Fillable New Patient Packet- Family And Internal Medicine 0921

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New Patient Packet- Family And Internal Medicine 0921

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WELCOME TO WILMINGTON HEALTH TRUE CARE
T
hank you for your trust in Wilmington Health. Please fill out and submit the enclosed
forms two days before your appointment to help us provide the best care possible.
We look forward to serving you!
WHY CHOOSE WILMINGTON HEALTH?
At Wilmington Health, it starts with Trust, at a place that Respects you.
Where expert care meets Unmatched value. And where a collaborative,
Empowering approach to wellness is not only our top priority, it’s also our
promise to you. Since 1971, no other area provider has oered better, more
aordable care than Wilmington Health. We call it TRUE Care.
And it’s what we oer our patients every single day.
WILMINGTONHEALTH.COM
Demographics
Please print, complete all fields, and sign.
Emergency Contact Information
First Name_______________________ Middle ______________Last_________________________ Relationship______________________________
Street ____________________________________________City________________________________State____________Zip___________________
Birthdate ________________________Home Phone _________________________Cell _____________________Work_________________________
Billing or PO Box Address Secondary or Physical Address
Street____________________________________ Apt/Bldg/Lot________ Street____________________________________ Apt/Bldg/Lot________
City___________________________ State_______ Zip______________ City___________________________ State_______ Zip______________
County__________________ Country: US_____ Other_______________ County__________________ Country: US: _____Other______________
Primary Care Provider________________________ Marital Status___________ Race_____________ Language___________ Ethnicity_____________
1-Primary Insurance Name _________________________________
Policy ID#________________________________ Group#____________
Insurance Address____________________________________________
City___________________________ State_________ Zip____________
Policy Holder (Sponsor) Name__________________________________
Birthdate________________ Sex______ Phone____________________
Street _____________________________________ Apt/Bldg/Lot______
City______________________________ State_______ Zip___________
Policy Holder’s Relationship to Patient____________________________
Employer___________________________________________________
2-Secondary Insurance Name _________________________________
Policy ID#________________________________ Group#____________
Insurance Address____________________________________________
City___________________________ State_________ Zip____________
Policy Holder (Sponsor) Name__________________________________
Birthdate________________ Sex______ Phone____________________
Street _____________________________________ Apt/Bldg/Lot______
City______________________________ State_______ Zip___________
Policy Holder’s Relationship to Patient____________________________
Employer___________________________________________________
Patient Contact Information
Home Phone______________________ Cell_______________________
Day Phone________________________ Alternate__________________
Preferred Contact (check 1) Home____ Cell____ Work____ Portal____
Preferred Notification (check 1) Phone___ Text___ Voice Reminders____
E-Mail______________________________________ Decline E-Mail____
Patient Portal (check 1) Desires registration____ Already registered____
Mother/Parent 1 (of patient under 18)
First Name____________________ Middle________________________
Last____________________________ SSN_______________________
Phone__________________________ Birthdate____________________
Street _____________________________________ Apt/Bldg/Lot______
City______________________________ State_______ Zip___________
E-Mail______________________________________ Decline E-Mail____
Father/Parent 2 (of patient under 18)
First Name____________________ Middle________________________
Last__________________________ Suffix____ SSN________________
Phone__________________________ Birthdate____________________
Street _____________________________________ Apt/Bldg/Lot______
City______________________________ State_______ Zip___________
E-Mail______________________________________ Decline E-Mail____
Patient Last Name______________________________________ Suffix_______ First________________________________ Middle_______________
Prior Last Name_________________________Nickname________________SSN________________Birthdate____________ Male____ Female______
Office Use Only: Recorded By: ____________________ Date: ______________
A copy of this authorization and assignment shall be considered as valid as the original. Form - Demo Revision 09-2019
(1) I understand that I am responsible for charges not covered or reimbursed by the above agents. I agree, in the event of non-payment, to assume the cost of the interest, collection and legal
action (if required). (2) We are required by applicable federal and state law to maintain the privacy of your medical information. Our Notice of Privacy Practices document informs you of our
notice at any time. (3) My right to payment for all pharmaceuticals, procedures, tests, medical equipment rentals, supplies and nursing/physician services including major medical benefits are
hereby assigned to Wilmington Health. This assignment covers any and all benefits under Medicare, other government sponsored programs, private insurance and any other health plans. I
acknowledge this document as a legally binding assignment to collect my benefits as payment of claims for services. In the event my insurance carrier does not accept Assignment of Benefits,
or if payments are made directly to me or my representative, I will insure such payment to Wilmington Health.
