INTZ03 New Patient Information Form

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

Social Security Number

Gender

Email

example@example.com

Primary Phone Number

Please enter a valid phone number.

What type of phone is your Primary Phone Number

Alternate Phone Number

Please enter a valid phone number.

What type of phone is your Alternate Phone Number

Marital Status

Spouse

First Name

Last Name

Spouse Phone Number

Please enter a valid phone number.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Is your mailing address different from your street address?

Yes

No

Mailing Address (if different from Street Address)

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Do you have an alternate address?

Yes

No

Alternate Address if any

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Do you have Medicare?

Yes

No

INTZ03%20Medicare%20Bookmark.65e77e2f565914.33676405

Do you have insurance?

Yes

No

If no insurance, what is the name of the responsible party?

First Name

Last Name

Responsible Party's Phone Number

Please enter a valid phone number.

Responsible Party's Email

example@example.com

Responsible Party's Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Primary Insurance

ID

Group

Do you have secondary insurance?

Yes

No

Secondary Insurance

ID

Group

Prescription Info: RX Bin

Preferred Pharmacy

Preferred Pharmacy Phone Number

Please enter a valid phone number.

Authorization to leave medical reports on voice mail

Yes

No

Emergency Contact

First Name

Last Name

Emergency Contact Phone Number

Please enter a valid phone number.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature *

Initial Clinical History Form

Patient Information

Patient Name

First Name

Middle Name

Last Name

Date of Birth

Date

Age

Race

Caucasian

African American

Asian

Hispanic

Multi-Racial

Other

Gender

Male

Female

Marital Status

Single

Married

Divorced

Widowed

Number of Children

Education (please check highest level)

Grade School

High School

College

Post Graduate

Occupational History

Employer

Job Title

Past Medical History

Please check all conditions that you have or have had

	Check all that apply	Details
None
Heart Disease
High Blood Pressure
Stroke/TIA
Obstructive Sleep Apnea
Coronary Artery Disease
Depression
Anxiety
Bleeding Difficulties
Hepatitis A, B or C
HIV
Diabetes-Diet Controlled
Diabetes-Oral Meds
Diabetes-On Insulin
High Cholesterol
Seizure
Loss of Consciousness
Arthritis-specify Type in Details Column
Asthma
Emphysema
Osteoporosis
Allergy: Food
Allergy: Seasonal
TB
Hypothyroid
Hyperthyroid
Cancer-specify Type /Treatment in Details column
Headaches
Weight Gain-Rapid
Weight Loss-Rapid
Other-Specify in Details column

Colonoscopy

Yes

No

Date Performed

Performed by

Past Surgical History

	Type of Surgery	Year
1.
2.
3.
4.
5.
6.

Prescription Medications

	Medication	Dose	Number per day
1.
2.
3.
4.
5.
6.

Non-Prescription Medications

	Medication	Dose	Number per day
1.
2.
3.
4.
5.
6.

What is your weight?

How long have you been at this weight?

What is your height?

Have you taken Cortisone type drugs?

Yes

No

If YES, When?

Have you ever had blood products transfused?

Yes

No

If YES, When?

Allergies/Type of Reaction

	Name of Allergen	Type	Reaction
1.
2.
3.
4.
5.
6.
7.
8.

What is your main problem(s)?

For Females

Are you pregnant?

Yes

No

Are you breastfeeding?

Yes

No

Number of Pregnancies

Number of Deliveries

Type of Birth Control

Date of first menstrual period

Date of last menstrual period

Last Pap

Last Mammogram

Last Bone Density Scan

Have you had a hysterectomy?

Yes

No

If yes, Date

If yes, Reason

For Males

Do you experience impotency?

Yes

No

Erectile problems?

Yes

No

If yes, explain

Social History

Tobacco Use

	Check all that apply	Details	If yes for any, how many years
Never
Quit-Specify when in Details column
Cigarettes-Specify packs per day in Details column
Pipe
Cigars
Chewing tobacco

Alcohol Use

	Check all that apply	Details
Never
Socially
Daily
Heavy

Have you ever been treated for alcoholism?

Yes

No

If yes, when?

Drug Use

	Check all that apply	Details
None
Marijuana
Amphetamines
Other-Specify in Details column

Have you ever been treated for drug use?

Yes

No

If yes, when?

Do you exercise?

Yes

No

Exercise

	Check all that apply
None
1-2x/week
3-4x/week
5-7x/week

Type of exercise

Do you drink any caffeine?

