, Cheri, Lisa, Danielle, Beth, Ana, Jeanne,

Mikayla, Kim, Dakota, Christina & Breanna

The Patient-Centered Primary Care Home (PCPCH) model is part of Oregon’s efforts to fulfill a vision of better

health, better care, and lower costs for all Oregonians. A PCPCH is a health care clinic that has been recognized for

their commitment to patient-centered care. In a primary care home you are the most important part of your care.

Evergreen Family Medicine is recognized as a PCPCH. Evergreen is structured with teams (pods) of a variety of

PAs, FNPs, and MD/Dos to assist in your healthcare. We currently have eight teams. When you are assigned to

your primary care provider, you are also assigned to that provider’s team. Your primary care provider’s team will

handle all of your healthcare needs.

Each primary care provider is assigned one certified medical assistant or nurse who will work with that provider to

assist in your coordination of care. This is typically the person you will speak to on the phone regarding clinical

questions, but you may speak with any of the clinical team members.

Family practice has several front office and support staff members who also assist with your coordination of care.

Please know that anyone who answers the main phone line is cross-trained with all providers and pods to know

proper procedures to better assist you.

Below is the current listing of our teams (pods)

Standards for care•Access to care: Patients get the care they need, when they need it.

•Accountability: Recognized clinics are responsible for making sure

patients receive the best possible care.•Comprehensive: Clinics provide patients all the care, information and services they need.•Continuity: Clinics work with patients and their community to improve

patient and population health over time.•Coordination and integration: Clinics help patients navigate the system

to meet their needs in a safe and timely way.•Patient and family-centered: Clinics recognize that patients are the

most important members of the health care team and that they are

Evergreen Family Medicine follows CDC

guidelines for prescribing opiates.

It is important for potential patients to understand that Evergreen Family

Medicine providers share a consistent and cautious philosophy regarding

treatment of chronic pain not associated with a terminal illness and long term

utilization of controlled substances. If your previous provider chose to prescribe

narcotics or tranquilizers, it does not obligate us to continue those.

It is our job to care for patients and to help facilitate a long healthy life and

lifestyle. Therefore, if you come to us on narcotics, it is very likely we will work

to reduce or stop your dependence on those agents. If we choose to continue

your narcotic or other controlled substances, conditions will apply. These will

include, but are not limited to: the need to sign and abide by a narcotic contract,

3 month follow up appointments, be subject to random urine drug tests and pill

counts, comply in mental health assessments and follow up care, and

participate in other educational programs or referrals designed to improve

function and quality of life. We will not continue controlled drugs in a situation

where other drugs, including marijuana, are used.

If this approach is unacceptable to you, please do not submit a request to begin

transferring your medical care to Evergreen Family Medicine. Our policy is not

negotiable. By submitting this request, you acknowledge your understanding

and acceptance of these terms.

Attention: Please read the following documents

and agreements. You will be required

at check-in to electronically sign

acknowledging that you have received

them and agree to them.

CENTENNIAL MEDICAL GROUP EAST dba EVERGREEN FAMILY MEDICINE

NOTICE OF PRIVACY PRACTICES

(Effective 4/2003; Revised 11/2016)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please contact Sandy Wright, Privacy Officer, 541-677-2457

DEFINITIONS

Definitions Notice of Privacy Practices (The Notice) – a written notice in compliance with the requirements of Health Insurance Portability and Accountability Act (HIPAA), and the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act (ARRA) of 2009, made available from Mercy Medical Center to an individual or the individual’s personal representative at the first delivery of service, or at the individual’s next visit fo llowing a revision to the Notice, that describes the uses and disclosures of protected health information that may be made by Mercy Medical Center and the individual’s rights and Mercy Medical Center ’s legal duties with respect to protected health information. Protected Health Information (PHI) – individually identifiable health information that is transmitted or maintained in any form or medium, including electronic media. Protected health information does not include employment records held by Mercy Medical Center in its role as an employer. Mercy Medical Center, an affiliate member of Catholic Health Initiatives (CHI), and other affiliated members of CHI participate in an Organized Health Care Arrangement (OHCA) in order to share health information to manage joint operational activities. A complete list of CHI affiliated members is available at www.catholichealthinitiatives.org by clicking on “Locations”. A paper copy is available upon request. The CHI OHCA may use and disclose your health information to provide treatment, payment, or health care operations for the affiliated members and includes activities such as integrated information system management, health information exchange, financial and billing services, insurance, quality improvement, and risk management activities. Mercy Medical Center and its affiliates Mercy Services Corporation, Linus Oakes, Mercy Foundation, Oregon Surgery Center, Centennial Medical Group East dba Evergreen Family Medicine, Centennial Medical Group, including all physicians with staff privileges participate in an OHCA to manage their joint operating activities similar to the CHI OHCA. The Mercy Medical Center OHCA may use and disclose your health information to provide treatment, payment, or health care operations for the affiliated members and includes activities such as integrated information system management, health information exchange, financial and billing services, insurance, quality improvement, and risk management activities.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION For Treatment. We will use your health information to provide you with health care treatment and to coordinate or manage services with other health care providers, including third parties. We may disclose all or any portion of your health information to your attending physician, consulting physician(s), nurses, technicians, health profession students, or other facility or health care personnel who have a legitimate need for such information in order to take care of you. Different departments of the facility will share your health information in order to coordinate the health care services you need, such as prescriptions, lab work and X-rays. We may disclose your health information to family members or friends, guardians or personal representatives who are involved with your health care. We may also use and disclose your health information to contact you for appointment reminders and to provide you with information about possible treatment options or alternatives and other health-related benefits and services. We also may disclose your health information to people outside the facility who may be involved in your health care after you leave the facility, such as other physicians involved in your care, specialty hospitals, skilled nursing care facilities, and other healthcare-related services. We may use and disclose your health information to prescription networks to obtain your prescription benefits from payers, to obtain your medication history from different health care providers in the community such as pharmacies, and to send your prescriptions electronically to your pharmacy. For Payment. We will use and disclose your health information for activities that are necessary to receive payment for our services,

