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Patient'Information'
Name:!___________________________________________!I!prefer!to!be!called:!___________________!
Address:!______________________________________!City:!______________State:!_____!Zip:!_______!
Primary!Phone:!(_____)____________________!!Secondary!Phone:!(_____)________________________!
!!!!!!!May!we!leave!you!a!message?!!!Primary!Phone:!! Yes!!! No!!!!!!!Secondary!Phone:!! Yes!!! No!!
Date!of!Birth:!______________________!Social!Security!Number:!_______________________________!
EHmail!Address:!_________________________________________!
May!we!discuss!your!health!information!with!a!spouse!or!relative:!!! !Yes!!!!! !No!
If!so,!who?!Name!and!relationship!to!the!patient:____________________________________________!
!!!!!!!Check!appropriate!box:!!! Minor!!! Single!!!! Married!!!! Widowed!!!!! Separated!!!! Divorced!
Employer:!_______________________________________________!Phone:!(____)_________________!
Address:!________________________________________!City:!____________________!State:!_______!
Emergency!Contact:!______________________________!!Phone:!_______________Relation:_________!
Whom!may!we!thank!for!referring!you?!____________________________________________________!
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Insurance'Information!
We#require#proof#of#insurance#before#each#visit.##
If#you#do#not#have#your#insurance#card#with#you,#full#payment#at#time#of#service#is#required.!
Who!is!financially!responsible!for!your!visit!today?!Please!check!one:!! Self!!! Spouse!!! !Parent!!! Other!
Primary!Insurance!
Name!of!Insured:!_______________________________________________!DOB:!__________________!!
Relation!to!Insured:!____________________________!Social!Security!Number:!____________________!
Name!of!Employer:!_____________________________________!Work!Phone:!____________________!
Address!of!Employer:!_________________________________!City:!___________!State:!____!Zip:!_____!
Insurance!Company:!________________________________Group!#:!__________!ID#:!______________!
Insurance!Co.!Address:!______________________________!Insurance!Co.!Phone:!__________________!
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!Secondary!Insurance!(leave!blank!if!none)!
Name!of!Insured:!_______________________________________________!DOB:!__________________!!
Relation!to!Insured:!____________________________!Social!Security!Number:!____________________!
Name!of!Employer:!_____________________________________!Work!Phone:!____________________!
Address!of!Employer:!_________________________________!City:!___________!State:!____!Zip:!_____!
Insurance!Company:!________________________________Group!#:!__________!ID#:!______________!
Insurance!Co.!Address:!______________________________!Insurance!Co.!Phone:!__________________!
*We!have!the!right!to!call!and!obtain!information!over!the!phone!with!your!insurance!carrier!for!your!benefit.!However,!eligibility!and!benefit!
information!given!by!phone!does!not!constitute!an!authorization,!and!does!not!guarantee!payment.!Actual!payment!is!subject!to!the!patient’s!
contracted!and!eligibility!at!the!time!of!service.!
*By!signing!below,!I!have!read!and!do!fully!understand!that!about!benefits!and!eligibility!explained!to!me!by!AFMC,!Inc.!I!also!understand!that!in!the!
event!my!insurance!does!not!cover!any!of!the!above!benefits!or!denies!any!of!the!above!benefits!due!to!medical!necessity,!I!am!fully!responsible!for!
payment!in!full.!AFMC!is!inHnetwork!with!Premera!Blue!Cross!Blue!Shield!and!Aetna.!
Cancellation!Policy:!We!require!24!hours!notice!of!canceling!an!appointment.!Canceling!with!less!than!24!hours!notice,!or!not!showing!up!for!your!
scheduled!appointment!will!result!in!a!$50.00!fee.!!
Returned!Checks:!Any!checks!that!have!bounced!or!have!been!returned!will!result!in!a!$50.00!fee.!
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Patient!Signature:!_____________________________________________!Date:!__________________!
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Financial'Responsibility'
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Payment!of!your!deductible,!if!not!already!met,!and!the!patient!portion!of!your!charges!are!
required!at'the'time'of'service.!Payment!can!be!made!by!cash,!check!or!credit!card.!
