New Patient 1Patient Demographics2Consent of Information Disclosure3Notice of Privacy Practices4Current Medical Problems or Chronic Illnesses Patient DemographicsToday's Date(Required) Month Day Year Name(Required) First Last Date of Birth(Required) Month Day Year Gender(Required)MaleFemaleDO YOU HAVE AN ADVANCED DIRECTIVE (LIVING WILL)?(Required)YesNoSocial Security Number(Required) Home Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Primary Phone Number(Required)Secondary Phone NumberMarital Status(Required)SingleMarriedDivorcedWidowedOtherDefine "other"(Required) Do you have a current or past Primary Care Physician?(Required)NoYesName of current or past PCP(Required) Emergency Contact InformationName(Required) First Last Relationship(Required) Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance InformationPrimary Name Subscriber ID Group ID Front of Primary Insurance CardMax. file size: 128 MB.Back of Primary Insurance CardMax. file size: 128 MB.Secondary Name Subscriber ID Group ID Front of Secondary Insurance CardMax. file size: 128 MB.Back of Secondary Insurance CardMax. file size: 128 MB.Assignment of BenefitsI hereby assign all medical and/or surgical benefits, including major medical benefits and Medicare benefits, to which I am entitled to Cleveland Medical Associates. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I understand that I am financially responsible for all charges whether or not paid by my insurance carrier. I understand that I will be responsible for any court costs or collection fees should it become necessary to take action to collect for services/supplies rendered. Consent(Required)I hereby authorize Cleveland Medical Associates to release all medical information necessary to secure payment on my account. I agreePatient Name(Required) First Last Signature(Required)Today's Date(Required) Month Day Year Authorization for TreatmentYour signature below indicates that your consent for treatment of/as patient and responsibility for paying the bill. Please ensure that the physician listed on your card is the doctor you are seeing in our office before your appointment date. Consent(Required)I hereby authorize the release of any information acquired during my examination or treatment to my insurance company and authorize the payment of medical benefits directly to my physician. I agreeSignature(Required)Today's Date(Required) Month Day Year Consent of Information DisclosureThis form is necessary for us to release medical information to your family or friends. If their name is not on this list, we cannot release any information about you to them. If you do not want anyone to know this information, just strike a line through the blanks and sign the form. THIS FORM MUST BE SIGNED AND DATED. I give Cleveland Medical Associates consent to give personal, financial, and medical information to the following persons. Name(Required) First Last Relationship to the Patient(Required) Name First Last Relationship to the Patient Name First Last Relationship to the Patient Consent(Required)I consent to the use or disclosure of my protected health information by this facility, including its employees, physicians, and agents, for the purposes of diagnosing or providing treatment, obtaining payment for my health care bills or to conduct health care operations of this facility. I understand that diagnosis or treatment of me by this facility may be conditioned upon my consent as evidenced by my signature of this document. I understand that I have the right to request restriction as to how my protected health information used or disclosed to carry out treatment, payment, or health care operations of this facility, its employees, physicians, or agents. However, I understand that this facility is not required to agree to the restrictions that I may request. If the facility agrees to the restriction that I request, the restriction is binding on the facility. I have the right to revoke this consent, in writing, at any time, except to the extent that the facility has taken action on this consent. My protected health information means health information, including my demographic information collected from me and created or received by this facility, my physician, another health care provider, a health plan, my employer, or a health care clearinghouse. This protected health information may relate to my past, present, or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe that the information may identify me. It may also refer to alcohol, drug abuse, communicable disease including HIV status, and/or psychiatric diagnosis complied during my visit, encounter, or hospitalization. I understand that state law requires the facility to report certain positive test results, such as hepatitis and the antibody for HIV/AIDS virus to the health department. My medical information described above, and appropriate records as permitted by law may be disclosed and released to any such persons or organizations upon their request both during and after my facility stay. I understand and agree that federal and state entities, including but not limited to , the Centers for Medicare and Medicaid Services, the state Department of Health and Joint Commission on the Accreditation of Healthcare Organizations, may have access to my medical records. I discharge and release the facility and its employees from any responsibility and liability arising out of the disclosure or use of such information by such persons and organizations. I also authorize the release of my medical information to the physician(s) listed as my personal or family physician(s) upon registration and to any referral physician. By