such as determining insurance coverage, billing, payment and collection, claims management, and medical data processing. For example, we may tell your health plan about a treatment you are planning in order to receive approval or to determine whether your plan will pay for the proposed treatment. We may disclose your health information to other health care providers so they can receive payment for health care services that they provided to you, such as your personal physician, and other physicians involved in your health care such as an anesthesiologist, pathologist, radiologist, or emergency physician, and ambulance services. We may also give information to other third parties or individuals who are responsible for payment for your health care, such as the named insured under the health policy who will receive an explanation of benefits (EOB) for all beneficiaries who are covered under the insured’s plan. For Health Care Operations. We may use and disclose your health information for routine facility operations, such as business planning and development, quality review of services provided, internal auditing, accreditation, certification, licensing or credentialing activities (including the licensing or credentialing activities of health care professionals), medical research and education for staff and students, assessing your satisfaction with our services, and to other healthcare entities that have a relationship with you and need the information for operational purposes. We may use and disclose your health information to the external agencies responsible for oversight of health care activities such as The Joint Commission, external quality assurance and peer review organizations, and credentialing organizations. We may also disclose health information to business associates we have contracted with to perform services for or on our behalf such as patient satisfaction survey organizations. We may also disclose your health information to medical device manufacturers or pharmaceutical companies in order for those companies to carry out their legal obligations to state and federal agencies. CHI Health Information Exchange. Mercy Medical Center, as a member of the CHI OHCA, participates in the CHI Health Information Exchange (HIE). Your health information is maintained electronically and healthcare providers, employed, under contract, or otherwise associated with Mercy Medical Center, and the CHI OHCA members may access, use, and disclose your health information for treatment, payment, and healthcare operations. Health Information Exchange. CHI Mercy Health participates in multiple internet-based health information exchanges. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may opt out and prevent searching of your health information available through the health information exchange by calling Health Information Management at 541-677-4316, or completing and submitting an Opt-Out form to CHI Mercy Health, Health Information Management, 2700 Stewart Parkway, Roseburg, OR 97471. Facility Directory. The facility directory is available so that your family, friends, and clergy can visit you and generally know how you are doing. We may include your name, location in the facility, your general condition (for example, fair or stable), and your religious affiliation in the facility directory. The directory information, except for your religious affiliation, may be released to people who ask for you by name. You must notify Mercy’s Admissions Office at 541-677-2418 or 2700 Stewart Parkway, Roseburg, OR 97471 verbally or in writing if you do not want us to release information about you in the facility directory. If you do not want information released in the facility directory, we cannot tell members of the public such as flower or other delivery services or friends and family that you are here or about your general condition. Future Communications. We may provide communications to you with newsletters or other means regarding treatment options, health related information, disease management programs, wellness programs, or other community based initiatives or activities in which our facility is participating. Fundraising Activities. We may use your health information, or disclose your health information to a foundation related to us for Mercy Medical Center’s fundraising efforts. These funds would be used to expand and improve services and programs we provide to the community. We would only release information such as your name, address, other contact information, age, gender, dates of birth, health insurance status, the dates you received treatment or services from us, the department of service and the outcome of those services. You have a right to opt out of receiving such communications. To opt out of these communications, contact the Communications Department, at 541-677-2114. Research. We may use and disclose your health information to researchers either when you authorize the use and disclosure of your health information, or an Institutional Review Board and/or Privacy Board approves an authorization waiver for the use and disclosure of your health information for a research study. A waiver may allow a researcher to use or disclose your health information to prepare for research, to screen and identify participants for inclusion in a research study, or to conduct research on a decedent’s information. Organ and Tissue Donation. If you are an organ donor, we may release your health information to organizations that handle organ procurement and transplantation or to an organ donation bank as necessary to facilitate organ or tissue donation and transplantation.

USES AND DISCLOSURES THAT ARE REQUIRED OR PERMITTED BY LAW

Subject to requirements of federal, state and local laws, we are either required or permitted to report your health information for various purposes. Some of these reporting requirements and permissions include: Public Health Activities. We may disclose your health information to public health officials for activities such as for the prevention or control of communicable disease, bioterrorism, injury, or disability; to report births and deaths; to report suspected child, elder, or spouse abuse or neglect; to report reactions to medications or problems with medical products; to report information to the federal Centers for Disease Control or to authorized national or state cancer registries for their data aggregation. Disaster Relief Efforts. We may disclose your health information to an entity assisting in a disaster relief effort, such as the American Red Cross, so that your family can be notified about your condition and location. Health Oversight Activities. We may disclose your health information to a health oversight agency for activities authorized by law. Such agencies include federal Centers for Medicare and Medicaid Services, and state health professional oversight agencies or boards such as state medical or nursing boards. These oversight activities may include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor activities such as health care treatment and spending, government programs, and compliance with civil rights laws. Judicial or Administrative Proceeding. We may disclose your health information in response to a legal court or administrative order, a subpoena, discovery request, civil or criminal proceedings, or other lawful process. Law Enforcement. We may release your health information if asked to do so by a law enforcement official or if we have a legal obligation to notify the appropriate law enforcement or other agencies: o In response to a court order, subpoena, warrant, summons or similar legal process; o Regarding a victim or death of a victim of a crime in limited circumstances; o In emergency circumstances to report a crime, the location or victims of a crime, or the identity, description or location of a person who is alleged to have committed a crime, including crimes that may occur at our facility, such as theft, drug diversion, or attempts to obtain drugs illegally Coroners, Medical Examiners and Funeral Directors. We may release health information to a coroner or a medical examiner. This may be necessary to identify a person who died or to determine the cause of death. We may release health information to help a funeral director to carry out his/her duties. Workers' Compensation. We may release your health information for workers’ compensation benefits or similar programs that provide benefits for work-related injuries or illnesses if you tell us that workers’ compensation is the payer for your visit(s). Your employer or their workers’ compensation carrier may request the entire medical record pertinent to your workers’ compensation claim. This medical record may include details regarding your health history, current medications you are taking, and treatments. To Avert a Serious Threat to Health or Safety. We may disclose your health information when necessary to prevent a serious threat to your health and safety or the health and safety of another person or the public. National Security. We may disclose your health information to federal official(s) for national security activities and for the protection of the President and other Heads of State. Military and Veterans. If you are a member of the armed forces, we may release your health information as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority. Inmates. If you are an inmate of a correctional institution or in the custody of a law enforcement official, we may release your health information to the institution or law enforcement official. This release would be necessary for the institution to provide you with health care, to protect your health and safety or the health and safety of others, or for the safety and security of the correctional institution

OTHER USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

Other uses and disclosures of your health information not covered by this notice or the laws that apply to Mercy Medical Center will be made only with your written authorization. If you provide us with authorization to use or disclose your health information, you may revoke that authorization in writing at any time. When we receive your written revocation we will no longer use or disclose your health information for the purpose of that authorization. However, we are unable to retrieve any disclosures already made based on your prior authorization. Mercy Medical Center will obtain your authorization to use and disclose your health information for these specific purposes when required by law and regulation: Marketing Marketing is a communication about a product or service that you may be interested in purchasing. If Mercy Medical Center receives payment from a third party in order for Mercy Medical Center to promote the product or service to you, then Mercy Medical Center is required to obtain your written authorization before we can use or disclose your health information. Mercy Medical Center is not required to obtain your authorization to discuss with you about Mercy Medical Center health care treatment options, health-related products,, case management or care coordination, or to direct or recommend alternative treatments, therapies, providers, or settings of care, providing face to face discussions and offering samples or promotional gifts of nominal value. You have the right to revoke your marketing authorization and Mercy Medical Center will honor the revocation. To opt out of these communications, please contact the Communications Department, at 541-677-2114. Psychotherapy notes Psychotherapy notes are notes by a mental health professional that document or analyze the contents of a conversation during a private counseling session or a group, joint, or family counseling session. If psychotherapy notes are maintained separate from the rest of your health information they may not be used or disclosed without your written authorization, except as may be required by law. Sensitive Medical Information We may obtain a separate authorization from you, when required by specific state and federal laws, to use or disclose sensitive medical information, such as psychiatric, substance abuse, infectious disease, or genetic testing information. Sale of Health Information Mercy Medical Center will obtain your authorization for any disclosure of your health information which Mercy Medical Center directly or indirectly receives remuneration in exchange for the health information.