Yes

No

Caffeine Use

	Check all that apply
None
Occasional
Daily

How much?

Family History

Family Medical History

	Pick One	Current Age or Age at Death	Medical History or Cause of Death	Heart Disease	Diabetes	Cholesterol	Cancer-Specify Type in Details column	Details
Father
Mother
Brothers
Sisters

Other medical conditions for your Mother not listed above

Other medical conditions for your Father not listed above

Other medical conditions for your Brother(s) not listed above

Other medical conditions for your Sister(s) not listed above

Acknowledgement

I, the above named patient, have received a copy of Internal Medicine of Arizona's Notice of Privacy Practices.

Other medical conditions for your Mother not listed above

Other medical conditions for your Brothers not listed above

Other medical conditions for your Sisters not listed above

INTZ03%20Privacy%20Practices.65e11a8c1d4b82.35084555

Receipt of Notice of Privacy Practices

Written Acknowledgement Form

Digital Signature Authorization: *

I, the above named patient, have received a copy of Internal Medicine of Arizona's Notice of Privacy Practices. ALSO, I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature of Patient *

HIPPA Medical Information Release Form

I authorize Internal Medicine of Arizona to release and discuss my medical history and medical condition with

Relationship to Patient

I authorize Internal Medicine of Arizona to release and discuss my medical history and medical condition with

Relationship to Patient

STATEMENT OF FINANCIAL RESPONSIBILITY, ASSIGNMENT OF BENEFITS AND AUTHORIZATION TO RELEASE INFORMATION

I acknowledge that I am responsible for all charges for Internal Medicine of Arizona services provided to me, including any amount not paid by my insurance plan, Medicare or other health service plans.

If my health insurance will not allow direct payment to IMA or if IMA chooses not to accept assignment of medical benefits, I agree to make payment to IMA all health insurance payments I receive for care at IMA immediately upon receipt of such payments. I understand that IMA has the right to refuse or accept assignment of medical benefits.

I also authorize IMA to release all medical information including, but not limited to, information relating to the diagnosis and treatment of psychiatric conditions, sickle cell anemia, alcohol and drug abuse and HIV or communicable diseases, if any such information exists, necessary for processing insurance claims to my insurers, the Health care financing administration (Medicare) or any other third-party payer or their agents.

I authorize IMA to contact my insurance company, health plan administrator or other third-party payer and obtain all pertinent financial information concerning coverage and payments made under my policy. I direct the insurance company, health plan administrator or third party payer and obtain all pertinent financial information concerning coverage and payments made under my policy. I direct the insurance company, health plan administrator or other third party payer to release such information to IMA. I agree that these provisions will remain in effect until otherwise revoked by me.

I understand that I must notify IMA if my illness or injury is work related prior to receiving any care. If I fail to notify IMA my claims will not be sent to the workers compensation carrier and I will be responsible for any charges. IMA will not file claims with the Worker’s Compensation carrier if notified after care has been provided.

STATEMENT OF RIGHT TO A LIVING WILL/ADVANCED MEDICAL DIRECTIVES

I understand IMA recognizes a patient’s right to accept or refuse medical treatment and their right to have a Living Will, Medical Power of Attorney or other form of advance written directive which serves as written instructions for the provision of health care in the event the patient becomes incapable of making their own medical decisions. I understand if I have any type of advance written directive, a copy should be given to IMA so that it can be placed in my medical record.

POLICY REGARDING OUTSIDE MEDICAL RECORDS AND RADIOLOGY FILMS

IMA will accept and may review written medical records, radiology films, or other materials from another healthcare institution if related to your care at IMA. At the completion of your episode of care IMA discards the remainder to the material unless otherwise directed by you. Medical record information mailed directly to IMA from may not be released to you without authorization. For radiology films that you bring to IMA please notify your physician and request their return prior to leaving. Films directly mailed to IMA by another healthcare institution will be returned by mail. I authorize IMA to request medical records, x-ray, labs and other tests from outside facilities for the purpose of medical treatment.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature of Patient *

STATEMENT OF FINANCIAL RESPONSIBILITIY AND AUTHORIZATION TO RELEASE INFORMATION BY REPRESENTATIVE-IF OTHER THAN PATIENT

I acknowledge that I am responsible for all charges for Internal Medicine of Arizona services provided to:

Patient Name

First Name

Last Name

And authorize Internal Medicine of Arizona to proceed as stated above:

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature of Parent, Guardian, or Representative *