SWEDISH COVENANT MEDICAL GROUP AUTHORIZATION I. General Consent To Treatment: I agree and consent to the performance of diagnostic and therapeutic procedures deemed necessary by the patient's physician(s). I acknowledge that there are no guarantees, expressed or implied, as to the results of any procedures or m~dical treatment. II. Release of Information: I authorize physicians providing services on behalf of the patient to release all billing and medical information (including information concerning mental health, genetic testing, substance abuse and HIV status, if applicable) to physicians or institutions providing follow-up care, the Social Security Administration, Medicare, Medicaid (or their various intermediaries), and the insurance company, health maintenance organization, employer, person acting on behalf of a preferred provider arrangement or third party named on this patient information form (or any of their agents or representatives), when such information is requested for payment, worker's compensation, utilization review, or coverage determination purposes, I understand that this authorization will remain in effect unless revoked by me in writing and delivered to this physician's office. III. Receipt of Notice of Privacy Practices I acknowledge receipt of the Swedish Covenant Medical Group Notice of Privacy Practices. IV. Assignment of Insurance or Third Party Coverage A. I authorize any third party payor to pay directly to the physicians providing services to the patient, all benefits due and payable as a result of services rendered. I 1 I l l I B. 1 1 l Il I l V. I authorize assignment to the physician who has provided services to the patient the insured's rights to penalties and attorney's fees in the event that the insurer fails to timely pay such benefits in accordance with lllinois State Law. Acknowledgement of Responsibility to Pay for Services I understand that the physician will, as a courtesy, file claims with insurance carriers and third party payors. However, I acknowledge and agree that, except as provided by law, and in consideration of the services provided, I will pay any charges which, for any reason, are not paid by any third party payor unless there is a specific written agreement to the contrary between the physician and the patient or between the physician and the payor. VI. Medicare Patients I request that payment of authorized Medicare\Medigap benefits be made either to me or on my behalf to for any services furnished me by the provider. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services or my Medigap insurance and its agents any information needed to determine these benefits or the benefits payable for related services. I understand that this authorization will remain in effect unless revoked by me in writing and delivered to this physician's office. DATE SIGNATURE OF PATIENT/ REPRESENTATIVE Relationship of Representative SK Revised 02/21/12 SWEDISH COVENANT MEDICAL GROUP AUTHORIZATION I. General Consent To Treatment: I agree and consent to the performance of diagnostic and therapeutic procedures deemed necessary by the patient's physician(s). I acknowledge that there are no guarantees, expressed or implied, as to the results of any procedures or medical treatment. II. Release of Information: I authorize physicians providing services on behalf of the patient to release all billing and medical information (including information concerning mental health, genetic testing, substance abuse and HIV status, if applicable) to physicians or institutions providing follow-up care, the Social Security Administration, Medicare, Medicaid (or their various intermediaries), and the insurance company, health maintenance organization, employer, person acting on behalf of a preferred provider arrangement or third party named on this patient information form (or any of their agents or representatives), when such information is requested for payment, worker's compensation, utilization review, or coverage determination purposes, I understand that this authorization will remain in effect unless revoked by me in writing and delivered to this physician's office. III. Receipt of Notice