THIS NOTICE DOES NOT APPLY TO THE FOLLOWING HEALTH RELATED ACTIVITES

Some activities of Mercy Medical Center may not be covered by this notice. If you seek services at wellness or health fairs, for occupational health services, employee health related services, or direct access lab services this notice and its components do not apply.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION You have the following rights regarding your health information: Right to Inspect and Copy. You have the right to inspect your health information and receive a copy of medical, billing, or other records that may be used to make decisions about your care. The right to inspect and receive a copy may not apply to psychotherapy notes that are maintained separately from your health information. Your request to inspect and receive a copy of your health information must be submitted in writing. We may charge a fee for document requests to cover the costs of copying, mailing, or other supplies. You have the right to request your health information in electronic format. Mercy Medical Center will provide your health information in the form and format you request, if feasible, or in a mutually agreeable form and format. In limited circumstances we may deny your request to inspect or receive a copy of your health information. If we deny your request we will notify you of the reason. If you are denied access to your health information, you may request that the denial be reviewed. A licensed health care professional chosen by Mercy Medical Center will review your request and the denial. The person who conducts the review will not be the same person who denied your request. We will comply with the outcome of the review.

Right to Amend. You have the right to request an amendment to your health information that you believe is incorrect or incomplete. Submit your request in writing, including your reason for the amendment, using our “Request for Amendment to PHI” form and send to Medical Records 2700 Stewart Parkway, Roseburg, OR 97471 541-677-4316. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. We may also deny your request if you ask us to amend information that: o Was not created by Mercy Medical Center unless the person or entity that created the information is no longer available to make the amendment; o Is not part of the medical information kept by or for Mercy Medical Center; o Is not part of the information that you would be permitted to inspect and copy; or o Is accurate and complete. Right to an Accounting of Disclosures. We are required to maintain a list of certain disclosures of your health information. However, we are not required to maintain a list of disclosures that we made by acting upon your written authorizations. You have the right to request an accounting of disclosures that are not subject to your written authorization. Submit your request in writing using our “Request for Accounting of Disclosures of PHI” form and send to Medical Records 2700 Stewart Parkway, Roseburg, OR 97471 541-677-4316. Your request must state a time period, not longer than six years from the date of request. The Accounting Disclosure s of PHI is currently available in paper format. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request before any costs are incurred. Right to Request Restrictions. You have the right to request a restriction or limitation on how much of your health information we use or disclose for treatment, payment, or health care operations. You also have the right to request a restriction on the disclosure of your health information to someone who is involved in your care or payment for your care, such as a family member or friend. We are not required to agree to your request. However, if we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. You have the right to request to restrict the disclosure of your information to a health plan regarding a specific health care item or service that you, or someone on your behalf (other than a health plan), has paid for in full. We are required to comply with your request for this specific type of restriction. For example, if you sought counseling services and paid in full for the services rather than submitting the expenses to a health plan, you may request that your health information related to the counseling services not be disclosed to your health plan. Submit your request in writing or request and submit a “Request for Restrictions to Use or Disclose Protected Health Information” form and send to Medical Records 2700 Stewart Parkway, Roseburg, OR 97471 541-677-4316. You must include: a description of the information that you want to restrict, whether you want to restrict our use or disclosure or both; and to whom you want the restriction to apply. Right to Request Confidential Communications. You have the right to request that we communicate with you about health care matters in a certain way or at a certain location. For example, you can ask that we only contact you at an alternative location from your home address, such as work, or only contact you by mail instead of by phone. Your request must specify how or where you wish to be contacted. We do not require a reason for the request. We will accommodate all reasonable requests. Right to Receive Notice of a Privacy Breach. You have the right to receive written notification if Mercy Medical Center discovers a breach of unsecured protected health information involving your health information. Breach means the unauthorized acquisition, access, use, or disclosure of protected health information which compromises the security or privacy of the information. The Notice will include a description of the breach, health information involved, steps we have taken to mitigate the breach, and actions that you may need to take in response to the breach. Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. If you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. To ask questions about any of these rights, or to obtain a paper copy of this notice, contact Sandy Wright, Corporate Responsibility/Privacy Officer, 541-677-2457. Or, you may obtain a copy of this notice at our Web site, www.mercyrose.org. CHANGES TO THIS NOTICE We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information

we already have about you and for any information we may receive in the future. We will post a copy of the current notice in the facility and on our web site (if applicable) at www.mercyrose.org. The notice will contain the effective date. Upon your initial registration or admittance to the facility for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the notice currently in effect. Whenever the notice is revised, it will be available to you upon request. COMPLAINTS You may file a complaint with us or with the Secretary of the Department of Health and Human Services if you believe that we have not complied with our privacy practices. You may file a complaint with us by contacting Sandy Wright, Corporate Responsibility/Privacy Officer, 541-677-2457. We will not take any action against you or change our treatment of you in any way if you file a complaint.

Updated 2-14-18

2570 NW Edenbower Blvd, Ste 100, Roseburg, OR 97471 Ph (541)677-7200 Fax (541)229-3309

INTEGRATED HEALTHCARE ACKNOWLEDGEMENT

As a Rural Health Clinic and Patient Centered Primary Care Home, Evergreen Family Medicine is in a unique position to be able to offer fully integrated health services. Specialists in endocrinology, behavioral health, behavioral modification and social work are on staff working side by side with your primary care provider to offer care that is centered around you and your needs. If your primary care provider feels it is in the best interests for your care, he/she may invite one of these clinical providers, or another primary care provider to become involved in your care. This may happen during your visit, or you may be referred for a future visit. It is important for you to note that any integrated encounter, however long or brief these may be, are separately billable from your primary care providers charges and will be billed to your insurance. It is up to you to either accept or decline these services when offered. Providers addressing multiple issues on the same date of service may document all of the issues within a single chart note, including issues pertaining to mental health, anxiety or depression. This note may need to be released for treatment, payment or operations purposes for any or all of the diagnoses listed. By accepting this acknowledgement you are expressing that you understand this is a possibility and agree to allow the practice to release chart notes for this purpose.