Alaska!Functional!Medicine!Clinic!bills!your!insurance!as!a!courtesy.!However,!there!are!many!
insurance!plans!in!the!United!States!and!it!is!impossible!for!AFMC!to!know!the!specific!benefits!of!
your!plan.!It!is!your!responsibility,!not!your!insurance!companies,!to!make!sure!your!bill!is!paid.!
If!you!want!AFMC!to!bill!your!insurance,!you!must!provide!us!with:!
o An!assignment!of!benefits!!
o A!copy!of!your!insurance!card!
Your!insurance!must!pay!on!charges!according!to!their!usual!and!customary!fee!scale.!AFMC’s!
fees!are!set!independently!from!the!insurance!company!guidelines.!In!the!event!your!insurance!
company!determines!a!service!to!be!“not!covered”!or!“above!the!usual!or!customary!charges”,!
you!will!be!responsible!for!the!balance!due.!
AFMC!does!not!bill!Medicaid!or!Medicare!as!a!primary!or!secondary!insurance.!All!charges!must!
be!paid!at!time!of!service.!!
It'is'the'patient’s'responsibility'to'preauthorize'with'their'insurance'company'prior'to'any'
procedures'or'testing.'
In!many!instances,!your!practitioner!may!order!services!or!testing!which!are!independent!from!
Alaska!Functional!Medicine!Clinic.!Such!organizations!include!laboratories,!pathologists,!xKray!
facilities!and!hospitals.!These!organizations!and!physicians!will!directly!bill!you!and!your!insurance!
for!their!services.!Our!office!may!provide!them!with!billing!information.!'
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I!authorize!Alaska!Functional!Medicine!Clinic!to!bill!my!insurance!and!release!medical!or!other!information!
necessary!to!process!my!medical!claims.!I!request!payment!of!government!benefits!either!to!myself!or!to!
the!party!that!accepts!assignment.!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!________Initial!
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I!acknowledge!and!agree!to!all!financial!responsibilities!outlined!at!the!bottom!of!this!agreement.!
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I!understand!that!AFMC!has!opted!out!of!Medicaid!and!Medicare,!and!that!it!is!illegal!to!seek!
reimbursement!for!services!rendered!at!AFMC.!!I!agree!to!pay!in!full!at!the!time!of!service,!for!any!and!all!
services!provided.!!As!a!curtsey!to!our!Medicaid!and!Medicare!patients,!we!will!offer!a!25%!discount!on!
professional!services!rendered.!!!
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I!acknowledge!and!agree!that!I!have!received!a!copy!of!Alaska!Functional!Medicine!Clinic’s!Notice'of'
Privacy'Practices.'
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Patient!Name:!____________________________________________________!Date:!______________!
Patient!Signature:!______________________________________________________________________!
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RECEIPT'OF'NOTICE'OF'PRIVACY'POLICIES'AND'CONSENT'
Date:!________________________!
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Patient!Name:!___________________________________________!DOB:!_________________!
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Patient!Address:!________________________________________________________________!
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Patient!Contact:!Home:!________________Work:!________________!Cell:!________________!
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In!the!course!of!providing!service!to!you,!we!create,!receive!and!store!health!information!that!identifies!you.!It!is!often!
necessary!to!use!and!disclose!this!health!information!in!order!to!treat!you,!to!obtain!payment!for!our!services!and!to!
conduct!health!care!operations!involving!our!office.!
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The!Notice'of'Privacy'Practices!you!have!been!given!describes!these!uses!and!disclosures!in!detail.!You!are!free!to!refer!to!
this!notice!at!any!time!before!you!sign!this!form.!As!described!in!our!Notice'of'Privacy'Practices,!the!use!and!disclosure!of!
your!health!information!for!treatment!purposes!not!only!includes!care!and!services!provided!here,!but!also!disclosures!of!
your!health!information!as!may!be!necessary!or!appropriate!for!you!to!receive!follow!up!care!from!another!health!
professional.!Similarly,!the!use!and!disclosure!of!your!health!information!for!purposes!of!payment!includes!(1)!our!
submission!of!your!health!information!to!a!billing!agent!or!vendor!for!processing!claims!or!obtaining!payment;!(2)!our!
submission!of!claims!to!thirdNparty!payers!or!insurers!for!claims!review,!determination!of!benefits!and!payment;!(3)!our!
submission!of!your!health!information!to!auditors!hired!by!thirdNparty!payers!and!insurers;!and!(4)!other!aspects!of!
payment!described!in!our!Notice'of'Privacy'Practices.!