of Privacy Practices I acknowledge receipt ofthe Swedish Covenant Medical Group Notice of Privacy Practices. IV. Assignment of Insurance or Third Party Coverage A. I authorize any third party payor to pay directly to the physicians providing services to the patient, all benefits due and payable as a result of services rendered. B. V. I authorize assignment to the physician who has provided services to the patient the insured's rights to penalties and attorney's fees in the event that the insurer fails to timely pay such benefits in accordance with Illinois State Law. Acknowledgement of Responsibility to Pay for Services I understand that the physician will, as a courtesy, file claims with insurance carriers anQ third party payors. However, I acknowledge and agree that, except as provided by law, and in consideration of the services provided, I will pay any charges which, for any reason, are not paid by any .third party payor unless there is a specific written agreement to the contrary between the physician and the patient or between the physician and the payor. VI. Medicare Patients I request that payment of authorized Medicare\Medigap benefits be made either to me or on my behalf to for any services furnished me by the provider. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services or my Medigap insurance and its agents any information needed to determine these benefits or the benefits payable for related services. I understand that this authorization will remain in effect unless revoked by me in writing and delivered to this physician's office. DATE SIGNATURE OF PATIENT/ REPRESENTATIVE Relationship of Representative SK Revised 02/21112 SWEDISH COVENANT MEDICAL GROUP PATIENT CONTACT INFORMATION (6/29/Io) Date:- - - - - - Affix Patient Label Here Please tell us how you prefer to have your medical care provider communicate Confidential Personal Heath Information (PHI) to you. (Check as many as you wish) _Cell telephone number_ _ _ _ _ _ _ _ _ _ _ _ _ __ Best times- - - - - - - - - - - _Home telephone number________________ Best times _Work telephone number with extension_ _ _ _ _ _ _ _ __ ----------- Best times- - - - - - - - - - - US Postal Service May confidential PHI be left on phone voicemail? ___Y es_ _ _No May we leave confidential PHI, including test results, with another person? ___Yes_ _ _N,o If yes, with whom may we leave the message? Name_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Personal relationship to you_ _ _ _ _ _ _ _ __ Keep in mind that ifyou choose your cell, home, or work telephone as preferred choice, we cannot protect confidential PHI! It is your responsibility to notify this office if there is a change in address/telephone Thank you! Patient/Guardian Signature_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ SWEDISH COVENANT MEDICAL GROUP Personal Health History Form Affix Patient Label Here DATE: ______________ Patient N a m e : - - - - - - - - - - - - - Primary D o c t o r : - - - - - - - - - - - - - Medications: Referred B y : - - - - - - - - - - - - - - Reason for v i s i t : - - - - - - - - - - - - - - - - - - - - - - D Married (Living with domestic partner) Personal Profile: DSingle DDivorced Allergies: DWidowed Current or most recent occupation/date: Have you recently traveled outside the U.S.? YES NO Country Visited _ _ _ _ _ _ _D,ate______ GYNECOLOGICAL HISTORY Date of last pap: __/__/__ Results: Normal Abnormal (Please circle one) If abnormal, explain: - - - - - - - - - - - - Have you ever had an abnormal Pap test? YES NO Age of your first period: First day of your last Menstrual Period: Length of your period: (Number of bleeding days) ____/_ _/_ _ Number of days between each period: _____ Date of last mammogram: __/__/__ Any Breast Biopsies: YES NO Date_/__/__ Last Bone Density Scan: __/__/__ Last Colonoscopy: __/__/_ Have you had any menstrual problems? YES NO If yes, e x p l a i n : - - - - - - - - - - - - - - Do you bleed through your clothing or sheets? YES NO Do you often wear a tampon AND a pad for more protection? Do you ever stay home from work due to bleeding? YES NO YES NO Does your bleeding affect your work, social, athletic or sexual