Patient Agreement Form Updated 1/9/17 Page 1

PATIENT AGREEMENT FORM

CO-PAYMENTS AND DEDUCTIBLES ARE DUE AT TIME OF SERVICE: We will collect your co-

payment and past due balances at the time of each appointment. Patient or responsible party must make payment

arrangement for all procedures and services rendered.

MEDICATIONS: Please bring a list of your medications and vitamins or the bottles of all medications and vitamins

that you are currently taking to the first appointment with your provider, or if you’ve had any medication changes

made by other providers.

PLEASE NOTE: Some medications are under the surveillance of the Drug Enforcement Agency, including opiate

pain medications (such as Vicodin, oxycodone, methadone) and benzodiazepines (such as Ativan,Valium, Xanax,

and Klonopin). By clinic policy, you may be required to sign a pain management agreement. If you are on a

medication such as this on a continuous basis, please obtain a refill from your prior medical provider to cover you

until your first appointment at our clinic.

PRESCRIPTION REFILLS: Call your pharmacy for all prescription refills and the pharmacy will contact our

office for a refill. Even if there are no refills left, the pharmacy will contact our office for authorization. Those

prescriptions requiring a hard copy to be hand carried to the pharmacy can be picked up at the clinic. Please request

a refill 24-48 hours before it’s due to be filled. Our clinic policy is that providers must review and confirm medical

records prior to prescribing medications to the patient.

VACCINATIONS: Our physicians follow CDC guidelines for vaccinations and all children will need to be up-to-

date on vaccines by the age of 2. We do not accept patients who choose not to vaccinate according to CDC

guidelines.

CHECK-IN TIME: You are expected to check in 15 minutes prior to your scheduled appointment time.

CANCELLED APPOINTMENTS: We require a 24-hour notice when cancelling your appointment.

FAILED APPOINTMENTS: A late cancellation is considered a failed appointment. If you arrive over 10 minutes

late to your appointment, you may be asked to reschedule.

NEW PATIENTS: New Patients that fail to attend 2 New Patient appointments without cancelling 24 hours in

advance will no longer have the opportunity to schedule further appointments at Evergreen Family Medicine.

ESTABLISHED PATIENTS: Established patients that fail to attend 3 appointments without cancelling 24 hours in

advance within a 12 month period will be dismissed from the practice and no longer able to schedule appointments

at Evergreen Family Medicine.

Patient Agreement Form Updated 1/9/17 Page 2

INSURANCE BILLING: As a courtesy to you, we submit claims to your insurance company. Please provide us

with complete and accurate insurance information at every appointment, as well as any changes in your

address, telephone number and employer. We accept all commercial insurances, Medicare and Medicare

Advantage plans, and Oregon Health Plan managed care plans including DCIPA (UHA). We do not accept any

Medicaid insurance programs through other states or counties. Patients must be aware of their insurance coverage

and agree to the payment of non-covered services. All prices quoted are just estimates and may not be what your

insurance covers.

NON-INSURED: Our clinic offers a sliding scale fee based on your annual income to discount the charges for our

services. Please ask a receptionist for an application. Self pay patients automatically qualify for a 31% discount if

paid in full within 30 days of date of service.

LABS and IMAGING: The majority of lab specimens collected in our lab are sent to Mercy Medical Center for

completion, and some imaging is completed at a Mercy site. Mercy Medical Center bills separately for its services

and uses a separate sliding scale for their charges. If you have any questions about your lab or imaging bill please

contact Mercy Medical Center directly. Please notify us if your insurance specifies a specific lab.

REMINDER CALLS: With my consent, Evergreen may call your home or other designated location and leave a

message reminding you of your appointments. Please provide the appropriate contact numbers or let us know if you

do not want to be contacted.

SCRIBES: Evergreen utilizes scribes to document in your medical chart which allows your provider to focus on

your care, and not the computer. Scribing will either be completed by a person physically accompanying the

provider into the exam room, or electronically through Scribe-X Northwest utilizing voice and video software.

Scribe-X Northwest will assign only qualified and trained Medical Scribes, will comply with and ensure that all

Medical Scribes comply with, all rules, regulations, policies and procedures of EFM. This includes security

procedures concerning systems and data and access thereto, HIPAA privacy & security policies, medical record

documentation standards, clinic security procedures, licensing agreements between EFM and any electronic medical

records vendor, and general health and safety practices and procedures.

CHILDREN VISITS: Parents or Guardians MUST NOT LEAVE THE CLINIC before/during a child’s visit.

Treatment will not be rendered if a parent or guardian is not present, according to Oregon statutes. Patients are asked

to be seen once a year to remain an active patient.

ADULT VISITS: Our providers value your time and attention during your visit. Please limit distractions (such as

phone calls, fussy children, uninvited guest, etc) during your time in the clinic. Patients are asked to be seen once a

year to remain an active patient.

Patient Agreement Form Updated 1/9/17 Page 3

PATIENT RIGHTS:

Patients have the right to be treated with dignity and respect.

Patients have the right to every consideration of privacy concerning their medical care.

Patients have the right to expect that all records pertaining to their care are confidential. Except when required by

law, patients are given the opportunity to approve or refuse their release. Records are shared with specialty

providers you are referred to for continuity of care.

Patients have the right to have access to information concerning their care, including their medical records, as

provided by state and federal laws.

Patients have the right to participate in decisions involving their health care, except when such participating is not

indicated due to medical reasons.

Patients have the right to refuse treatment to the extent permitted by law and to be informed of the medical

consequences of their actions.

Patients have the right to receive all information necessary to sign an informed consent prior to the start of any

procedure and /or treatment, except in emergencies where their lives or health may be in serious danger.

Patients have the right to voice complaints or grievances about the medical care provided.

PATIENT RESPONSIBILITES:

Participate in the development and adhere to the treatment plan recommended by your provider(s).

Be on time for appointments or notify us as soon as you know you will be unable to keep an appointment.

Provide your provider(s) with needed information about your medical history and symptoms.

Advise us on any changes in your insurance plan and billing/payment information.

Make payment for services on the day services are provided (charges, co-pays, deductibles, and past due

balances).

Be courteous to all employees.

Be respectful of other patients by monitoring your cell phone usage and your children.

Name: _______________________________________________________________Date:___________

Signature: ____________________________________________________________________________

NOTICE OF REFERRAL RIGHTS AND ACKNOWLEDGMENT

THIS NOTICE DESCRIBES YOUR REFERRAL RIGHTS WHEN YOUR HEALTH CARE PROVIDER

REFERS YOU TO ANOTHER PROVIDER OR FASCILITY FOR ADDITIONAL TESTING OR HEALTH

CARE SERVICES.

