New Patient Registration Forms

Health Maintenance Survey Name: ____________________

Date of Birth: ___/___/_______

Today’s Date: ___/___/_______

 

  1. Immunizations

    1. Last Pneumovax: ________________ (Date, estimates ok)

_____ ( I do not take)

 

b. Last Tdap: ____________________

_____ ( I do not take)

 

c. Ever had a Zostavax Yes _____ (Date) _____ No _____

 

  1. Last Flu Shot __________

_____ (I do not take)

 

  1. Mammogram ( for women)

    1. Last Mammo (recommended yearly):

__________/___________ (Date/ Normal?)

    1. Last Breast Exam: ________________ (Date), Do you want

updated today? ________________ (yes/no)

 

  1. Pelvic/Pap (for women)

    1. Last Pap (recommended every 3 years age 21-65):

______________________ (Date/ Normal?), Do you want

updated today? __________ (yes/no)

    1. Pelvic can also be done for symptoms, Any ongoing pelvic

symptoms? __________(yes/no)

 

  1. Colonoscopy

    1. Last Colonoscopy: _________________ (Date/Normal?)

    2. Follow up recommendations vary based on individual history

 

  1. Prostate ( for men)

    1. Last PSA: ________________________ (date)

    2. Last Prostate Exam: _________________ (date)

 

  1. Dexa ( for women)

    1. Last Dexa: ________________________ (date)

 

  1. Depression Screen:

    1. How is your energy/stress level? ________________________

    2. How are you sleeping? ________________________________

    3. Do you drive a car? __________________________________

    4. Do you have a supportive circle of family and friends? ______

    5. What activities do you enjoy doing? _____________________

 

Please Note

 

If you want information released to a member of your family including lab results, appointments and any other information pertaining to your health, you MUST sign and date below as well as list their information.

 

_______________________________________ /____________________________

Signature/ Date

 

 

 

Name: _________________________________________________________________

Relationship: ____________________________ Phone #: _____________________

 

Name: _________________________________________________________________

Relationship: ____________________________ Phone #: _____________________

 

Name: _________________________________________________________________

Relationship: ____________________________ Phone #: _____________________

 

Name: _________________________________________________________________

Relationship: ____________________________ Phone #: _____________________

 

Name: _________________________________________________________________

Relationship: ____________________________ Phone #: _____________________

 

Name: _________________________________________________________________

Relationship: ____________________________ Phone #: _____________________

 

Name: _________________________________________________________________

Relationship: ____________________________ Phone #: _____________________

 

Name: _________________________________________________________________

Relationship: ____________________________ Phone #: _____________________

 

 

 

 

 

DATE_______________ REFERRING DOCTOR_________________________

NAME Last ____________________ First ____________________ MI __________

ADDRESS ____________________________________________________________

CITY _______________________STATE _____________________ ZIP _________

PHONE __________ PHONE ___________ RACE ________ ETHNICITY _______

SOCIAL SECURITY #___________________ DATE OF BIRTH________________

SEX_____ MARITAL STATUS____________ SPOUSE NAME_________________

EMPLOYER NAME______________________EMPLOYER PHONE____________

EMERGENCY NOTIFICATION_______________________ PHONE____________

RELATIONSHIP TO PATIENT___________________________________________

EMAIL ADDRESS_____________________________________________________

 

Insurance Information

 

PRIMARY INSURANCE ________________________________________________

POLICY HOLDER NAME _______________________________________________

MEMBER ID #__________________________GROUP # ______________________

SECONDARY INSURANCE _____________________________________________

POLICY HOLDER NAME ______________________RELATIONSHIP __________

MEMBER ID# __________________________GROUP # ______________________

 

AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize Sangre De Cristo Internal Medicine Associates, Douglas Duffee, MD, Mdiv, FACP, to release any information aquired in the course of examination or treatment needed to determine benefits or the benefits payable for related services or for coordination of care.

 

ASSIGNMENT OF BENEFITS: I hereby authorize payment of medical benefits are made directly to above named Doctor for services provided.

 

SIGNATURE ______________________________ DATE _____________________

 

Please Note

 

If you want any information release to your emergency contact person, you MUST sign and date below.

 

SIGNATURE ______________________________ DATE _____________________

 

 

Personal Health Information Policy

 

  1. In our attempt to make information both secure and portable, any patient requested ( or patient representative requested) transfer of medical records can occur by the following methods:

    1. Released directly to you or your representative via your patient portal. Most recent Lab, Mammo, Pap, Colonoscopy, Dexa Scan, EKG and Chest Xray are released for free.