signing this consent form, you are agreeing that your provider at Cleveland Medical Associates may receive and use your prescription medication history automatically through channels in our EMR from other healthcare providers and/or third party pharmacy benefit payers for treatment purposes. I agreeSignature(Required)Today's Date(Required) Month Day Year Consent(Required)By signing this consent form, you are agreeing that your provider at Cleveland Medical Associates may receive and use your medical history, hospital records, or consult notes automatically through channels in our EMR from other healthcare providers and/or third party pharmacy benefit payers for treatment purposes. I agreeSignature(Required)Today's Date(Required) Month Day Year Notice of Privacy PracticesConsent(Required)I understand that under the Health Insurance Portability and Accountability Act of 1996 (“HIPPA”), I have certain rights to privacy regarding my protected health information (PHI). I understand that this information can and will be used to: - Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly. - Obtain payment from third-party payers. - Conduct normal healthcare operations such as quality assessments and physician certifications. I agreePatient Signature(Required)Date(Required) Month Day Year Practice Use OnlyI attempted to obtain the patient’s signature in acknowledgement of the Notice of Privacy Practices Acknowledgement but was unable to do so as documented below. Reason Date MM slash DD slash YYYY InitialsFinancial PolicyWelcome to our practice. We ask that all our patients read, understand, and accept our financial policy as described below. For your convenience, we accept all the following methods of payment: Cash Check (with photo identification) Visa Mastercard Discover American Express Consent(Required) I have read and agree to the terms of the financial policy described above.Patient Signature(Required)Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Medicare beneficiaries are responsible for paying an annual deductible and 20% coinsurance. We are dedicated to providing you with the best care and services possible. Thank you for accepting responsibility for prompt payment. Current Medical Problems or Chronic IllnessesCheck all that applyName(Required) First Last Date of Birth(Required) Month Day Year Eye Problems(Required) Glaucoma Macular Degeneration NONE Ear Problems(Required) Hearing Loss Hearing Aid NONE Heart Problems(Required) Heart Attack Heart Failure High Blood Pressure Irregular Heartbeat (Arrhythmia) High Cholesterol NONE Bone & Joint Problems(Required) Arthritis Osteoporosis Fractured Hip, Wrist, or Spine Gout NONE GI Problems(Required) Ulcers Heartburn Hiatal Hernia Diverticulitis Liver Disease Cirrhosis Colon Polyps NONE Lung Problems(Required) Asthma COPD NONE Kidney & Urinary Problems(Required) Kidney Disease Prostate Disease Bladder or Kidney Infections NONE Gland Problems(Required) Diabetes Hypothyroidism Hyperthyroidism NONE Nervous System Problems(Required) Stroke/TIA Dementia or Alzheimer’s Epilepsy or Seizures NONE Other Problems(Required) Allergies Anemia Hernia Thrombosis (blood clot) Cancer NONE What kind of cancer?(Required) List any other medical problems or chronic illnesses(Required)if none, type NONELIST ANY PHYSICIANS AND/OR PRACTIONERS YOU CURRENTLY SEEName of Physician Specialty Name of Physician Specialty Name of Physician Specialty LIST ANY ALLERGIES TO MEDICATION, DYES, OR FOOD(Required)if none, type NONELIST ANY PAST SURGERIES OR HOSPITALIZATIONS (INCLUDE YEAR)(Required)if none, type NONESurgeries and HospitalizationsList any past surgeries of hospitalizations. Include Year. Use the + button to add more medicationsSurgery/HospitalizationYear Add RemoveAre you on any medications currently?(Required)NoYesCurrent Medications(Required)List any medications that you currently take including over-the-counter. Use the + button to add more medications. NameStrengthDirection Add RemoveRECORD THE LAST YEAR YOU HAD THE FOLLOWING:If unknown or not applicable, leave blankGLAUCOMA/EYE EXAMEnter year, ex: 2023 COLON CANCER SCREENEnter year, ex: 2023 MAMMOGRAMEnter year, ex: 2023 BONE DENSITY SCAN:Enter year, ex: 2023 ABDOMINAL AORTIC ANEURYSM SCREENINGEnter year, ex: 2023 PSA TESTEnter year, ex: 2023 PAP SMEAREnter year, ex: 2023 COVID VACCINEEnter year, ex: 2023 FLU VACCINEEnter year, ex: 2023 HEPATITIS B SHOTEnter year, ex: 2023 SHINGLES SHOTEnter year, ex: 2023 PNEUMONIA VACCINEEnter year, ex: 2023 TETANUS DIPHTHERIA VACCINEEnter year, ex: 2023 Social HistoryDo you drink alcohol?(Required)NoYesIf yes, how much?(Required) Have you ever smoked or chewed tobacco?(Required)NoYesIf yes, how much?(Required) Do you drink caffeine?(Required)NoYesIf yes, how much?(Required) Do you do any form of exercise every day?(Required)NoYesIf yes, how much?(Required) Marital Status(Required)SingleMarriedDivorcedWidowedOtherDefine "other"(Required) Family HistoryList health problems and causes of death if applicable. FatherLiving or Deceased? Age Medical ProblemsMotherLiving or Deceased? Age Medical ProblemsBrothersif you have multiple brothers, use the + sign to add more to your listLiving or DeceasedAgeMedical Problems Add RemoveSistersif you have multiple sisters, use the + sign to add more to your listLiving or DeceasedAgeMedical Problems Add RemoveChildrenif you have multiple children, use the + sign to add more to your listLiving or DeceasedAgeMedical Problems Add RemoveDo you have any other health problems that you would like your doctor to know about before your visit?(Required)If none, type "NONE"PhoneThis field is for validation purposes and should be left unchanged.
