New Patient Packet

Date

Date of Birth

Due to HIPPA regulations only those persons who you may list below will be allowed access to your medical information.

Primary:

Arthritis or Sore JointsAnemia or Low Blood CountsAsthma or Hay FeverBroken BonesCancer/Type_Chemical Dependency/AlcoholismDeafness, Dizziness, Ringing In The EarsEar InfectionsGall StonesHead Injury (Open or Closed)Headaches/MigrainesAbnormal EKGAnxietyAbnormal Bruising or BleedingBronchitis or EmphysemaChest PainDiabetes (Type 1 or 2)Epilepsy or SeizuresHeart Attack or DiseaseGall StonesHepatitis (A, B or C)GoutAbnormal EKGAnxietyAbnormal Bruising or BleedingBronchitis or EmphysemaChest PainDiabetes Heart MurmurHigh CholesterolHIV / AIDSJaundiceLiver DiseasePsychiatric CareShortness of BreathStomach Disorders / UlcersSinus Troubles / Chronic SinusitisThyroid ConditionTrouble Falling or Staying AsleepHemorrhoidsHigh Blood PressureKidney or Bladder IssuesNight SweatsPhlebitis or Clot IssuesSTDsSkin DiseasesStool or Bowel ProblemsStrokeTuberculosis (TB) Test PositiveTremors

Smoke Tobacco?
YesNo

Chew Tobacco?
YesNo

Drink Caffeine?
YesNo

Exercise?
YesNo

Have you ever been hospitalized? If so please list the dates and reasons below:

Medication List:

Supplement List:

Allergies:

Immunizations / Vaccines:

MMR
YesNo

Date

Hepatitis B
YesNo

Date

Pneumonia
YesNo

Date

Tetanus
YesNo

Date

Influenza

Alcoholism
YesNo

Date

Family History:

Alcoholism
YesNo

Allergies
YesNo

Anemia
YesNo

Arthritis
YesNo

Asthma
YesNo

Birth Defects
YesNo

Cancer & Type(s)
YesNo

Diabetes
YesNo

Emphysema
YesNo

Epilepsy
YesNo

High Blood Pressure
YesNo

Leukemia
YesNo

Liver Disease
YesNo

Mental Illness
YesNo

Migraines
YesNo

Obesity
YesNo

Sickle Cell Anemia
YesNo

Ulcers
YesNo

Stroke
YesNo

Personal Health Information:

Women Only

Pelvic Pain
YesNo

Abnormal Vaginal Bleeding
YesNo

Vaginal Discharge
YesNo

Sexual Dysfunction
YesNo

Date of Last Menses
YesNo

Personal Health Information:

Men Only

Straining or Pain with Urination
YesNo

Discharge from Penis
YesNo

Difficulty with Erection
YesNo

Sexual Dysfunction
YesNo

Health Maintenance Tests:

Please list the approximate dates and outcomes to the following tests/procedures

MEN ONLY

WOMEN ONLY

Date:

Date:

HIPPA- Notice of Practice Privacy

We collect information from you and store it in a password protected computer. Passwords are only afforded to the appropriate personal. Medical records are stored in a compliant electronic record keeping software. Housekeeping, maintenance and other non-office personnel have no access to these records. Within our office we restrict the disclosure of this information to doctors, nurses, technicians, medical assistants and healthcare personnel. We may use your medical information for treatment, payment to outside vendors and health care operations.

Outside of our office, we restrict the disclosure of this information to those people, entities, and agencies for which you authorize disclosure such as other health care providers (doctors, nurses, and extended care facilities), insurance companies, billing agencies, hospitals and surgery sites, or those agencies and entities for whom legal and administrative requirements demand disclosure such as:

When Required by Law

• • Public health activities (deaths, child abuse, neglect, domestic violence, problems with products, reactions to medications, product recalls, disease/infectionexposure, isease/injury/disability ontrol/prevention)

• • Health oversight activities (audits, investigations, inspections)

• • Judicial and administrative proceedings (courtorder)

• • Appropriate law enforcement requests (to identify or locate a suspect fugitive, material witness, or missing person)

• • Deceased person information to coroners, medical examiners, funeral directors

• • Organ and tissuedonation

• • Research, provided authorization is RB-approved or privacy board-approved

• • Specialized government functions (military, inmates)

• • Workers compensation

• • Disaster Relief and Fund Raising

Privacy Right

• • Inspect and copy medical information from your chart. You may submit a written request to our office and receive a copy of your record. There will be a copy fee to provide this service to you. We must respond within (30) days if the record is readily available and within (60) days if it is not readily available.

• • Amend medical information in your chart. You may identify inaccurate or incomplete information in your chart. You can do this with a written request, directed to our office, to amend your chart. We must respond within (60) days.

• • Receive an accounting of any disclosures made from your record over the last six years. You can do this with a written request, directed to our office, to amend your chart. We must respond within (60) days.

• •Request restrictions as to the amount of medical information we disclose. This is limited as noted above, and your request may not supersede the typical disclosure noted above. You may revoke or restrict consent.

• • Request Confidential communications. All communications in our office are confidential. You may specifically request that all communications be confidential with a written request directed to our office.

• • Receive a copy of this notice by printing it or with a written request directed to our office, and a copy of this notice will be given with all new patient packets.
  We are required by law to maintain the privacy of your personal health information, and to provide you notice of our legal duties and privacy practices and adhere to this notice. We reserve the right to make changes to this notice. We will post a notice that the notice has been changed and the
  effective date of the change.Copies will be made available. If you have questions or would like to lodge a complaint regarding our privacy policy, you may contact our Privacy Officer at 727-572-8016.
  I have received a copy of KR MEDICAL privacy notice as required by HIPAA

Date:

Office Financial Policy:

• BASIC POLICY

  Payment for service is due in full at the time service is provided in our office.

• MISSED APPOINTMENTS

  In fairness to other patients and practitioners, we require at least a 24 hour notification of an appointment cancellation. If a 24 hour notification is not given and no acute emergency medical condition arises then a $50 no show fee will be charged and must be paid in full before any future services are rendered in this office.

• ASSIGNMENT OF INSURANCE BENEFITS (Health Insurance)

  Patients with insurance please read and sign below that you understand and agree with the following statement.

• I understand that I am financially responsible for all charges unpaid by health insurance and or those services that a re not included in my health insurance policy. The office of K R MEDICAL has informed me that they are not contracted with any health insurance plans and therefore all services rendered by the staff of K R MEDICAL will be self-payment. I have read, understood and agreed to the above financial policies for payment of professional fees.

I agree to all the terms of this contract