1. health and fitness

Consent for Treatment. I consent to medical care and treatment as recommended by the health care providers caring
for me at Kirby Medical Center and/or Kirby Medical Group (collectively "Facility"). My consent includes all Facility
services, diagnostic procedures and medical treatment rendered, including without limitation, infectious/communicable
disease testing, clinical examinations, diagnostic imaging, laboratory procedures and other tests, interventions, treatments
and medications and monitoring that do not require my specific informed consent. I understand that the health care
providers who provide treatment to me while I am at the Facility may or may not be Facility employees. I understand that
the Facility has affiliations with medical schools and other educational institutions, and I agree that medical residents and
students may participate in my care, under supervision as appropriate.
Consent to Photographs / Videotapes / Recordings. I authorize the Facility to obtain photographs, videotapes and/or
recordings of me for identification, diagnosis, treatment, and internal health care operations. I understand I may revoke
this consent up until a reasonable time before such images/recordings are used. Any further use and/or disclosure of
these images/recordings is restricted to those purposes I consent to at a later time.
Valuables. I understand and agree that the Facility assumes no liability for any loss or damage to any money, jewelry,
documents, or other articles brought by or for me to the Facility. No employee or other person is authorized to
recommend storage of such articles at Facility.
Assignment of Insurance Benefits / Charges / Refunds. I hereby request, authorize, assign and direct any payment or
benefit otherwise payable to me (including benefits available through Medicare, Medicaid and other third party payors) to
be paid directly to the Facility for the services provided to me. My health care providers may consult with physicians on
the medical staff that I may not meet, such as radiologists, pathologists, anesthesiologists, etc. I realize these physicians
will likely produce a bill for services that is separate from the Facility’s bill. I am aware that some physicians may not
participate in the health plan or payment program that pays for my care and, thus, I may be subject
to additional or out-of-network charges. I certify that the information provided by me to assist in identifying third party
payors and applying for payment is complete and accurate.
Financial Disclosure Statement & Agreement. You, the undersigned are about to sign a FINANCIAL AGREEMENT
obligating yourself to pay all Facility charges. Before you sign the FINANCIAL AGREEMENT, the Facility is required by
federal law to supply you with certain information. That information is as follows: There will be NO (0) FINANCE
CHARGE assessed against you and there will be NO (0) ANNUAL PERCENTAGE RATE as a result of the terms of the
FINANCIAL AGREEMENT. If you fail to make one or more payments when due as specified in the FINANCIAL
AGREEMENT, collection costs including court costs and reasonable attorney fees will be assessed against you. The
undersigned agrees, whether he/she signs as agent, relative, or as patient, that in consideration of the services to be
rendered to the patient, he/she will himself/herself pay the account of the Facility for such services in accordance with its
regular rates and terms. The undersigned further agrees that if this account becomes delinquent he/she will
himself/herself pay all costs of collecting the same including court costs and reasonable attorney fees. No extension of
time or payment shall operate to release the undersigned from this obligation. I understand that I am financially
responsible to the Facility and the independent physicians who render services to me. I agree to pay the Facility’s regular
charges as set forth in its then current chargemaster and pay all charges of physicians and others, including co-insurance
and deductibles, not covered by my insurance, subject to applicable Medicare and Medicaid advance notice requirements.
I authorize the Facility and its designees to call me at any contact number I provided to Facility, including calls to
mobile/cellular or similar devices for any lawful purpose. The Facility will not reimburse me for any fees or charges that I
may incur for incoming/outgoing calls to/from Facility or its designees, to or from any such number. Methods of contact
may include an automated dialing device, as applicable.
Home Health, Hospice and Durable Medical Equipment. Even at the time of admission/registration, it is important to
plan for post-discharge care. I understand that I have the freedom to choose and the right to select my provider/supplier
for post-discharge care and equipment. The Facility does not own, endorse or recommend any agency, company, facility
or provider. The Facility will provide me with a list of providers/suppliers, and I may ask a staff member for a copy of the
list at any time.