In accordance with Oregon law, when you are referred for care outside of our clinic, we, CMGE dba

Evergreen Family Medicine, are required to notify you that you may have the test or service done at a

facility other than the one recommended by your physician or health care provider.

Oregon law says (ORS 441.098):

• A referral for a diagnostic test or health care treatment or service shall be based on the patient’s

clinical needs and personal health choices.

• A health practitioner or the practitioner’s designee shall provide notice of patient choice at the time

the patient establishes care with the practitioner and at the time the referrals is communicated to the

patient.

• The oral or written notice of patient choice shall clearly inform the patient:

o That when referred, a patient has a choice about where to receive services; and

o Where the patient can access more information about patient choice

• The patient has a choice and when referred to a facility for a diagnostic test or health care treatment of

service the patient may receive the diagnostic test or health care treatment or service at a ability other

than the one recommended by the health practitioner;

• If the patient chooses to have the diagnostic test, heath care treatment or service at a facility different

from the one recommended by a practitioner, the patient is responsible for determining the extent of

coverage or the limitation on coverage for the diagnostic test, health care treatment or service at the

facility chosen by the patient.

• A health practitioner shall not deny, limit or with draw a referral solely because the patient chooses to

have the diagnostic test or health care treatment or service at a facility other than the one

recommended by the practitioner.

Non-Discrimination Policy

As a recipient of Federal financial assistance, Mercy Medical Center, Centennial Medical Group dba Evergreen Family Medicine, does not exclude, deny benefits to, or otherwise discriminate against any person on the ground of race, color, national origin, disability, age, or sex in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, and in staff and employee assignments to patients, whether carried out by Mercy Medical Center directly or through a contractor or any other entity with which Mercy Medical Center arranges to carry out its programs and activities. This statement is in accordance with the provisions of Title VI of the Civil Rights Act of 1964 (nondiscrimination on the basis of race, color, national origin), §504 of the Rehabilitation Act of 1973 (non-discrimination on the basis of disability), the Age Discrimination Act of 1975 (non-discrimination on the a basis of age), §1557 of the Patient Protection and Affordable Care Act of 2010 (non-discrimination on the basis of sex), and regulations of the U.S. Department of Health and Human Services issued pursuant to these three statutes at Title 45 Code of Federal Regulations Parts 80, 84, and 91. In case of questions, please contact: Mercy Medical Center, Centennial Medical Group Contact Person/Section 504/Civil Rights Coordinator: Denise Jones, 541-677-3555 TTY or State Relay Number: 541-677-4336

Spanish - ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-541-677-3555 (TTY: 1-541-677-4336). Vietnamese - CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-541-677-3555 (TTY: 1-541-677-4336).

Chinese - 注意：如果您使用繁體中文，您可以免費獲得語

言援助服務。請致電 1-541-677-3555 (TTY: 1-541-677-

4336). Russian - ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-541-677-3555 (TTY: 1-541-677-4336).

Korean - 주의: 한국어를 사용하시는 경우, 언어 지원

서비스를 무료로 이용하실 수 있습니다. 1-541-677-3555

(TTY: 1-541-677-4336)번으로 전화해 주십시오.

Ukrainian - УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-541-677-3555 (TTY: 1-541-677-4336).

Japanese - 注意事項：日本語を話される場合、無料の言

語支援をご利用いただけます。1-541-677-3555 (TTY: 1-

541-677-4336).まで、お電話にてご連絡ください。

Arabic - ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية

-1تتوافر لك بالمجان. اتصل برقم xxx-xxx-xxxx -والبكم)رقم هاتف الصم

541-677-3555 (TTY: 1-541-677-4336). Romanian - ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-541-677-3555 (TTY: 1-541-677-4336). Mon-Khmer, Cambodian - ប្រយ័ត្ន៖ បរើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, បសវាជំនួយខ្ននកភាសា

បោយមិនគិត្ឈ្នួល គឺអាចមានសំរារ់រំបរើអ្នក។ ចូរ ទូរស័ព្ទ 1-541-677-3555 (TTY: 1-541-677-

4336). Cushite (Oromo) - XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-541-677-3555 (TTY: 1-541-677-4336). German - ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-541-677-3555 (TTY: 1-541-677-4336). Persian(Farsi) - توجه: اگر به زبان فارسی گفتگو می کنید، تسهیالت زبانی

-TTY: 1) 3555-677-541-1بصورت رايگان برای شما فراهم می باشد. با 541-677-4336). French - ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-541-677-3555 (TTY: 1-541-677-4336). Thai - เรียน: ถา้คุณพูดภาษาไทยคุณสามารถใชบ้ริการช่วยเหลือทางภาษาไดฟ้รี โทร 1-

541-677-3555 (TTY: 1-541-677-4336).

Attention: The following forms MUST be filled out

in their entirety. If sections are left

blank or signatures are missing, the

packet will be returned for completion

before an appointment can be

scheduled.

Evergreen Family Medicine

2570 NW Edenbower Blvd, Ste 100 Roseburg, OR 97471

RESPONSIBLE PARTY/ GUARANTOR (to whom statements are sent)

ADDITIONAL DOCTORS YOU SEE:

FAMILY BILLING STRUCTURE

Patient’s Name_________________________________________________ Male Female Last First MI

Date of Birth___________________________ SS# __________ -- __________ -- __________ Physical Address_______________________________________________________________

Street City State Zip

Mailing Address________________________________________________________________ Box City State Zip

Home Phone (_____)_____________ Work (_____)____________ Cell (_____)_____________ By listing phone numbers above, you are authorizing the use of those numbers as a means to contact you. Please indicate primary contact number: Home Work Cell

Marital Status: Single o Married o Partnership o Divorced o Widowed o Separated o Employer__________________________________ Occupation __________________

Driver's License Number ______________________

Guarantor's relationship to patient: Self/Spouse/Parent/Step-parent/Legal Guardian/Other ________

Guarantor’s Name ______________________________________ Date of Birth _____________Last First MI

Guarantor’s Address_____________________________________________________________Box/Street City State Zip

Guarantor’s Employer _____________________ (___)___________ __________________ Name Phone Guarantor’s SSN

Guarantor (to whom statements are sent) _________________________ Date of Birth ____________ Family Member ______________________ DOB________ Relation to Guarantor ____________

Family Member ______________________ DOB________ Relation to Guarantor ____________

Family Member ______________________ DOB________ Relation to Guarantor ____________

Family Member ______________________ DOB________ Relation to Guarantor ____________

By listing all family members with date of births, your family will only receive one billing statement.

Primary Care __________________________________________________________________

Other ________________________________________________________________________

PRIMARY INSURANCE for the patient

SECONDARY INSURANCE for the patient

The undersigned patient or individual acting on the behalf of the patient agrees as follows:

1.

