Apply – Healing Hands

Patient Information

First Name *

Last Name *

Preferred First Name *

Email *

Date of Birth *

Social Security *

Gender *

Mobile Phone *

Home Phone *

Work Phone *

Would you like email appointment reminders? * YesNo Preferred Method of Communication * E-mailHomeCell

Address *

Preferred Pharmacy *

Can we retrieve your prescription history from your pharmacy? * YesNo

Responsible Party’s Information/Guarantor:

Initial here if same as above

Name *

Relationship to Patient *

Social Security *

Date of Birth *

Address *

Phone *

Ethnicity: Hispanic/LatinoNon-Hispanic Race (select all that apply): American IndianAsianBlack/African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther

Emergency Contact / Next of Kin

Name of Emergency Contact / Next of Kin:

Relationship to Patient:

Phone:

Address:

Insurance Information

Please present your insurance card and ID with this form if you have not already done so.

Primary Insurance Plan Name * Secondary Insurance Plan Name (If applicable)

Policy Number *

Group Number *

If policy holder name is different than patient, please fill out below:

Subscriber Name

Relationship to Patient

Disclosures to Friends and/or Family Members DO YOU WANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM THE PROVIDER MAY DISCUSS YOUR MEDICAL CONDITION? IF YES,WHOM?

I give permission for my Protected Health Information to be disclosed for purposes of communicating results,findings and care decisions to the family members and others listed below:

Name	Relationship to Patient	Contact Information

Patient may revoke or modify this specific authorization and that revocation or modification must be in writting.

In the event we are unable to reach you by phone, may we leave a detailed message on your voicemail? * YesNo

Consent for Treatment

The Patient must complete and sign this Consent Form.
If the Patient is a for the Patient must complete and sign this Consent Form.

Patient’s Name (print legibly) *

Patient’s Date of Birth *

Patient’s Age:*

I, the undersigned, for myself or s the Patient, hereby t before the Patient may be treated by a Healing Hands Mobile Physician Group health care provider, this signed Consent Form must be on file with Healing Hands Mobile Physician Group.

CONSENT TO TREAT:

I authorize my treating physician and other healthcare providers to order for me all forms of diagnostic testing and treatment which they judge to be appropriate. I request and authorize Healing Hands Mobile Physician Group and its agents and employees, to provide all treatment services to me as directed by my physicians. I acknowledge that no representation or guarantees have been made to me because of the treatment of care.

ASSIGNMENT AND RELEASE:

I hereby certify that the insurance information I have provided is accurate, complete, and current, and that I have no other insurance coverage. I assign my right to receive payment of authorized benefits under Medicare, Medicaid, and/or any of my insurance carriers to the provider or supplier of any services furnished to me by that provider or supplier. I authorize my provider to file an appeal on my behalf for any denial of payment and/or adverse benefit determination related to services and care provided. If my health insurance plan does not pay my provider directly, I agree to forward to my provider all health insurance payments which I receive for services rendered by my provider and its health care providers. In the event of default of payment, I agree to pay a thirty (30) percent fee, including attorney’s fees. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.

FINANCIAL AGREEMENT:

I will make every effort to actively assist Healing Hands Mobile Physician Group with securing payment for services rendered for which I am liable. If I am the parent/guardian of a minor patient, I understand that unless addressed in my third-party payer agreements, I am financially responsible for all services rendered, and that the parent who authorizes treatment will be responsible for any balance due. I understand that Healing Hands Mobile Physician Group submits claims to insurance carriers to assist its patients and that I am responsible for the balance owed at any time unless other arrangements have been made. I understand that if I do not provide sufficient and timely information and releases of information for Healing Hands Mobile Physician Group to process insurance claims, I will be responsible to pay Healing Hands Mobile Physician Group full and standard fees.

HIPAA:

I acknowledge that I have received or have been provided the opportunity to receive a copy of the “Notice of Privacy Practices.” I understand the Notice of Privacy may change over time and that the obligations of Healing Hands Mobile Physician Group and my rights under it may change.

Initial: ________

CONTROLLED MEDICATION POLICY ACKNOWLEDGEMENT

I understand that Healing Hands Mobile Physician Group is primarily staffed with nurse practitioners. The Healing Hands Mobile Physician Group policy states that a nurse practitioner cannot order/prescribe Schedule II narcotics, therefore, these will not be written unless the MD prescribes them to me. I further understand that no other controlled substance will be called in after normal business hours. I also agree to comply with all state and federal regulations regardingrandom drug testing as well as being seen intermittently by the MD for any scheduled medications that are written by the NP. If requirements are not met, I understand that refills will not be given.

Consent for Care Management & Monitoring Services:

As a patient with two or more chronic conditions, you are eligible to participate in the Medicare benefits called Chronic Care Management (CCM) and Remote Physiological Monitoring (RPM) and Behavioral Health Integration (BHI) that Healing Hands Mobile Physician Group is now offering. CCM, RPM, and BHI are available to you because you have 1) been diagnosed with two or more chronic conditions expected to last at least 12 months, which place you at significant risk of decline, and/or 2) been diagnosed with one or more conditions that require frequent monitoring and management, and/or 3) have been diagnosed with a behavioral health condition. Our goal is to ensure you get the best care possible by working to keep you out of the hospital.