*****PATIENT LABEL*****
*ADMCON*
CONSENT FOR TREATMENT-NPP
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Release of Information. I understand that the Facility is authorized by law to use and disclose all or part of my general
patient health care records for treatment, payment and health care operations without my authorization. Nonetheless, I
hereby authorize the Facility to disclose all or part of my health care records for treatment, payment, and operational
purposes, to medical service companies, insurance companies, Medicare, Medicaid, any other federal or state
reimbursement programs, the Social Security Administration or its intermediaries or carriers, and worker’s compensation
carriers. However, I recognize that the Facility needs my authorization to disclose, if applicable, my HIV test results and
treatment records related to mental health, developmental disabilities or alcohol and drug abuse (collectively, “Sensitive
Information”) for payment and health care operations. Accordingly, I hereby authorize the Facility to disclose my Sensitive
Information, as applicable, to Facility billing personnel, my health plan and any other identified payers as necessary for the
purpose of billing, collection or payment of claims. This authorization will remain in effect for as long as my Sensitive
Information is needed for these purposes. The Facility is also authorized to release copies of my record(s) to my primary
care physician and to all subsequent treatment providers. I am aware that I may revoke my authorization in writing at any
time, except to the extent the Facility has already acted in reliance upon the authorization. In addition, I understand that I
have a right, upon request, to inspect and receive a copy of all such information being disclosed.
I have read and understand this Consent / Agreement and I have provided the Facility with complete and accurate
information. I hereby authorize, permit, certify, agree, and acknowledge as indicated above.
X
__
Signature of Patient / Representative
X
Print Name
Relationship (as applicable)
_____
Date
________
Witness
Date
Acknowledgement of Receipt of Notice of Privacy Practices.
I acknowledge that the Facility has provided me a copy of its Notice of Privacy Practices (Notice), which provides
information about how the Facility may use and disclose protected health information. I understand the Notice is subject
to change and that I may obtain a copy of the revised Notice on the Facility’s website http://www.kirbyhealth.org or on
request from the Facility.
X ____________ Initials of Patient/Representative
Reason Acknowledgement Not Obtained
Patient refused to initial Acknowledgement of Receipt statement
Obtained previously
Other______________________________________________________________________________________
X _________________________________________________
Signature of Facility Representative
*****PATIENT LABEL*****
CONSENT FOR TREATMENT-NPP
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PHI Access Form
Family, Friends and Others Involved In Your Care
Patient Name: _____________________________________________ MR#: ______________
Patient Date of Birth: ______________________
Patient Address: ___________________________________________________________
By completing this form and signing below, you are granting Kirby Medical Center/Kirby Medical Group permission
to share protected health information (PHI), including without limitation, appointment information, test results,
diagnosis, or treatment plans, with the individual(s) listed below who is/are a family member, close friend, or other
person involved in your care. Under certain medical circumstances, however, a licensed health care professional
may identify one or more individuals after determining in his/her professional judgment that sharing PHI on a
continual basis would be in the best interest of that patient (e.g. emergency situations, patient has Alzheimer’s
and no power of attorney was granted to the caregiver, etc). There may be other medical situations where the
Hospital may disclose PHI to family members or friends in accordance with federal or state law. Categories of
people will not be accepted (e.g. “all family members” or “all members of your church”) because of the difficulty in
verifying their identity.
Name
Relationship
Address and Phone Number
___________________________ _________________________
_________________________________________
___________________________ _________________________
_________________________________________
___________________________ _________________________
_________________________________________
____________________________ ________________________
_________________________________________
Patient Signature (required): _______________________________________ Date: __________________
Staff Signature (if applicable): ______________________________________ Date: __________________
If you have any questions and/or concerns related to completing this form, contact Medical Records at 217-7621860.
Verified Identification Presented:
 Illinois Driver’s License
 State ID ________________________
 Other ________________________________
*****PATIENT LABEL*****
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9/2011
KIRBY MEDICAL GROUP
Narain Mandhan, M.D. • James E. Manint, D.O.,FAAFP • Joshua E. Sawlaw, M.D.