I am knowingly requesting medical services be rendered by Evergreen Family Medicine and/or their designated medical providers and staff.

3.

Authority is granted to Evergreen Family Medicine to access and store medical records for the purpose of rendering services to the above named patient. This authority is granted to Evergreen Family Medicine as the custodian of records for the above named patient.

4. I understand that I am responsible for all charges incurred through Evergreen Family Medicine and authorize payment of medical benefits to Evergreen Family Medicine for services rendered.

5.

Authorization Period will be for 12 months after the date on this form unless otherwise noted.

Lifetime (Or until notified)

Limited From __________________ to__________________

I request that payment under the medical insurance program be made to the provider named above on anybillsfor services furnished me during the effective period of this authorization and I authorize the above namedprovider to release to the Social Security Administration any information needed for this claim or any relatedMedicare claim. I further permit a copy of this authorization to be used in place of the original. NSF checks willbe assessed a $35 fee. If it becomes necessary to use a professional collection agency to collect my account,the undersigned agrees to pay for all costs and expenses, including reasonable attorney fees and court costsand a $50 collection fee.

Signature____________________________________________Date________________________________

Insurance Name__________________________ Member/Policy ID #_______________________

Subscriber Name___________________________Subscriber Date of Birth_______________

Relationship to patient__________________

Insurance Name__________________________Member/ Policy ID #_______________________

Subscriber Name___________________________Subscriber Date of Birth________________

Relationship to patient__________________

2.

I understand that Evergreen Family Medicine may electronically access my prescription information from participating pharmacies in order to check for interactions. I understand that I

may opt out o, but doing so may hinder the prescribing process in the future.

2570 NW Edenbower Blvd, Suite 100

Roseburg, Oregon 97471

PROTECTED HEALTH INFORMATION DISCLOSURE AUTHORIZATION

Patient Name: ____________________________ Patient Date of Birth: _________________

I hereby authorize all Evergreen Family Medicine staff, providers and contracted affiliates to disclose health

information in the following ways via person or automated message.

Patient Contact:

Authorization to leave a voicemail Yes / No

Authorization to send text message Yes / No

Additional contacts;

Voicemail (VM)- Authorization to leave a message regarding appointment reminders, test results, or

diagnostic results.

Emergency Contact (EC)- Authorization to contact for emergent purposes, or in the case that the

patient cannot be reached. Choose only one Emergency Contact.

Full Medical Disclosure (FMD)-Authorization to discuss all health information and allowed to

authorize the release of protected health information.

Consent for Care (CC)-Authorization to consent for medical care for the patient.

Please complete the contact information and INITIAL each type of authorizations described above that apply:

Contact Name Relationship Phone VM EC FMD CC Example name Spouse 541 999 9999 EN EN EN EN

____________________________ __________ ( ____ ) _____ -________ _____ _____ _____ _____

____________________________ __________ ( ____ ) _____ -________ _____ _____ _____ _____

____________________________ __________ ( ____ ) _____ -________ _____ _____ _____ _____

____________________________ __________ ( ____ ) _____ -________ _____ _____ _____ _____

____________________________ __________ ( ____ ) _____ -________ _____ _____ _____ _____

_________________________________________________________ __________________

Signature Date

If you are signing as the patient’s guardian or legal power of attorney (documentation required):

_________________________________________________ __________________________ Print Name Describe Authority

2570 NW Edenbower Blvd, Ste 100, Roseburg, OR 97471 Ph (541)677-7200 Fax (541)229-3309

Patient Name _____________________________________ DOB ___________________

Please provide the additional information which is required for federal standards. All information provided on this form will be kept confidential.

1. Primary Language (i.e. English, Spanish, Sign Language, etc.) ____________________

2. Race

Caucasian (White)

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander Other _________________________ More than one race _________________________

3. Ethnicity Do you consider yourself to be Hispanic or Latino according to the definitions below? (Choose only one)

No, Not Hispanic or Latino

Yes,

Central American

Cuban

Dominican

Hispanic or Latino/Spanish

Latin American/Latin, Latino

Mexican

Puerto Rican

South American

Spaniard

DECLINE: By checking this box, I hereby decline to provide the above information.

______________________________________________________________ ___________________ Patient Signature or Patient Representative Signature Date

______________________________________________________________ Print Name if signing on patient’s behalf (Power of Attorney paperwork must be provided)

Important: Please take adequate time to completely

fill out the next portion of your packet.

You are the most important member of

your healthcare team and we value your

input. By providing us with the most up to

date information you will steer the first

major decision made regarding your care.

The following information will help us

when assigning you to a team that will fit

your needs.

FILLING OUT THE RELEASE FOR MEDICAL RECORDS

(FOLLOWING PAGE)

• Please be aware that you may only list one medical provider/office per release.

If you need additional releases you may copy the one provided in this packet

or call our office to request additional releases.

• Please initial all four lines on the next page, regardless of if they apply to you:

o HIV/AIDS related records

o Drug/Alcohol diagnosis, treatment or referral information

o Mental Health Information

o Genetic Testing Information

***If you do not initial the four lines, we can still send for your records, but

please be aware that it will take the full 30 days to receive the records due

to the other office having to go through every section of your records. If

your records are not received prior to your appointment, there may be

medical issues that would need to be addressed at another appointment

after the records are received.

• If you would like the release to have an expiration date, please make sure that

you give enough time for us and your other office to process your request.

Time frames shorter than 30 days could cause records to not be sent.

• If you have any questions, please call our office at 541-677-7200

• IF YOU HAVE SEEN A PCP WITHIN 5 YEARS, A COMPLETELY FILLED OUT

RECORDS RELEASE IS MANDATORY AS YOUR APPOINTMENT WILL NOT BE

SCHEDULED WITHOUT RECEIPT OF YOUR PREVIOUS PCP RECORDS.

• By signing below I attest that my records release will be blank because I have

not seen a Primary Care Physician within 5 years and have no records to

request.

Signed__________________________________________ Date____________________

2570 NW Edenbower Blvd, Suite 100 Roseburg, OR 97471 Phone: (541) 677-7200 Fax: (541) 229-3309

AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION Please read all information and instructions before completing and signing the authorization form.