Print Name
Relationship to Patient
Date
Patient
Responsible Party
(Of Patient Under 18
Or HealthCare POA)
Wilmington Health Primary Care
Adult New Patient Health History Form
Name: ___________________________________ Date of Birth: _________________ Email: _________________________
Local Pharmacy:_______________________________ Mail order Pharmacy: ____________________________
Reason for your visit today:________________________________________________________________________________
Previous/current physicians: _______________________________________________________________________________
Personal Medical History -Please mark each of the following that applies to you (currently or in the past)
❑Allergies
❑Anemia
❑Anxiety
❑Arthritis (Type____________)
❑Asthma
❑Atrial Fibrillation
❑Enlarged Prostate (BPH)
❑Blood Clots/Clotting Disorder
❑Cancer (Type _______________)
❑COPD/Emphysema
❑Coronary Artery Disease/Stents
❑Depression
❑Diabetes (Type 1 or 2)
❑High Cholesterol
❑GERD/Reflux
❑Headaches/Migraines
❑Heart Disease/Heart Failure
❑Hepatitis/Liver Disease
❑High Blood Pressure
❑Irritable Bowel
❑Heart Attack
❑Osteoporosis
❑Kidney Disease
❑Seizures
❑Stroke
❑Thyroid disease
❑Parkinson’s Disease
❑Sleep Apnea
❑Substance Abuse
❑Tuberculosis
❑Dementia
❑HIV/AIDS
❑Fibromyalgia
❑Lupus
Women Only:
❑Abnormal PAP smear
#______ of Pregnancies
#______ of Children
Last Menstrual Period ___________
Other Medical Problems (not listed above) _________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Medication List - Please list currently prescribed medications and any supplements.
Medication Name
Dosage
How often?
30/90 day RX?
Refills needed?
Allergies - Please describe any allergic reactions to medications, foods, or the environment.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Name: ___________________________________ Date of Birth: _________________
Surgical History- If additional space is needed, please use back of sheet
Type of Surgery (example: hysterectomy)
Date (year)
Health Maintenance – Please bring a copy of your immunizations to your appointment.
Date
Results
Colonoscopy
Mammogram (women only)
PAP smear (women only)
DEXA (Bone density)
Social History- What is your occupation? ______________________________________________________
Marital Status: ❑Married ❑Single ❑Divorced ❑Widowed ❑Life Partner
Who do you live with? __________________________________________________________________________
Tobacco Use ❑Current User ❑Never User ❑Former User
Type Used: ___________________ Amount per day: __________
# of Years used:__________ Quit Year _________
Alcohol Use ❑Current User ❑Never User ❑Former User
Type of alcohol: ____________ How much per week:__________
Drug Use/Substance Abuse ❑Current User ❑Never User ❑Former User
Family History- Please indicate your family history in the boxes below
❑ Please check here if adopted (no family history available)
Family Member
Deceased?
List any medical problems (with age at diagnosis if known)
Parent 1
Parent 2
Sister(s)
Brother (s)
Daughter(s)
Ages:
Son(s)
Ages:
Parent 1 Grandmother
Parent 1 Grandfather
Parent 2 Grandmother
Parent 2 Grandfather
Other relations
Revised 06/18/21
AUTHORIZATION for USE and/or DISCLOSURE of
PROTECTED HEALTH INFORMATION
I authorize the use and/or disclosure of my protected health information, as set forth below. I understand
that this authorization is voluntary. I understand that, if the persons or organizations I authorize below are
not health care providers, they may further disclose the protected health information and it may no longer
be protected by federal health information privacy laws. This authorization will remain in place until a
notice of change is provided in writing.