Lauren Coovert, PA-C • Joseph Lamb, PA-C • Laurie Lee, PA-C • Beth Mathews, CNP
KMG in Monticello
1000 Medical Center Drive
Monticello, IL 61856
Phone: 217-762-6241
Fax: 217-762-1702
KMG in Atwood
108 S. Main, Box 705
Atwood, IL 61913
Phone: 217-578-3814
Fax: 217-578-3100
AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION
Patient Name: _______________________________________________________________________________________
Patient Address: _____________________________________________________________________________________
Date of Birth: ______/______/______
1.
Telephone: _____________________
Med Record No.: ___________________
I, the above named patient, hereby authorize:
_________________________________________ to disclose to ______________________________________________
_________________________________________
______________________________________________
_________________________________________
______________________________________________
2.
The health information described below, which will be used for the purpose of ________________________________.
3.
The health information to be disclosed covers the period(s) of healthcare:
From (date) __________________________________to (date) ___________________________________ and
From (date) __________________________________to (date) ____________________________________
Information to be disclosed (please describe):
_____ Complete health record (s)
_____Discharge Summary
_____ History& Physical
_____ Physician Progress Notes
_____ Physical Therapy
_____ Emergency Department Record
_____ Laboratory Tests (describe dates and types)
_____ X-ray Reports (describe dates and types)
____________________________________
________________________________
_____ Other (please specify)____________________________________________________________________
Note: I understand that this will include information relating to (initial if applicable):
____Acquired immunodeficiency Syndrome (AIDS) or Human Immunodeficiency virus (HIV) infection
____ Behavioral Health Services/Psychiatric Care
____ Treatment for alcohol and/or drug abuse
4. I understand this authorization may be revoked in writing at any time, except to the extent that action has been taken in
reliance on this authorization. Unless otherwise revoked, this authorization will expire on the following event, condition,
or 90 days from the date of the authorization: ________________________________________________.
5. I understand that once the above information is disclosed, it may be redisclosed by the recipient and the information
may not be protected by federal privacy laws or regulations. The facility, its employees, officers, and physicians are
hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated
and authorized herein.
6. I understand authorizing the use of disclosure of the information identified above is voluntary. I need not sign this form
to ensure healthcare treatment.
Signed: __________________________________________________________
Date: ____________________
(Patient)
Signed: __________________________________________________________
(Or Legal Representative)
Signed: ___________________________________________________________
(Witness)
Verified Identification Presented:
# of pages ________________
 Illinois Drivers License
Date: _____________________
(Relationship to Patient)
 State ID____________________
Total Charge ____________________
Date: _____________________
 Other: ______________________________
KMG 14 7/2014
Patient History Form
Date of completion ________________________ Updated Date_________________________ Updated Date_________________________
PATIENT INFORMATION:
Patient Name_________________________________________________ Sex: M F Date of Birth_______________________
Address_________________________________________
Marital Status: M S D W e-mail: _______________________
City_______________________________ State_______ Zip Code____________ Ph#___________________________
Birthplace__________________________ S.S. #___________________________ Cell#__________________________
Employer_______________________________ Occupation___________________________ Work#______________________________
Are you responsible for this account? Y N if not, whom? ___________________________________________________________________
Emergency Contact Name____________________________________________________ Ph#____________________________________
Address____________________________________________________________ Relationship to Patient_________________________________
INSURANCE INFORMATION:
Insurance Carrier____________________________________________ Group Name/Number________________________________________
Policy ID#_________________________________________________
Policy Holder________________________________________________ DOB____________________ S.S. ______________________________
Policy Holder Address______________________________________________________________ State__________ Zip Code_______________
Secondary Insurance? Y N Carrier_________________________________________ Policy Holder________________________________
ADVANCED DIRECTIVES:
Have you completed a Living Will? Y N
Have you completed a Power Of Attorney for Healthcare? Y N
If you have completed these documents, please bring them to the office as soon as possible;
So we can make a copy for our records.
If you have not completed Advanced Directives, would you like more information? Y N
Have you completed a DO NOT RESUSCIATE form? Y N
PATIENT HEALTH HISTORY:
Have you had a recent change in weight? Y
N Gain of _____________lbs.