Patient’s Name __________________________________________________________ Birth Date______________________ (PLEASE PRINT) LAST FIRST MI

Reason for release (i.e. transferring care): ____________________________________ Previous Last Name: ___________________

INFORMATION TO BE RELEASED BY: INFORMATION TO BE RELEASED TO: Evergreen Family Medicine _________________________________________________ Organization/Person _________________________________________________ Street Address

_________________________________________________ City State Zip

_________________________________________________ Phone Fax

Evergreen Family Medicine _________________________________________________ Organization/Person _________________________________________________ Street Address

_________________________________________________ City State Zip

_________________________________________________ Phone Fax

TYPE OF MEDICAL INFORMATION REQUESTED: LAST FULL YEAR OF CHART NOTES FROM DATE OF LAST SERVICE LAST FULL YEAR OF LABS/PATHOLOGY FROM DATE OF LAST SERVICE LAST FULL 2 YEARS OF IMAGING REPORTS FROM DATE OF LAST SERVICE MOST RECENT REPORTS: EKG MAMMOGRAM COLONOSCOPY PAP SMEAR DEXA/BONE DENSITY MY HEALTH INFORMATION RELATING ONLY TO THE FOLLOWING TREATMENT OR CONDITION: _______________________________________ MY HEALTH INFORMATION ONLY FOR THE FOLLOWING DATE(S): ________________________________________________________________ OTHER: _______________________________________________________________________________________________________________

INITIAL ONLY!!! PROTECTED OR SENSITIVE INFORMATION: I understand that certain information cannot be released without specific authorization as required by Federal/State Law. BY INITIALING, I authorize the release of the following protected or sensitive information: ______ HIV/AID related records ______ Drug/Alcohol diagnosis, treatment or referral information ______ Mental Health Information ______ Genetic Testing Information

❖ MINORS AGE 13-17: A minor patient’s signature is required in order to release the following information: (1) conditions relating to the minor’s reproductive care including, but not limited to : contraception, pregnancy, and pregnancy termination, sterilization, and sexually transmitted diseases (age 14 and older), (2) alcohol and/or drug abuse (age 13 and older), and (3) mental health conditions (age 13 and older).

❖ I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected under

Federal law.

❖ I also understand that the information used or disclosed pursuant to this authorization may be subject to disclosure of HIV/AIDS information, mental health

information, generic testing information and drug/alcohol diagnosis, treatment or referral information.

❖ You do not need to sign this authorization. Refusal to sign the authorization will not adversely affect your ability to receive health care services or reimbursement

for services. The only circumstance when refusal to sign means you will not receive health care services is if the health care services are solely for the purposes of

providing health information to someone else and the authorization is necessary to make the disclosure.

❖ You may revoke this authorization IN WRITING at any time. If you revoke your authorization, the information described above may no longer be used or disclosed

for the purposes described in this written authorization. The only exception is when a covered entity has taken action in reliance on the authorization was

obtained as a condition of obtaining insurance coverage.

To revoke this authorization, please send or deliver a written statement to: Evergreen Family Medicine; a division of Centennial Medical Group

Medical Records Custodian 2570 NW Edenbower Blvd, Suite 100

Roseburg, OR 97471 PLEASE STATE CLEARLY THAT YOU ARE REVOKING THIS AUTHORIZATION

THERE MAY BE A CHARGE FOR COPIES OF YOUR MEDICAL RECORD UNLESS YOUR COPIES ARE BEING SENT TO ANOTHER PHYSICAN OR HEALTHCARE FACILITY.

I have read this authorization and I understand it. Unless specified, this authorization will expire one year from date signed. _________________________ (Specified Expiration Date)

___________________________________ ______________________ _____________________________________ (Signature of Individual or Personal Representative) (Date Signed) (Description of Personal Representative’s Authority)

Health History Questionnaire

Welcome to Evergreen Family Medicine, where our family cares for yours! In order to improve our understanding of your health needs, we would like you to complete the attached forms before your first visit in our office. If you feel unsure or uncomfortable with the answers to any of the questions, they may be left blank. Please add any comments you think would better allow us to understand your health care concerns. We look forward to the privilege of caring for you. The EFM Provider team

Name: ____________________________________ M F Age: _____ Date: _____________

Chief Complaint: _______________________________________________________________________ (Please describe the current primary reason for your visit)

Please list any significant concerns you would like to discuss with your provider:

1._____________________________________________________________________________________

______________________________________________________________________________________

2._____________________________________________________________________________________

______________________________________________________________________________________

3._____________________________________________________________________________________

______________________________________________________________________________________

FAVORITE PHARMACY (Name, Address, Phone #):_______________________________________________________

__________________________________________________________________________________________________________________________________

MAIL ORDER PHARMACY ____________________________________________________________________________________

__________________________________________________________________________________________________________________________________

Health History Questionnaire

PAST MEDICAL HISTORY

Please list your Surgical History and the Date of the procedure.

1. __________________________________________________ Date _________________

2. __________________________________________________ Date _________________

3. __________________________________________________ Date _________________

4. __________________________________________________ Date _________________

Please fill in the table below with current Medications. Name Strength Form (Tab/Cap/ etc.) How Often? OTC / Prescription

IMMUNIZATIONS:

Please list your most recent dates (if known) of:

Tetanus __________

Hepatitis A __________ [ ] series complete

Hepatitis B __________ [ ] series complete

Flu vaccine __________

MMR __________

Shingles __________ [ ] series complete

HPV __________ [ ] series complete

Meningitis __________

Varicella __________ [ ] series complete

IS PATIENT VACCINATED ACCORDING TO

CDC GUIDELINES? Yes [ ] No [ ]

If you have an immunization record or current medication list, we would be glad to copy it for your

medical record.

PAST PROBLEMS Have you ever had or do you have: Year Diagnosed: Comments:

Alcoholism/Recovering Alcoholic [ ] No [ ] Yes ______________________________________

Alzheimer’s [ ] No [ ] Yes ______________________________________

Anemia [ ] No [ ] Yes ______________________________________

Anxiety/Depression [ ] No [ ] Yes ______________________________________

Arthritis [ ] No [ ] Yes ______________________________________

Asthma [ ] No [ ] Yes ______________________________________

Back Problems [ ] No [ ] Yes ______________________________________

Bleeding Disorders [ ] No [ ] Yes ______________________________________

COPD [ ] No [ ] Yes ______________________________________

Cancer/Tumor [ ] No [ ] Yes ______________________________________

Diabetes [ ] No [ ] Yes ______________________________________

Drug Addiction/Use [ ] No [ ] Yes ______________________________________

Fibromyalgia [ ] No [ ] Yes ______________________________________

GI Disease [ ] No [ ] Yes ______________________________________

ALLERGIES/ Adverse Reactions:

No Known Drug Allergies

___________________ Reaction ______________

___________________ Reaction ______________

___________________ Reaction ______________

___________________ Reaction ______________

___________________ Reaction ______________

Please list name of doctor if

Surgical History includes

Colonoscopy

Health History Questionnaire - PAST PROBLEMS continued. Year Diagnosed: Comments: Gout [ ] No [ ] Yes ______________________________________