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Our!Notice'of'Privacy!Practices!will!be!updated!whenever!our!privacy!practices!change.!When!you!sign!this!document,!you!
signify!that!you!agree!that!we!can!and!will!use!and!disclose!your!health!information!to!treat!you,!to!obtain!payment!for!
our!services!and!to!perform!health!care!operations.!You!also!signify!that!you!have!received!a!copy!of!our!Notice'of'Privacy'
Practices.!
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You!have!the!right!to!ask!us!to!restrict!the!uses!or!disclosures!made!for!purposes!of!treatment,!payment!or!healthcare!
operations,!but!as!described!on!our!Notice'of'Privacy'Practices,!we!are!not!obligated!to!agree!to!these!restrictions.!If!we!
do!agree,!however,!the!restrictions!are!binding!on!us.!Our!Notice'of'Privacy'Practices!describes!how!to!ask!for!a!
restriction.!!
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I!have!read!this!document!and!understand!it.!I!consent!to!the!use!and!disclosure!of!my!health!information!for!purposes!of!
treatment,!payment!and!healthcare!operations.!I!acknowledge!that!I!have!received!the!Notice'of'Privacy'Practices!from!
Alaska!Alternative!Medicine!Clinic.!
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Patient!Signature:!____________________________________________________!Date:__________________!
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If'signing'as'a'personal'representative'of'the'patient,'describe'the'relationship'to'the'patient'and'the'source'of'authority'to'
sign'this'form:'
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Name!and!Source!of!Authority:!________________________________________________________________!
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Relationship!to!Patient:!__________________________________________________!!!Date:!______________!
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Surgical History
List Procedure(s) and Date(s): ___________________________________________________________________
Allergies
Medications: ________________________________________________ Severity:__________________________
Foods: ______________________________________________________ Severity:__________________________
Medical History – check all that apply
__ADHD
__AIDS/HIV
__Abuse/Domestic Violence
__Allergies
__Anemia
__Anesthesia Complications
__Anxiety Disorder
__Arthritis
__Asthma
__Autism Spectrum Disorder ASD
__Bedwetting
__Birth Defects
or Inherited Disease
__Bladder or Kidney Problems
__Blood Diseases
__Blood Transfusion
__Breast Cancer
__Breast Problem
__COPD
__Cancer
__Chicken Pox
__Chronic ear infections
__Congestive Heart Failure (CHF)
__Constipation
__Coronary Artery Disease
__Depression
__Developmental or
Behavioral Disorders
__Diabetes
__Difficulty swallowing
__Diverticulitis
__Ear or Hearing Problems
__Eating Disorder
__Eczema
__Endometriosis
__Fibromyalgia
__GI Problems
__Gout
__Headaches
__Heart Disease
__Heart Problems
__Hepatitis
__High Cholesterol
__Hospitalizations
__Hypertension
__Hyperthyroidism
__Hypothyroidism
__Infertility
__Kidney Disease
__Kidney Stones
__Liver Disease
__Lung Disease
__Meniere's disease
__Mental Disorder
__Mental Illness
__Muscle, Joint,
or Bone Problems
__Nasal polyps
__Obesity
__Osteoporosis
__Other
__Ovarian Cancer
__Polyps
__Pre-Eclampsia
__Pulmonary Embolism
__Reflux/GERD
__Seizures/Epilepsy
__Skin Problems
__Stroke
__Thrombophilias
__Thyroid Problems
__Tuberculosis
__Varicosities
__Vision or Eye Problems
__MRSA exposure
Social History
Able to Care for Self? Yes No
Alcohol intake, drinks per week: _________
Caffeine intake, drinks per week: _________
Nicotine intake (circle):
Smoking / E-cigs / Chewing tobacco
How much? __________ Since Age: ________
Secondhand smoke exposure? Yes No
Illicit drugs: __________________________
Animal exposure? Yes No
Are you currently employed? Yes No