By signing this Agreement, you consent to the provider(s) of Healing Hands Mobile Physician Group providing chronic care management and/or remote physiological monitoring, and/or Behavioral Health (referred to as "CCM/RPM/BHI Services") to you as more fully described below.

The Provider or his clinical staff will:

Explain to you (and your caregiver, if applicable), and offer to you, all the Services that are applicable to your conditions.
Provide a copy of the care plan to you according to your preference specified below.

Beneficiary Acknowledgement & Authorization:

By signing this agreement, you agree to the following:

You consent to the Provider providing CCM and/or RPM and/or BHI Services to you.
You authorize communication (verbal, electronic, or other HIPAA compliant method) of your medical information with other treating providers as part of the coordination of your care, including the practitioner consulting with relevant specialists, such as psychiatry, if applicable.
You opt in to receiving occasional (estimated frequency is one per month) text messages and/or email messages to help identify care needs you may have and to help the provider align resources.
You acknowledge that only one practitioner can furnish CCM/RPM/BHI Services to you during a calendar month.
You understand that cost sharing may apply to these services, so you may be billed for a portion of the Services even though Services will not involve a face-to-face meeting with the provider. Your doctor/provider may choose to waive cost sharing during the Public Health Emergency.
You have the right to stop CCM/RPM/BHI Services by revoking this consent, which will apply at the end of a calendar month. You may revoke this agreement verbally or in writing.

Programs Consented * Chronic Care ManagementRemote Physiological MonitoringBehavioral Health Integration My preference is that I would like to receive / review my CCM care plan the following way. * Verbal review with care team during engagementElectronically via email or patient portalPaper copy mailed.

( one row is mandatory )

Verbal Consent

Patient Name *	Name of Who Consented/Patient or Family (if family denote relationship) *	Date of Verbal Consent *

Patient’s Name *

Today’s Date *

Patient’s Date of Birth *

Reason for today’s visit *

YOUR MEDICAL HISTORY - Please indicate if YOU have a history of the following

Please Check all that apply. * Alcohol AbuseColon CancerLow ThyroidRheumatic FeverAllergies/SinusCongestive Heart FailureIrritable Bowel Syndrome (IBS)Rheumatoid ArthritisAlzheimer’sCOPD/EmphysemaKidney StonesSeizures / ConvulsionsAnemiaCoronary Artery DiseaseLiver CancerSexually Transmitted DiseaseAnxietyCrohn’s DiseaseLung CancerSleep ApneaArthritisDepressionLupusStomach UlcerAsthmaDiabetes Type 1MigrainesStroke / CVABirth DefectsDiabetes Type 2Multiple SclerosisSuicide AttemptBipolar Disorder Adult-onsetGoutOsteoporosisTuberculosis (TB)Bleeding DiseaseHeart AttackParkinson’sBlood ClotsHepatitisProstate DiseaseBreast CancerHigh Blood PressureProstate CancerCataractsHypothyroidReflux / GERDOtherNone of these Other Disease, Cancer, or Significant Medical Illness (please specify):

SOCIAL HISTORY

Are you employed? * YesNo

Occupation

Marital Status * MarriedSingleDivorcedWidow

TOBACCO/ALCOHOL USE

What is your smoking status? * Never SmokeFormer SmokerCurrently every day smoker If current smoker, how many packs per day? * Do you drink alcohol? * YesNo Do you eat healthy meals? * YesNo Do you exercise regularly? * YesNo Do you use any drugs? * YesNo Do you take a daily aspirin? * YesNo Do you have working smoke detectors? * YesNo Do you keep firearms in your home? * YesNo Do you always wear seatbelts? * YesNo Are you sexually active? * YesNo Have you been exposed to sexually transmitted infections or diseases? * YesNo If so, what type and how often?

SURGICAL HISTORY

Please mark each box that applies to you. * AppendectomyBreast AugmentationBreast LumpectomyBreast ReductionCarotid ArteryCataractFootGallbladderHeart BypassHysterectomy due to CancerHysterectomy not due to cancerInguinal HerniaKidney RemovalKneeLow Back DiscLungMastectomyNeck DiscOvary RemovalPacemakerProstateShoulderSinusThyroid RemovalTonsillectomyTotal Knee ReplacementTubal LigationVasectomyWeight LossNone of these Please check here if you have had surgeries. * YesNo Do you have any known allergies? * YesNo

Drugs	Severity	Onset
	MildModerateSevere	ChildAdultUnknown
	MildModerateSevere	ChildAdultUnknown
	MildModerateSevere	ChildAdultUnknown

FAMILY MEDICAL HISTORY: ADOPTEDFAMILY HISTORY UNKNOWNNO SIGNIFICANT FAMILY MEDICAL HISTORYMother, Grandmother, or Sister developed heart disease before the age of 65.Father, Grandfather, or Brother developed heart disease before the age of 55.Other Family Medical History (specify illness & family member)

