Fillable Welcome to the department of General Surgery at (Pinnacle Medical Group)

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Welcome to the department of General Surgery at (Pinnacle Medical Group)

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Dear Paent:
Welcome to the department of General Surgery at Pinnacle Medical Group. Please
take the me to complete the aached forms as Dr. Paige Pennebacker requires as
much informaon as possible to ensure the best possible care.
To allow Dr. Pennebacker to develop a safe and effecve treatment plan for your
condion we would appreciate you having the following items with you on the day of
your visit:
-CDs or films from any relevant X-Ray, US, or CT Scan
-Operave reports from any prior surgery performed by another surgeon
-Any relevant endoscopy reports (such as an EGD, or colonoscopy)
Note – if you had any of the above services performed at Pinnacle Medical Group
or Blake Medical Center please inform our staff upon arrival for your appointment.
Thank you for vising our offices and allowing us to become partners in your
health care.
Sincerely,
Pinnacle Medical Group
General Surgery Department
A Division of West Florida Physician Network, LLC
315 75th Street West, Bradenton, FL 34209
P: 941-795-3600 F: 855-521-2857
PATIENT REGISTRATION FORM (eCW)
PATIENT INFORMATION
(Please print)
Patient’s Legal Name: (Last)___________________________________ (First)________________________________ (MI) __________
Preferred Full Name (if different from above): ________________________________
Home Phone Number (landline):__________________________ Cell:_________________________ Work: _______________________
Address: _______________________________________________________________________________________________________
City, State, Zip: __________________________________________________________________________________________________
Email Address:____________________________________________________________________ Date of Birth: ___________________
Gender Identity:
Female Male Transgender Female to Male Transgender Male to Female Genderqueer
Choose not to disclose Additional Gender Category not listed ________________________________________
Race:
American Indian/Alaska Native Asian Native Hawaiian/Pacific Islander Black/African American White
Hispanic Choose not to disclose Other not listed __________________________
Ethnicity:
Hispanic or Latino Not Hispanic or Latino Choose not to disclose
Preferred Language:
English Spanish ASL Japanese Mandarin Korean French Swahili Portuguese Arabic
Indian: Hindi, Tamil, Gujarati etc Russian Vietnamese Haitian Albanian Burmese Cambodian
Creole Bosnian/Croatian/Serbian/Serbo-Croatian Tagalog Farsi-Iranian/Persian Other not listed_____________
Patient Social Security Number:______-______-_______
RESPONSIBLE PARTY INFORMATION (If not self)
(Information used for patient balance statements)
Responsible Party:
Another Patient Guarantor Self Check here is address and telephone information is same as patient
Responsible Party Name: (Last)___________________________________ (First)________________________________ (MI) _______
Date of Birth: MM_____/ DD_____/ YYYY_________ Sex:
Female Male
Address: _______________________________________________________________________________________________________
City, State, Zip: __________________________________________________________________________________________________
Responsible Party Social Security Number:______-______-_______ Phone Number:_____________________________
INSURANCE INFORMATION: Provide your insurance card(s) (primary, secondary, etc.) to the front desk at check-in.
EMERGENCY CONTACT INFORMATION
Emergency Contact Name: (Last)_________________________________ (First)_____________________________________________
Phone Number:________________________________________________ Do you have a living will: Yes No
Emergency contact relationship to patient: _______________________________________________________________
Guardian
Address: _______________________________________________________________________________________________________
City, State, Zip: __________________________________________________________________________________________________
Home Phone:______________________________________________ Work Phone:_______________________________ Ext.________
GENERAL CONSENT FOR CARE AND TREATMENT CONSENT
TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to
be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved.
At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the
evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).
This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are
indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you
consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing.
You have the right at any time to discontinue services.
You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have
any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions. I voluntarily request a physician,
and/or mid-level provider (nurse practitioner, physician assistant, or clinical nurse specialist), and other health care providers or the designees as deemed
necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this
practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent
forms prior to the test(s) or procedure(s).
I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.
Signature of patient or personal representative:___________________________________________________Date:__________________
Printed name of patient or personal representative:__________________________________ Relationship to patient: _________________
Last Updated: May 2018

 
 

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

   
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  
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CERTIFICATION


