Beruflich Dokumente
Kultur Dokumente
Aimee
Date
DOB:____________
Address:___________________________________________________
Release From:_________________________
_________________________
_________________________
Release To: Dr. Heinlens Health Care Clinic
806 N State Street
Phone: (989)283-2595
PO Box 477
Stanton, MI 48888
Records Requested:
____X-ray Report(s)
____Diagnostic Studies
____Consultation(s)
____Laboratory Reports
____Progress Notes
____All
____Other: _______________________________
Dates of records requested:
From: _____________
To: _________________
Patient Registration
Legal Name:___________________________ Birthdate:________
Last, First MI
Address:________________________________________________________
City:____________________ State:__________ Zip: ______________
Daytime Phone #:__________________Alt.Phone#:___________________
E-Mail: ______________________________
Social Security #:_______________
Are you: Married Single Divorced Widowed
Primary Language:____________________________ Race: _______________
Ethnic Background: Hispanic/Latino or Not Hispanic/Latino
In case of an emergency, contact:______________________________
Relationship:_________________ Phone:_____________________
Employer:___________________________ Phone: ______________
Primary Insurance:__________________________________
Subscriber:______________________ Birth Date:__________
Policy Number:_____________ Group Number: __________
Secondary Insurance:__________________________________
Subscriber:______________________ Birth Date:__________
Policy Number:_____________ Group Number: __________
I AUTHORIZE Dr. Heinlens Health Care Clinc TO BILL MY INSURANCE CARRIER AND
IF NECESSARY TO RELEASE ANY MEDICAL OR PERSONAL INFORMATION REQUIRED
TO PROCESS THE INSURANCE CLAIM ON MY BEHALF.
Signature:_________________________________
Patient or Legal Guardian Signature
Printed Name: _____________________________
Date:______________
Dose
How Often
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Please attach a complete list of medication if you need more room.
If you have a list of your immunization history, please attach a copy. If you do not
have one, we will get the history from the Michigan Care Improvement Registry
(MCIR) website.
SOCIAL HISTORY:
Recreational Drug Use: No Yes If yes, which ones:________
Smoking: Currently Past Never Packs/day:________________
Alcohol: Currently Past Never Drinks/day:_______________
Please put the date of your last test. If you are not sure of the date, leave it blank. If
it does not apply to you put NA.
HgbA1C (diabetic lab)________ Cholesterol:________
Pap:________ Mammogram:________ Bone Density:________
Prostate Cancer Screen:________ Colonoscopy:________
Were any of those tests abnormal? ______________________
Is Mom still living? _______ If deceased, what age and what was
Diabetes:___________________________________________________
COPD/Asthma:________________________________________________
Blood Pressure:_____________________________________________
High Cholesterol:___________________________________________
Heart:______________________________________________________
Cancer:_____________________________________________________
Explain Yes answers:________________________________________
____________________________________________________________
Do you have any other health problems such as depression, anxiety, bipolar,
arthritis, joint problems, vision, hearing, bowel problems, kidney problems, liver
problems, male/female problems, etc?
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
What surgeries have you had? _______________________________
_____________________________________________________________
_____________________________________________________________
List other medical providers you see on a regular basis (i.e. Cardiologist, Mental
Health Provider, Kidney Doctor, etc.)
_____________________________________________________________
Employment Status: Unemployed
___________________________
Retired
Disability
Type of work:
Regularly Never
I/we are the parents or legal guardians of the minor listed above. We appoint the
person/s listed below as a temporary delegate to bring our child or children in to Dr.
Heinlens Health Care Clinic for evaluation and treatment.
At times a patients family member or friend may call requesting information on test
results, appointment times, or other medical information. Federal law states that we
may not talk to them about your medical information without your permission.
Please list anyone whom you give us permission to talk to regarding your medical
information.
This authorization stays into effect until it is revoked by the patient or their legal
guardian.
Payment. Your health information may be used to seek payment from your health
plan, from other sources of coverage such as an automobile insurer, or from credit
card companies that you may use to pay for services. For example, your health
plan may request and receive information on dates of service, the services
provided, and the medical condition being treated.
Disclosure of
your health information or its use for any purpose other than those listed above
requires your specific written authorization.
If you change your mind after
authorizing a use or disclosure of your information you may submit a written
revocation of the authorization. However, your decision to revoke the authorization
will not affect or undo any use or disclosure of information that occurred before you
notified us of your decision to revoke your authorization.
Individual Rights
You have certain rights under the federal privacy standards. These include:
We also are required to abide by the privacy policies and practices that are outlined
in this notice.
As permitted by law, we reserve the right to amend or modify our privacy policies
and practices. These changes in our policies and practices may be required by
changes in federal and state laws and regulations. Upon request, we will provide
you with the most recently revised notice on any office visit. The revised policies
and practices will be applied to all protected health information we maintain.
You may generally inspect or copy the protected health information that we
maintain. As permitted by federal regulation, we require that requests to inspect or
copy protected health information be submitted in writing. You may obtain a form
to request access to your records by contacting Patsy Chavez or Dr. Gary Kraus.
Your request will be reviewed and will generally be approved unless there are legal
or medical reasons to deny the request.
Complaints
If you would like to submit a comment or complaint about our privacy practices, you
can do so by sending a letter outlining your concerns to:
If you believe that your privacy rights have been violated, you should call the
matter to our attention by sending a letter describing the cause of your concern to
the same address.
You will not be penalized or otherwise retaliated against for filing a complaint.
Contact Person
Date