Elevated Health NYC- General Intake Form

Elevated Health NYC

Personal Information

Patient First Name

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Patient Last Name

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Preferred Name:

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Date of Birth:

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Age

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Gender:*

Male

Female

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Are you pregnant?*

Yes

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Marital Status

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Address:

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City:

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State:

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Zip Code:

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Home Phone:

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Work Phone:

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Cell Phone:

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Occupation:

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Employer:

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Emergency Contact:

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Phone:

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Relation to Patient:

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Insurance Information:

Aetna

BCBS

Cigna

GHI

Oxford

UHC

None

Other:

ID#

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Policy #:

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Is your condition due to an auto accident or job-related injury?*

Yes

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If Yes, Name of Company:

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How did you hear about us?

Health Fair

Internet

Friend/ Co-Worker

Referred by doctor:

I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself.
Furthermore, I understand that this Office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this Office, will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for
professional services rendered to me will be immediately due and payable.

Pain Chart

Please Describe the pain that you are feeling - list the body part(s), the sensation you are feeling, and the intensity on a scale of 1-10.

What pain are you feeling?

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MEDICAL ILLNESS HISTORY

Check if you have or have had any of the following

Asthma

Diabetes

Ulcer

Rheumatic Disease

Heart Disease

High Blood Pressure

Emphysema

Seizures

Tuberculosis

STD

Abdominal Disorders

Kidney Disorder or Stones

Gyno. Disorders

Prostate Disease

Cancer

Arthritis

Thyroid Disease

Nervous Disorder

Muscular Disease

Skin Disease

Eye Disease

Hearing Defect

Gallbladder Disease

Other

REVIEW OF SYMPTOMS:

Check if you have or have had any of the following in the past year

Headache

Blurred Vision

Hearing Loss

Nosebleeds

Chest Pain

Shortness of Breath

Dizziness

Fainting

Vomiting

Constipation

Diarrhea

Indigestion

Weight Gain/Loss

Palpitations

Loss of Appetite

Urine Infection

Blood in Urine

Other Urine Issue

Stress

MuscleCramps

Numb/Tingling

Neck Pain

Back Pain

Joint Pain (list)

Frequent Cough

Wheezing

Blood in Stool

Abdominal Pain

Swollen Glands

Swollen Joints

Fatigue

Other

Additional Health History Comments:

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OFFICE RULES & FINANCIAL POLICY

Our providers share your concern about the cost of medical care. We strongly believe that the best medical service is based on friendly, mutual understanding between Doctors and Patients. We therefore invite you to discuss frankly with us any questions you may have regarding our services and fees. Please feel free to speak with our front desk staff and one of our managers will reach out to you within 2 business days to address your concerns.

Required Co-payments and / or Co-insurance: We accept all major insurances. Depending on your plan and coverage, some of our providers are either non-participating or participating. Your financial responsibility will be discussed prior to your start of care (i.e., per visit fees, Health Savings Account, Flex Spending Accounts and such) We appreciate payment at the time of service and will accept cash, checks, Visa, Mastercard, American Express and Discover. Prompt payments help keep both our costs and fees down. Payment will be collected at the time of arrival and you will receive a receipt of your payment (printed or via email).
Missed Appointments and Late Cancellation Notices: When a patient does not show for an appointment or cancels with less than 24 hours notice, the patient will be subjected to a $50.00 no show or late cancellation fee. This fee will be taken out automatically from the credit card on file. A receipt will be emailed to the patient detailing the missed time and date of the set appointment. Note that our front desk staff will confirm all appointments.
Additional Services: Elevated Health NYC Offers ancillary services to our patients. There might be a separate fee for adjunct services. Please check with our front desk staff for specific fees and additional services.

CREDIT CARD INFORMATION:

Name on the card:

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Card Number:

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Expiration Date:

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CVV:

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Zip Code:

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Email me a receipt

Print me a receipt

Both

PRIVACY: We value your privacy, please note that all information gathered for this patient will only be used by Elevated Health NYC. Personnel only unless otherwise by the signatory verbally or through a written consent. Prior to any charges on this Credit/Debit Card, an email will be sent to the patient notifying them of such change. A follow up email with the receipt with a detailed breakdown of the charges will be sent.

PATIENT CONSENT FOR USE & DISCLOSURE OF PROTECTED HEALTH INFORMATION

I hereby give my consent for Elevated Health NYC to use and disclose protected health information about me to carry out treatment, payment and healthcare operations. Elevated Health NYC Notice of Privacy Practices provides a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. Rock Professional offices reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to:

Elevated Health NYC 315 Madison Avenue,
Suite 801 New York, NY 10017

With this consent form, Elevated Health NYC may call my home or other alternative location and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out treatment, payment and healthcare operations such as appointment reminders, insurance items and any calls pertaining to my clinical care including laboratory results, among others.

With this consent form, Elevated Health NYC may mail to my home or other alternative location any items that assist in carrying out treatment, payment, or healthcare operations such as appointment reminder cards and patient statements as long as they are marked personal and confidential.

With this consent form, Elevated Health NYC may email to my home or other alternative location at any time to assist the practice in carrying out treatment, payments, or healthcare operations such as appointment reminders. I have the right to request that Elevated Health NYC restrict how it uses or discloses my PHI to carry out treatments, payments and healthcare operations. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to Elevated Health NYC use and disclosure of PHI to carry out treatment, payment and healthcare operations.

I may revoke my consent in writing except to the extent the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent or later revoke it, Elevated Health NYC may decline to provide treatment to me.

Patient Name

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Date

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NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that under the Health Insurance Privacy & Accountability Act of 1996 (HIPAA) I have certain rights to privacy regarding my protected health insurance. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among multiple healthcare providers who may be involved in that treatment directly and indirectly.
Obtain payment from third party payers.
Conduct normal healthcare operations such as quality assessments and physician certification.

I acknowledge that I have reviewed your Notice of Privacy Practice containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do not agree that you are bound to abide by such restrictions.

Patient Name:

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Relationship to Patient:

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Date:

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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