activities? YES NO Are you in a sexual relationship? YES NO Are there any sexual problems? YES NO If yes, explain: - - - - - - - - - - - - - - Sexual Partners are: Men Age at first intercourse: _ __ Women Both Total number of sexual partners in your lifetime: _ __ Total number of sexual partner within the last year: ___ Method of birth control: Presently _ _ _ _ _ _ _ _ _ _ In the P a s t - - - - - - - - - - - - - - - - OBSTETRIC HISTORY Number Number Pregnancies Miscarriages Full term births Abortions Preterm births(< 37 weeks) Ectopic/Tubal pregnancies Vaginal Births Complications: Cesareans Explain: Number of living Children Gestational Diabetes: Yes No Yes No PAST MEDICAL HISTORY: please check off Illness NO YES Diabetes High Blood Pressure Sexually Transmitted Diseases (Gonorrhea, Hepatitis B, Hepatitis C, Chlamydia or HIV) YES Seizures/Convulsions/Epilepsy Asthma/TB/Iung disease Kidney Infections/Stones Ulcers/Reflux Bowel Problems Hepatitis/Liver Disease Tuberculosis Depression/Anxiety Cancer Blood Transfusions Rheumatic Fever Gall Bladder Disease Lupus None NO Stroke Headaches/Migraines Osteoporosis Thyroid Disease Urinary Tract Infections Blood Clots in Lungs or Legs Surgeries: Illness Heart Attack/Disease Rheumatoid Arthritis Adult Bone Fractures Glaucoma 0 Date Surgery Any Complications SOCIAL HISTORY NO YES Tobacco (Present or past use) Alcohol Recreational Drug Use Calcium Supplements Have you ever been sexually, physically or verbally abused? Herbal or Alternative Medicines or Therapies FAMILY HISTORY NO YES Packs per day: Drinks per day: Type of Drug: Quantity: By Whom? Relationship Breast Cancer Colon Cancer Ovarian Cancer Uterine Cancer Cancer Other Blood Clots in Legs or Lungs Osteoporosis Diabetes #of Years: Drinks per week: How used: Dose: Currently? NO YES Stroke (under age 50) Heart Attack (under age 50) Thyroid disease High Cholesterol Birth defects or Mental Retardation Alcoholism or Drug Abuse Alzheimer's Disease PATIENT SIGNATURE_ _ _ _ _ _ _ _ __ DATE____~/______/ _________ PHYSICIAN SIGNATURE _ _ _ _ _ _ __ DATE____~/_ ___:/_____ Revised 1/201 0 Relationship . (~ I .· ; .• PRENATAL HISTORY 1. When was Ute first day of your last menstruat period _ _ _ _ _ _ _ _? 2. Are you sure about thls date or just the month 3. Wa~ ? yOw- last period of nonnal amount and duration _ _ _ _ _ _ _ _? 4. Do you have regular monthly periods _____________,__? 5~ About how often do they come (i.e. every 28 days, 30 days) _ _ _ _ _? 6. Where you on birth controJ at the time of conception ? 7. Old you take a home pregnancy teat or blood test to confirm this pregnancy? Yes or No. If yes, when did you take the test ? 8. Please list any past pregnancies (fast six): Date or Blt1ll GA u:' sa Blrtll WdJIIt MIP Labor Ddlyery ' \ ~ A•a. f'lae.oJ l"w. DtiiYerT Ten~~ La..r vm Co -. Co.......C. ,., .. \." Past Medical History Have you or anyone In your Immediate family ever had the following: • ·-·•order Ytr Or No uonnoealacL Daft ct Treatmeat Dbear............er Yea Or No IJemiliednd. Datt & Treatment 16. Rh Seasitized 2. Hyporteusion J1. P\J (TB, Al1bma) 3. Heart Disease 18. Alleraiea r (Drup) 4.Auto 19. Breat Disorder · S. -./ Dlleue 20.0ynecolop Uriuuy Tract haC. S\qery 6. • ·v Epilepsy 22• .{ c Complications 8. Hepatitiaf 2l.Hiltory ef AboormaiPap Livu Diseaso 9. v . 24. UtaiPc Anomalies 10. Thyroid 25. IDfedility Dys1imctiOD II. Thtumal 26. Family Histo.ry· Doaadc Violence 12. HistoJy of Bloocl Tnalftuioa ADIMDt Per Day rre-Prepaaq 13. Ti 14. ·Amoat P'er Day Number of Yean DllliDc ilrepaaq 01l1se . i Genetic Screening/Teratology Counseling lncludea patient. baby'a father, or anyone In either family with: YES YES NO J. Patient'a Age> 35 Yean 2. Th~l . (Italian, <heok. Medlteqaacan, or Allan Back· NO II. Huntfa&toa Olorea 12. Mental Rctardalionl Autism Oround) If yes, wu penon tested for J. Neunl TUbe Oofectt (Mcnfnaomyclocele, Spina Biftda . fragile X?) or" haly) 4. Conaoaital Heart Defect 13. Other blherited ocnodc or Ovomoaomal Dflordor 5.Dowa~1 .e:..- 6. T..,~ ~B.a. 1~ caJun or French Canadian) ,. · 7. Sictlc CeU DSMUe or Ttait - . (Afiicaa) 8. Hemopbilia 9. ·u.~--.-Y 10. Cystic Fibrom I 8. Aay OCher INl'BCTION BJSroRY 1.