HIV/AIDS [ ] No [ ] Yes ______________________________________

Headaches [ ] No [ ] Yes ______________________________________

Heart Attack [ ] No [ ] Yes ______________________________________

Heart or Vascular Disease [ ] No [ ] Yes ______________________________________

Hepatitis [ ] No [ ] Yes ______________________________________

Hearing Aids/Hearing Loss [ ] No [ ] Yes ______________________________________

Hernia [ ] No [ ] Yes ______________________________________

High Blood Pressure [ ] No [ ] Yes ______________________________________

High Cholesterol [ ] No [ ] Yes ______________________________________

Kidney Diseases [ ] No [ ] Yes ______________________________________

Liver Disease/Jaundice [ ] No [ ] Yes ______________________________________

Lung Disease [ ] No [ ] Yes ______________________________________

Mental Illness [ ] No [ ] Yes ______________________________________

Migraines [ ] No [ ] Yes ______________________________________

Neurologic disease [ ] No [ ] Yes ______________________________________

Obesity [ ] No [ ] Yes ______________________________________

Osteoporosis [ ] No [ ] Yes ______________________________________

Respiratory Infections [ ] No [ ] Yes ______________________________________

Seizures/Epilepsy [ ] No [ ] Yes ______________________________________

Skin/Derm [ ] No [ ] Yes ______________________________________

Sleep Disorder [ ] No [ ] Yes ______________________________________

Stroke [ ] No [ ] Yes ______________________________________

Thyroid Disorders [ ] No [ ] Yes ______________________________________

Urinary Disorders [ ] No [ ] Yes ______________________________________

Other: 1________________________ 2________________________ 3________________________

4________________________ 5________________________ 6________________________

SOCIAL HISTORY

Smoking Status: Never [ ] Former [ ] Every Day [ ] Some Days [ ] Years of Use _______

Age Started _____ How much per day/week ______________

Current/Most recent Occupation/Position: _________________________________ Student [ ] Retired [ ]

Last level of Education Completed: >8 / 8 / 9 / 10 / 11/ 12 / 2 years college / 4 years college / post graduate

Marital Status: Single [ ] Married [ ] Divorced [ ] Widowed [ ] Remarried [ ]

What is your alcohol intake? None [ ] Occasional [ ] Moderate [ ] Heavy [ ]

What is your caffeine intake? None [ ] Occasional [ ] Moderate [ ] Heavy [ ]

Do you chew tobacco? No [ ] 1/day [ ] 2-4/day [ ] 5+/day [ ]

Please list any recreational drugs used and dates of last use: ______________________________________

Advance Directive? Yes [ ] No [ ]

Power of Attorney? Yes [ ] No [ ]

Last Pelvic/ Breast exam __________

Last Colonoscopy __________

Last Flu Vaccine __________

Last PSA __________

ADDITIONAL SOCIAL HISTORY FOR CHILDREN

Excersise Level: None [ ] Occasional [ ] Moderate [ ] Heavy [ ]

Sports Activities: __________________________________

_________________________________________________

Sexually Active? Yes [ ] No [ ]

Health History Questionnaire

PHYSICAL LIMITATIONS

Deaf or Difficulty Hearing Yes [ ] NO [ ] Blind or serious difficulty Seeing Yes [ ] NO [ ]

Difficulty walking or climbing stairs? Yes [ ] NO [ ] Difficulty dressing or bathing Yes [ ] NO [ ]

Difficulty doing errands alone Yes [ ] NO [ ]

Difficulty concentrating, remembering or making decisions? Yes [ ] NO [ ]

FAMILY HEALTH HISTORY

Please list significant health problems in your family. Include diabetes, high blood pressure, heart attack,

stroke, high cholesterol, cancer, alcoholism, TB, epilepsy or psychiatric illness, or other major problems.

Please list current age or age at death.

Relation Problem(s) Age if living Age when passed

Mother _____________________________ _______ ________

Father _____________________________ _______ ________

Maternal Grandmother_____________________________ _______ ________

Maternal Grandfather _____________________________ _______ ________

Paternal Grandmother _____________________________ _______ ________

Paternal Grandfather _____________________________ _______ ________

Brother / Sister _____________________________ _______ ________

Brother / Sister _____________________________ _______ ________

Brother / Sister _____________________________ _______ ________

REVIEW OF SYSTEMS: Please check any of the following symptoms that you have had during the past year. CONSTITUTIONAL

Fever

Night sweats

Weight Gain

Weight Loss

Exercise Intolerance

EYES

Dry eyes

irritation

vision change

EARS

Difficulty Hearing

Pain

NOSE

Frequent Nosebleeds

Sinus Problems

MOUTH/THROAT

Sore Throat

Bleeding gums

Snoring

Dry mouth

Oral abnormalities

Mouth ulcer

Teeth Abnormalities

Mouth Breathing

CARDIOVASCULAR

Chest pain with

exertion

Arm pain with

exertion

Shortness of breath

when walking

Shortness of breath

when lying down

Palpitations

Known heart

murmur

light-headed on

standing

RESPIRATORY

Cough

Wheezing

Shortness of breath

Coughing up blood

Sleep apnea

GASTROINTESTINAL

Abdominal pain

Vomiting

Change in appetite

Black or tarry stool

Frequent diarrhea

vomiting blood

GENITOURINARY

Urinary Loss of

control

Difficulty urinating

Urinary frequency

Hematuria

Frequency

Incomplete

emptying

MUSCULOSKELETAL

Muscle aches

Muscle weakness

arthralgas/joint pain

back pain

INTEGUMENTARY

Abnormal mole

Jaundice

Eczema

Rash

Itching

Dry skin

Growths/Lesions

NEUROLOGIC

Loss of

consciousness

Weakness

Numbness

Seizures

Dizziness

Frequent or severe

headaches

Migraines

Restless legs

PSYCHIATRIC

Depression

Mania

Sleep disturbances

Restless sleep

feeling unsafe in

Relationship

Alcohol abuse

ENDOCRINE

Fatigue

Increased thirst

Hair loss

increased hair

growth

Cold intolerance

HEMATOLOGIC/

LYMPHATIC

Swollen glands

Easy bruising

Excessive bleeding

ALLERGIC/

IMMUNOLOGIC

Runny nose

Sinus pressure

Itching

Hives

Frequent Sneezing

Health History Questionnaire

GYN History:

Date of your last menstrual period? ______________

Date of your last pap smear? ______________

Contraceptive method(s) __________________

Menses monthly: Yes [ ] No [ ]

Frequency of cycle? ____ day(s) [ ] regular [ ] irregular

Duration of flow? ____________ Flow: Light [ ] Moderate [ ] Heavy [ ]

Age at Menarche ______________ Age at Menopause ______________

Date of your last mammogram? ____________

Date of your last Dexascan/ Bone density? ____________

Pregnancies: Total____ Full term births____ Premature births____ Miscarriages____ Abortions____