FAMILY MEDICAL HISTORY

Illness	Father	Mother	Grandfather	Grandmother	Brother	Sister
Alcohol Abuse	Yes	Yes	Yes	Yes	Yes	Yes
Anemia	Yes	Yes	Yes	Yes	Yes	Yes
Arthritis	Yes	Yes	Yes	Yes	Yes	Yes
Asthma	Yes	Yes	Yes	Yes	Yes	Yes
Bipolar Disorder	Yes	Yes	Yes	Yes	Yes	Yes
Bleeding Disease	Yes	Yes	Yes	Yes	Yes	Yes
Breast Cancer	Yes	Yes	Yes	Yes	Yes	Yes
Colon Cancer	Yes	Yes	Yes	Yes	Yes	Yes
COPD / Emphysema	Yes	Yes	Yes	Yes	Yes	Yes
Depression	Yes	Yes	Yes	Yes	Yes	Yes
Diabetes Type 1	Yes	Yes	Yes	Yes	Yes	Yes
Diabetes Type 2 (adult onset)	Yes	Yes	Yes	Yes	Yes	Yes
High Blood Pressure	Yes	Yes	Yes	Yes	Yes	Yes
High Cholesterol	Yes	Yes	Yes	Yes	Yes	Yes
Osteoporosis	Yes	Yes	Yes	Yes	Yes	Yes
Seizures / Convulsions	Yes	Yes	Yes	Yes	Yes	Yes
Stroke / CVA of the Brain	Yes	Yes	Yes	Yes	Yes	Yes

PREVENTATIVE HEALTH

If over the age of 65, have you had the Pneumonia Vaccine?

Please indicate when you last had each of the applicable tests

When was Test	N/A	1 year or less	2 years ago	3 years ago	4 years ago	5+ years ago	Normal	Abnormal	I don't know
Mammogram	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Colonoscopy	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Pap Smear	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Bone Density / Dexa Scan	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Prostate Cancer Screening	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Stool Hemoccult (blood in stool)	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	check
Eye Exam	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes

List all medications you are currently taking * Do you have a Living Will or Power of Attorney for your healthcare? If yes, list details * YesNo

Date *

Signature *

Medical Records Release

By signing this form, I authorize you to release confidential health information about me by providing a copy of my medical records or a summary or narrative of my protected health information to the physician/person/facility/entity listed below.

Patient's Full Name *

Patient's Date of Birth *

The information you may release subject to this signed release form is as follows *

Complete Medical RecordsCare PlanPathology ReportsLab ReportsTreatment RecordMedication RecordRadiology ReportsHistory & PhysicalOther (Please explain below) Other *

Release my health information to the following physician/person/facility/entity and/or those directly associated with my medical care:

Name * Street *

City *

State *

ZIP *

Date *

Authorized By *

HIPAA

NOTICE OF PRIVACY PRACTICES

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices is NOT an authorization. This Notice of Privacy Practices describes how we, our Business Associates, and their subcontractors, may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health condition and related health care services.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law.

TREATMENT - We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. We will abide by the patient's request not to disclose PHI to a health plan for services which the patient has paid out of pocket and requests the restriction.

PAYMENT - Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

HEALTHCARE OPERATIONS - We may disclose, as needed, your protected health information to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment, employee review, training of medical students, licensing, and conducting or arranging for other business activities. We may use or disclose your protected health information in the following situations without your authorization. These situations include as required by law, public health issues as required by law, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, and other required uses and disclosures. Under the law, we must disclose it to you upon your request. Under the law, we must also disclose your protected health information when required by the Secretary of the Department of Health and Human Services to investigate our compliance with the requirements under Section 164.500.

USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization, or opportunity to object unless required by law. The same authorization/restrictions that were used while you are alive will remain in place for up to 50 years after your death. Without your authorization, we are expressly prohibited from using or disclosing your protected health information for marketing purposes. We may not sell your protected health information without your authorization. We may not use or disclose most psychotherapy notes contained in your protected health information. We will not use or disclose any of your protected health information that contains genetic information that will be used for underwriting purposes. You may revoke the authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

YOUR RIGHTS

The following are statements of your rights with respect to your protected health information: You have the right to inspect and have a copy of your protected health information (fees may apply). Pursuant to your written request, you have the right to inspect or have a copy of your protected health information whether in paper or electronic format. The records will be provided within 30 days of request. Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality.

Patient Requesting Medical Records Copies. There may be fees associated with requesting copies of medical records, such as copy fees, and/or shipping and handling fees. You have the right to request a restriction of your protected health information – You may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

You have the right to request confidential communications – You may ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. You have the right to request an amendment to your protected health information – You may ask us to correct health information about you that you think is incorrect or incomplete. We may say “no” to your request, but we will tell you why in writing within 60 days.

You have the right to receive an accounting of certain disclosures — You have the right to receive an accounting of disclosures, paper or electronic, except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law for up to six years prior to the date of the request.

You have the right to receive notice of a breach - We will notify you if your unsecured protected health information has been breached. You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice electronically. We reserve the right to change the terms of this notice and we will notify you of such changes in the following appointment. We will also make available copies of our new notice if you wish to obtain one.

Patient Printed Name *

Relationship (if not patient) *

Date *

Patient Signature *