~.0' tB/ 2.Livewida :witlalB ·or ExpOIOd to 1B 3. Patic:At or Putuer hal • ._,_.1 of~ -•· ·Rape~ ~~- 14. Matemal MoCabOiiC (o.c. iAiuUil depoadeat dfabofcl, PKU) IS. Patialt or I!_~·· Fatbor HacJ a Child with Birth Dcfectl Not Listed Abovo 16. Rec:urrent Pregnaacy Loll, or a Stillbirth 17. M ....Veet Dl'upl Alcohol Since Lut MeDitnlal Pcried lfYes, Which Ones: YES NO YES 4. Raila or ViraiiiiDc!el Silico Last Me8struaJ Period s. . ofsn>, oc, Cblamycti., HPV. Sypbilis 6:00. NO SWEDISH COVENANT MEDICAL GROUP Financial Policy Thank you for choosing us as your health care provider. We are dedicated to providing the best possible care for you, and we want you to completely understand our fmancial policies. Please feel free to speak with our Operations Manager if you have any questions about our fees or financial policy. • All new patients must complete our "Patient Registration Form" prior to seeing the provider. Please inform the receptionist if any of this information changes, especially a name change, address change, or phone number change. • It is the patient's responsibility to provide us with current insurance information and photo I.D., prior to seeing the provider. We will need to see your insurance card at each visit. • Our Practice accepts various insurances and managed health care programs (HMOs). For patients that are members of one of these plans, our business office will submit a claim for services rendered. The patient must complete all necessary forms required by the insurance company. • If a patient has insurance that we do not accept, our office will file the claim; however, payment in full is expected at the time of service. • It is the patient's responsibility to pay any deductible, co-payment or any portion of the charges as specified by the insurance plan at the time of visit. Any medical services not covered by an individual's insurance plan are the patient's responsibility and payment is due at the time of visit. • It is the patient's responsibility to ensure that any required referral for treatment is provided to the receptionist prior to the visit. Your visit may need to be rescheduled, or the insurance coverage may be denied if the referral is not provided in advance. • If you are unable to pay for urgent medical care, you may be eligible for a payment plan. However, charges for tests such as lab work, ultrasound, etc., must be paid for at the time of service, even though they are separate services not offered in our office. The bill you receive today may not be your fmal bill for any lab or radiology services billed by our office. It is your responsibility to inform us prior to the visit if this situation applies to you. • We accept Medicare assignment and our Practice will bill directly for services. Patients are responsible for payment of deductible or co-insurance after Medicare has processed the claim for the services rendered. • If a patient is being seen for an employer-authorized work-related injury, our Practice will bill workers' compensation directly. If the employer's verification of injury cannot be obtained, the patient will be responsible for payment and private patient billing information will be required. • If the patient is a minor (18 years and younger), the parent or guardian will be responsible for payment at the time of service. • Any patient account balance that is placed on a payment plan or is referred to a collection agency will be assessed a minimum 5 percent fee on the outstanding patient portion. • We ask that appointments be cancelled at least 24 hours in advance. If this does not occur and you cancel less than 24 hours in advance it will be considered a "no show". If we do not receive advance notice of the cancellation, a $25.00 charge will be billed to the patient directly and not the patient's insurance. • If a patient accrues more than 3 No Show's in a calendar year, provider may initiate dismissal from the practice. I have read and understand the practice's financial policy, and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time. Signature of Patient or Responsible Party, if minor Please print the name of the patient Revised.SK 07/11 Date