    2. Any custom or larger volume records requests are released to you or your representative at the cost of $25.00 per 3 mb via secure email or password protected thumb drive with payment consenting via the SDCIM store. We DO NOT fax or paper print patient requested records.

 

  1. Please note that SDCIM is participating in CORHIO. This is Colorado’s Health information data base. By Law, Colorado assumes automatic participation.

If you do not want a summary of your health information shared in this system you must “Opt Out”. Your signature below assumes you DO NOT want to “Opt Out”.

 

  1. Please note that SDCIM participates in CPC+. This is Medicare’s program for building strong primary care practices. You must also “Opt Out” if you do not want to have your personal health information shared with Medicare. Your signature below assumes you DO NOT want to “Opt Out”.

 

 

 

____________________________________ ________________________

Signature Date

Dear SDCIM Patient,

 

Medicare now pays SDCIM for the “outside of the office care” we provide you. In order to obtain this reimbursement, we need your consent. By signing this form, you authorize us to perform and bill for complex care coordination when indicated and when appropriate. This may be as often as once a month or as infrequent as never, based on the complexity of your day to day health status. The allowed charge is $40.00 per month and is subject to the same payment and coverage rules as a standard office visit.

 

This care may include but is not limited to Risk Management Calls, Care Coordination Calls, ER/Hospital follow up calls, Electronic access, Administrative Forms, Self Management Support Plans and Communication Calls with other providers.

 

__________________________________ _______________________

Signature Date

 

 

Sangre de Cristo Internal Medicine Associates

 

 

Fees for Services

We would like you to know about your charges in advance. Fees for medical services are based on the cost of medical supplies required, the amount of professional skill involved, and the amount of time spent. The Billing Dept. will be glad to talk to you about your fees. We will be happy to estimate your charges, although due to the nature of diagnosing medical problems, it will be difficult to be precise concerning total charges ahead of time. If you have any questions about your charges, please let us know.

 

Payment at time of Service

Co-Payments are required on the day of your visit. A $10.00 service fee will be assessed if co-pay is not received at time of visit. We can accept cash, check, money order or credit/debit card. (Please note that not all Health Savings Cards are accepted.) We will assess a $25.00 fee on all returned checks. If you have any medical insurance, we will estimate what your personal balance for the service will be after applying your deductable and co-insurance and ask that you pay that amount. (For patients without health insurance, we prefer full payment at the time of service) Credit Cards are accepted.

 

Delinquent Accounts

We want to be understanding and cooperative with everyone in paying their medical bills. The staff will work with you on payment arrangements. For those patients who do not fulfill their obligations after 60 days, it will be considered in everyone’s best interest for those accounts to be referred to our collection agency. Once an unpaid balance is placed with our collection agency, the account must settled through the collection agency office, not with Sangre de Cristo Internal Medicine Associates. Once your account goes into collection status, you will have 30 days to seek a new physician after which we will no longer manage your medical care.

 

Missed Appointments

If you have a total of 3 missed/cancelled appointments, we reserve the right to discontinue medical care. If so, you will have 30 days to transition to a new provider.

 

Physician and Hospital Charges

Charges for medical care provided by Dr. Duffee while you are in the hospital are billed by Sangre de Cristo Internal Medicine Associates. These should not be confused with charges billed by the hospital.

 

A Word about Your Insurance

As a service to you, we will file insurance claims for each of your insurance policies. IT IS YOUR RESPONSIBILTY TO UPDATE THE OFFICE WHEN YOUR INSURANCE INFORMATION CHANGES. It should be understood your insurance policy is an agreement between you and your insurance company to pay certain amounts for medical care. Your physician’s bill is an agreement between you and your physician. You are responsible for full payment of your account, regardless of the status of your insurance claim.

 

Acceptance of Responsibility

I understand that I am financially responsible for all charges whether or not paid by said insurance company. I know that it is my responsibility to notify Sangre de Cristo Internal Medicine Associates of all changes to my account, this includes changes in insurance, address, telephone numbers, emergency contacts, etc.

 

 

Patient’s Signature__________________________________ Date__________________

 

Patient’s Name (Print) _______________________________ Date__________________

 

 

MISSED APPOINTMENTS

 

 

If you have a total of three or more missed or cancelled appointments, we reserve the right to discontinue your medical care. You will then have 30 days to seek a new physician. A missed appointment is also considered if we called and confirmed with you and then you cancelled the day of the appointment.

 

 

 

 

_______________________________________ _______________________

Signature Date

 

6.4.2018