Occupation: _________________________
Blind or serious difficulty seeing Yes No
Deaf or serious difficulty hearing Yes No
Changes in family/social situation Yes No
Diet Description (ie. Gluten free, vegan, diabetic, etc) ________________________
Difficulty concentrating, remembering or making decisions Yes No
Social History - continued
Difficulty doing errands alone Yes No
Difficulty dressing or bathing Yes No
Difficulty walking or climbing stairs Yes No
Education Completed ______________________
Home water fluoridated (circle) Yes / No
General stress level (circle):
Low / Medium / High
Guns present in home Yes No
Exercise level (circle): None / Occasional / Moderate / Heavy
Live alone or with others? (ie. Roommates, Both parents, one parent, relatives, adoptive, siblings):
_____________________________________________________________________________________________________
Legally blind in one or both eyes? Yes No
Marital status _______________________
Number of children _____________________
School name: _____________________________
Seat belt/car seat used routinely? Yes No
Sexual orientation _________________________
Sexually active? Yes No
Number of sexual partners _______
Protected sex? Yes No Sometimes
Smoke/CO detectors in home? Yes No
Sporting activities: _________________________
Sunscreen used routinely? Yes No
1.
Women’s Health History
Abnormal Pap (circle) Yes No
12. Flow (circle) Heavy Moderate Light
2.
Age at First Child __________
13. Frequency of Cycle (Q days) __________
3.
Age at Menarche __________
14. Menses Monthly (circle) Yes No
4.
Current Birth Control Method __________
15. HPV Vaccine (circle) Yes
5.
Date of Last Menstrual Period __________
16. Age at Menopause __________
6.
Last Pap Smear __________
17. Post Menopausal Bleeding? Yes
7.
Last Colposcopy __________
18. Performs Monthly Breast Exams? Yes
8.
Last Mammogram __________
19. STIs/STDs (circle) Yes
No
9.
Last Bone Density __________
20. Sexual Problems? Yes
No
10. Desired Birth Control Method __________
21. Sexually Active? Yes
No
No NA
No
11. Duration of Flow (days) __________
22. Number of Pregnancies ___________ Miscarries __________ Children ____________
23. Currently on Hormone Replacement Therapy (circle) Yes No
Family History
__Alcohol abuse
__Alzheimer's disease
__Anemia
__Anxiety disorder
__Arthritis
__Asthma
__ADHD
__Blood coagulation disorder
__Cerebrovascular accident
__COPD
__Coronary arteriosclerosis
__Dementia
__Depressive disorder
__Diabetes mellitus
__Disease of liver
__Disorder of nervous system
__Disorder of thyroid gland
__Endometrial carcinoma
__Epilepsy
__Headache
__Heart disease
__Hypercholesterolemia
__Hypertensive disorder
__Kidney disease
__Liver problem
__Malignant neoplasm of uterus
__Malignant tumor of breast
__Malignant tumor of cervix
__Malignant tumor of colon
__Malignant tumor of lung
__Malignant tumor of ovary
__Mental disorder
__Migraine
__Multiple sclerosis
__Myocardial infarction
__Obesity
__Osteoporosis
__Seizure disorder
__Sleep disorder
__Substance abuse
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Medications
Please list all the dose and frequency of all prescriptions, over-the-counter, and/or supplements you
are currently taking:
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SureScripts Medication History
We have the technology to pull your most current medication history from SureScripts, the nation’s
largest e-prescription network. You may sign below to authorize Alaska Functional Medicine Clinic to
obtain this history, or you may opt-out.
I, ________________________________________ authorize Alaska Functional Medicine Clinic to obtain my
medication history through SureScipts national e-prescription network.
_________________________________________________
Signature
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Date