Loss of _____________lbs.
Date of last FLU shot______________________
Date of last PNEUMONIA shot__________________________
Most recent Primary Care Physician______________________________________ City/State__________________________________________
ALLERGIES
Have you had hives, skin rash, breathing problems or other allergic
reactions to medications? Y or N (please list)
Name of Med
Describe Allergic Reaction
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
Are there medications, other that those you are allergic to, you would prefer
not to take due to prior unpleasant side-effects? Y or N
(please
list)
______________________________________________
Have you had an allergic reaction to: (circle please)
Iodine or x-ray contrast dye? Y
N
Latex or Rubber (glove, condoms, balloons)? Y
N
Dental Medical procedures, vaginal or rectal exam? Y N
Bee or wasp stings? Y
N
Adhesive Tape? Y
N
List any food allergies_________________________________
_____________________________________________________
CHECK IF YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING:
HAY FEVER
ASTHMA
MENINGITIS
TUBERCULOSIS
ARTHRITIS
HEARING LOSS
RHEUMATIC FEVER
KIDNEY DISEASE
ECZEMA / PSORIASIS /
DERMATITIS
OTHER: ______________________
__________________________________
BLEEDING TENDENCY
HEART DISEASE
STOMACH ULCER
HEPATITIS (JAUNDICE)
ORGAN TRANSPLANT
HIGH BLOOD PRESSURE
STROKE / CVA
MENTAL HEALTH DISORDER
SEXUALLY TRANSMITTED
DISEASE
__________________________________
__________________________________
DIABETES
EPILEPSY
GLAUCOMA
PNEUMONIA
JOINT REPLACEMENT
MEASLES (RUBELLA)
CANCER
NEUROLOGICAL DISORDER
__________________________________
__________________________________
KMG 3
Pg 1 of 2
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DO YOU…
SLEEP WELL?
DRINK ALCOHOL?
USE TOBACCO?
DRINK CAFFEINE BEVERAGES?
USE RECREATIONAL/STREET DRUGS?
USE SEATBELTS?
EXERCISE?
FREQUENTLY
FREQUENTLY
FREQUENTLY
FREQUENTLY
FREQUENTLY
FREQUENTLY
FREQUENTLY
OCCASIONALLY
OCCASIONALLY
OCCASIONALLY
OCCASIONALLY
OCCASIONALLY
OCCASIONALLY
OCCASIONALLY
SELDOM
SELDOM
SELDOM
SELDOM
SELDOM
SELDOM
SELDOM
NEVER
NEVER
NEVER
NEVER
NEVER
NEVER
NEVER
HOSPITALIZATIONS:
YEAR (most recent first)
Specify Illness / Surgery
Hospital Name, City, & State
INJURIES:
YEAR (most recent first)
Type of Injury or Accident
Complication or Disability
CHECK IF ANY FAMILY MEMBERS HAS HAD ANY OF THE FOLLOWING:
ALLERGIES
ALCOHOLISM
ASTHMA
BLEEDING TENDENCY
BLINDNESS
TUBERCULOSIS
FAMILY MEMBER
FATHER
MOTHER
BROTHERS/SISTERS
M
F
M
F
M
F
M
F
M
F
SONS/DAUGHTERS
M
F
M
F
M
F
M
F
M
F
CANCER
HIGH BLOOD PRESSURE
DIABETES
KIDNEY DISEASE
EPILEPSY
MENTAL HEALTH DISORDER
HEART DISEASE
NEUROLOGICAL DISORDER
HEARING LOSS
STROKE/CVA
OTHER: _____________________________________________________________
LIVING OR DECEASED
L
D
L
D
L
D
L
D
L
D
L
D
L
D
L
D
L
D
L
D
L
D
L
D
L
D
L
D
MAJOR ILLNESS and/or CAUSE OF DEATH
PATIENT SIGNATURE: ___________________________________________________ DATE: ___________________
Signature of person completing for (other than patient): ___________________________________________________
(Relationship to patient)
KMG 3
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