Patient Information (please print):
Name: ________________________________________
Date of Birth: ___________________________________
Protected Health Information to Be Used and/or Disclosed:
I authorize Wilmington Health to discuss medical information regarding my care, test results,
appointments and/or billing information with someone other than myself? Yes□ N o□
If yes, I authorize Wilmington Health to disclose my protected health information to the following
individuals, who may be contacted directly by Wilmington Health:
NAME
RELATIONSHIP
PHONE NUMBER
1
2
3
I authorize Wilmington Health to leave a message regarding my medical care on my voicemail Yes□ No□
If yes, please provide the phone number:__________________________________________
I authorize Wilmington Health to send appointment reminders via Text Message? Yes□ No□
If yes. please provide the phone number:___________________________________________________
Please note data charges may apply per your cell phone carrier
I acknowledge that I have been made aware of Wilmington Health’s Notice of Privacy Practices. I have had full
opportunity to read and consider the contents of the Wilmington Health Notice of Privacy Practices.
Signature: ______________________________________ Date: ________________________
If this authorization is signed by a personal representative on behalf of the patient, complete the following:
Personal Representative’s Name: __________________________________________________________________
Relationship to Patient: _________________________________________________________________________
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1202 Medical Center Dr.
Attn: Medical Records
Wilmington, NC 28401
Phone: 910-341-3308
Fax Requests to: 910-341-3419
Fax Records to: 910-341-1900
HIPAA Form 1A (Revised 02/19)
Page 1 of 2
Records Requested FROM:
Where are the records coming from?
Name of Provider or Organization:
Address:
Phone:
Fax:
Authorization for Use, Disclosure, and/or Request of Protected Health Information
Patient Name:
Date of Birth: Phone Number:
Address:
City: State: Zip Code:
Specific information being requested:
o All Pediatric records
o History/Office Notes
o Laboratory Test results
o Pap Smears
o Mammograms
o Immunizations
o Colonoscopy and/or EGD reports including associated Pathology reports
o Radiology reports (includes Bone Density, CT/CTA, MRI/MRA, Vascular, etc.)
o Cardiology Studies
o Other: (Please be as specific as we will only be able to provide the specific information you list)
Time Frame of records to be released: (examples: 1 year, 2016 – current, or last 3 visits)
Unless initialed the following information will NOT be released or disclosed:
HIV/AIDS/Communicable Disease Status
Alcohol and/or Drug Abuse or Treatment
Mental Health Status or Treatment
Entities Authorized to Use, Disclose, or Receive: If persons or organizations authorized below are not
health care providers, they may further disclose the protected health information and it may no longer be
protected by federal health information privacy laws.
Records Being Sent TO:
Where are the records being sent?
Name of Provider or Organization:
Address:
Phone:
Fax:
Page 2 of 2 HIP
AA Form 1A (Revised 02/19)
1202 Medical Center Dr.
Attn: Medical Records
Wilmington, NC 28401
Phone: 910-341-3308
Fax Requests to: 910-341-3419
Fax
Records to: 910
-
341
-
1900
Preference for receipt of records:
Regular Mail
Fax: _____________________
Electronic Copy (disk)
The purpose of the Use, Disclosure, and/or Request: Fees may apply based on form of and reason for
release of information.
Changing Provider/Continuation of Care
Insurance
Attorney
Personal Use
Other: __________________________________________
This Authorization will expire: (choose one)
2 years after death of patient
Upon written revocation
Future Date: ______________
On the occurrence of the following event: __________________________________
By signing below, I understand:
• I authorize the use and/or disclosure of my protected health information as described in this
document.
• I may revoke this authorization at any time by providing written notice of my revocation. I
understand that revocation of this authorization will not affect any action taken in reliance on this
authorization before notice of revocation of authorization was received.
• I may refuse to sign this authorization and the request will be considered null and void.
• Wilmington Health may not condition my treatment on my refusal to sign this authorization.
Signature: __________________________________________________________________________
Date: _____________ Last 4 digits of patient’s social security number: _______________
If this authorization is signed by a personal representative on behalf of the patient, complete the
following:
Personal Representative’s Name: _______________________________________________
Relationship to Patient: ______________________________________________________
Witness: ___________________________________ Date: _________________________
If you have concerns about your privacy rights, please contact Wilmington Health Privacy Officer:
Phone: 910-796-7701 Fax: 910-772-1307 Address: 1202 Medical Center Dr. Wilmington, NC 28401
Ema
il: privacyofficer@wilmingtonhealth.com
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New Patient Packet- Family And Internal Medicine 0921

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Completed 1 December 2021

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