eForm

406A-Black Hills Lane SW
Olympia, WA 98502
(360) 754-1727 FAX (360) 754-1783

PATIENT INFORMATION


Patient's Name:
LastFirstMI
Mailing Address
StreetCityStateZip

Sex    Marital Status: 

Date of Birth:

Telephone://
HomeWorkCell

Email Address: (Required under new healthcare laws)

Portal Access:

Patient Employer: Occupation:

Spouse's Name: Spouse's Employer:

Telephone:/
HomeWork
















Whom may we thank for referring you?

INSURANCE INFORMATION


Primary Insurance:  Subscriber ID#
Group#  Effective Date: Relationship:
Subscriber Name: Date of Birth:
Secondary Insurance: Subscriber ID#
Group#  Effective Date: Relationship:
Subscriber Name: Date of Birth:

FINANCIAL AGREEMENT, EXTENSION OF CREDIT AND AUTHORIZATION FOR TREATMENT

I authorize treatment of the person named above. I understand that services provided may not be covered by my insurance carrier. I agree to be personally and financially responsible for payment in full of all fees and charges for such treatment, regardless of my insurance coverage and referral procedures. I agree to pay all charges for myself and members of my family shown by statement, promptly upon presentation thereof, unless credit arrangements are agreed upon in writing.
In accordance with the Federal Truth-in-Lending Act which requires us to give our patients information in connection with extension of credit, please be advised of the following policies which apply in this clinic. The responsible party agrees:
    1.   To pay the doctor at the time treatment or service is received or by previous arrangements.
    2.   That if payments are extended beyond 60 days from the date of patient responsibility to pay 1% per month on the unpaid balance (annual rate of 12%) with a minimum charge of $1 per month.
    3.   To pay cost and/or reasonable attorney's fees if any delinquent balance is placed with an agency or attorney for collection or suit.
    4.   To a $50.00 charge for missed or cancelled appointments within 24 hours of the scheduled appointment time.
    5.   To a $100.00 charge for missed or cancelled procedures within 72 hours of the scheduled appointment time.
It is agreed that payments will not be delayed or withheld because of any insurance coverage or the pendency of claims thereon, and all proceeds of insurance are assigned to this office where applicable, but without their assuming responsibility for the collection thereof. A copy of this assignment is as valid as the original.
   Electronically signed by:   Date:

OMNIBUS BUDGET RECONCILIATION ACT OF 1990 (OBRA '90') ADVANCE DIRECTIVES

Do you have a living will?
Do you have a durable power of attorney for health care?
If not, do you wish additional information?
The existence or execution of a living will, durable power of attorney for health care, or other written advance directive is not a condition of receiving health care services and may not otherwise be used to discriminate an individual.
   Electronically signed by:   Date:

PAYMENTS OF BENEFITS – AUTHORIZATION

I authorize payment of medical benefits to the Olympia Multi-specialty Clinic for any services furnished me. I also authorize the release medical or other information necessary to process claims for these services provided.
   Electronically signed by:   Date:

AUTOMATED TELEPHONE SYSTEM – AUTHORIZATION

I authorize Olympia Multi-specialty Clinic to use an automated telephone system and to use my first name, the name of the treating physician, and the time and place of my scheduled appointment(s), for the limited purpose of notifying me of a pending appointment(s). I also authorize Olympia Multi-specialty Clinic to disclose to third parties who may answer my phone, limited protected health information regarding my pending appointment(s).
   Electronically signed by:   Date:

TELEMEDICINE – AUTHORIZATION

I authorize Olympia Multi-specialty Clinic to use a Telemedicine systems to conduct my visit if it is scheduled as a remote or telemedicine appointment. I also authorize Olympia Multi-specialty Clinic to use e-mail for scheduling these appointments which may contain, limited protected health information regarding my pending appointment(s).
   Electronically signed by:   Date:

CONFIDENTIAL MESSAGES ON ANSWERING MACHINE OR VOICE MAIL - AUTHORIZATION

I authorize Olympia Multi-specialty Clinic to disclose protected health information on my answering machine or my voice mail.
   Electronically signed by:   Date:

ELECTRONIC MEDICATION HISTORY - AUTHORIZATION

I authorize Olympia Multi-specialty Clinic to obtain my medication history on my behalf.
   Electronically signed by:   Date:

Medical History Form

Date: Account#

Name: Birth Date: Age: Sex:
Medications
NameDoseTime TakenPrescribing Provider
Allergies
NameWhat happened? ( examples: rash, hives, nausea )
Symptoms that you have. Check all that apply.
General




Blood



Endocrine



Lungs



Skin

Heart






Gastrointestinal










Urinary Tract




Eyes/Ears/Nose




Nervous System





Bones/Joints


Sleep disorder


Problems or Conditions that you have. Check all that apply

























Family History (AGE) 

FatherMotherBrotherBrotherSisterSister
Age of Death
Heart Attack
Hypertension
Heart Bypass
Stroke
Cancer
Diabetes
Colon Polyps
Liver Disease
Gallbladder

Surgeries - Year













Tobacco
Packs/day

number/day
Alcohol
per day
glasses per day
ounces per day
Coffee
cups per day
cups per day
Routine Health Care - Date last
 
 
 
 
 
 
 
 
 
 
 
 
Reason for your visit
Family Physician
Referring Provider
Other Specialists
1)2)
3)4)

Standing Authorization To Verbally Disclose My Health Care Information


Patient Name:   Date of Birth:
Patient OMC Account Number:
I. My Authorization
     You may verbally disclose the following health care information (check all that apply):




You may verbally disclose health care information regarding testing, diagnosis, and treatment for:


You may verbally disclose this health care information to:
Name: Relationship:
Phone Number:

Name: Relationship:
Phone Number:

Name: Relationship:
Phone Number:

Reason(s) for this authorization (check all that apply):
  other (specify)
This authorization:
  OR     OR  
II. My Rights
I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment or enrollment). I also understand that this authorization only covers verbal disclosures. Washington State law (RCW 70.02) requires that a written authorization be signed for releases of protected health information other than verbal disclosures, and a written authorization of that type is only good for 90 days.

I may revoke this authorization in writing. If I did, it would not affect any actions already taken by Olympia Multi-specialty Clinic based upon this authorization.
Two ways to revoke this authorization are:
  • Fill out a revocation form. A form is available from our office. Or
  • Write a letter to the Olympia Multi-specialty Clinic.
Once health care information is disclosed, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.

   Electronically signed by:   Date:

NOTICE OF PRIVACY PRACTICES —ACKNOWLEDGEMENT




We keep a record of the health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting our Business Office at (360) 704-3450 or 406-A Black Hills Lane SW, Olympia, WA 98502.

Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information.








By my signature below I acknowledge receipt of the Notice of Privacy Practices.



   Electronically signed by:   Date:

This form will be retained in your medical record.