  
/ /
REVIEW OF SYMPTOMS Do you currently, or have you had a problem with:
Musculoskeletal:
Broken bones
Arm or leg weakness
Arm or leg pain
Joint pain or swelling
Arthritis
Yes
❑
❑
❑
❑
❑
No
❑
❑
❑
❑
❑
Allergic/Immunologic:
Food, Inhalant (nasal) allergies
Autoimmune disease (i.e., lupus)
Gastrointestinal:
Nausea
Heartburn
Yes
❑
❑
Yes
❑
❑
No
❑
❑
No
❑
❑
Neurological:
Fainting spells or “black outs”
Seizures
Yes
❑
❑
No
❑
❑
Vomiting
Blood in your vomit
Liver disease
❑
❑
❑
❑
❑
❑
Problems with memory
Disorientation
Difficulty with speech
Inability to concentrate
Double or blurred vision
Weakness in arms and/or legs
Loss of sensation
Difficulty with balance
Psychiatric:
Anxiety
Depression
❑
❑
❑
❑
❑
❑
❑
❑
Yes
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
No
❑
❑
Jaundice
Abdominal pain
Change in bowel habits
Ulcers or gastritis
Hematologic/Lymphatic:
Anemia
Hemophilia
Bleeding tendencies
Blood transfusion
Persistent swollen glands/lymph nodes
HIV
❑
❑
❑
❑
Yes
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
No
❑
❑
❑
❑
❑
❑
Constitutional:
Fever
Weight loss
Excessive fatigue
History of Falls
Cardiovascular:
Yes
❑
❑
❑
❑
Yes
No
❑
❑
❑
❑
No
Eyes:
Wear glasses
Infections
Injuries
Glaucoma
Cataracts
Yes
❑
❑
❑
❑
❑
No
❑
❑
❑
❑
❑
Chest pain or angina
High blood pressure
Irregular pulse
Heart murmur
High cholesterol
Swelling in hands or feet
Leg pain while walking
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
Genitourinary:
Urinary tract infections
Painful urination
Blood in your urine
Difficult starting/stopping stream
Incontinence
Kidney stones
Yes
❑
❑
❑
❑
❑
❑
No
❑
❑
❑
❑
❑
❑
Respiratory:
Asthma
Yes
❑
No
❑
Endocrine:
Diabetes
Yes
❑
No
❑
Emphysema
Shortness of breath
Pneumonia
Bloody sputum
❑
❑
❑
❑
❑
❑
❑
❑
Thyroid disease
Excessive thirst/urination
Skin/Breast:
Eczema
❑
❑
Yes
❑
❑
❑
No
❑
Ear, Nose, Throat & Mouth:
Wear hearing aid(s)
Hearing loss
Ear pain/infections
Ringing in ear
Nose bleeds
Yes
❑
❑
❑
❑
❑
No
❑
❑
❑
❑
❑
Seborrhea
Psoriasis
Hair loss
Skin Cancer
Rashes
Breast Cancer
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
Nasal congestion/drainage
Inability to smell
Sinus problems
Balance (vertigo, spinning, etc.)
❑
❑
❑
❑
❑
❑
❑
❑
Non-Healing wound
Mole change/bleeding
Lump
Nipple Discharge
❑
❑
❑
❑
❑
❑
❑
❑
Pinnacle Medical Group
MEDICATIONS
Please include all prescription medication, vitamins and supplements, and any over the counter
medication that you are currently taking.
Patient Name:_______________________________________ Date of Birth ______________
Allergies: ____________________________________________________________________
MEDICATION NAME STRENGTH DOSE AND FREQUENCY
Patient name: ______________________________
Date of birth: _______________________________
Patient Consent for Financial Communications
Financial Agreement
• I acknowledge, that as a courtesy, WEST FLORIDA PHYSICIAN NETWORK, LLC may bill my insurance
company for services provided to me.
• I agree to pay for services that are not covered or covered charges not paid in full including, but not limited to any
co-payment, co-insurance and/or deductible, or charges not covered by insurance.
• I understand
there is a fee for returned checks.
Third Party Collection. I acknowledge WEST FLORIDA PHYSICIAN NETWORK, LLC may use the services of a third-
party business associate or affiliated entity as an extended business office (“EBO Servicer”) for medical account billing
and servicing.
Assignment of Benefits. I hereby assign to WEST FLORIDA PHYSICIAN NETWORK, LLC any insurance or other third-
party benefits available for health care services provided to me. I understand WEST FLORIDA PHYSICIAN NETWORK,
LLC has the right to refuse or accept assignment of such benefits. If these benefits are not assigned to WEST FLORIDA
PHYSICIAN NETWORK, LLC, I agree to forward all health insurance or third-party payments that I receive for services
rendered to me immediately upon receipt.
Medicare Patient Certification and Assignment of Benefit. I certify that any information I provide, if any, in applying for
payment under Title XVIII (“Medicare”) or Title XIX (“Medicaid”) of the Social Security Act is correct. I request payment of
authorized benefits to be made on my behalf to WEST FLORIDA PHYSICIAN NETWORK, LLC by the Medicare or
Medicaid program.
Consent to Telephone Calls for Financial Communications. I agree that, in order for WEST FLORIDA PHYSICIAN
NETWORK, LLC or Extended Business Office (EBO) Servicers and collection agents, to service my account or to collect
any amounts I may owe, I expressly agree and consent that WEST FLORIDA PHYSICIAN NETWORK, LLC or EBO
Servicer and collection agents may contact me by telephone at any telephone number, without limitation of wireless, I
have provided or WEST FLORIDA PHYSICIAN NETWORK, LLC or EBO Servicer and collection agents have obtained or,
at any phone number forwarded or transferred from that number, regarding the services rendered, or my related financial
obligations. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic
dialing device, as applicable.
A photocopy of this consent shall be considered as valid as the original.
Patient/patient representative signature: _______________________________ Date: _________________
If you are not the patient, please identify your relationship to the patient. Circle or mark relationship(s) from list below:
Spouse Guarantor
Parent Healthcare Power of Attorney
Legal Guardian Other (please specify) _______________________________
Last Updated: July 2017
WEST FLORIDA PHYSICIAN NETWORK, LLC
P
ATIENT HIPAA ACKNOWLEDGMENT AND CONSENT FORM
Patient Name (Printed): _________________________ Date of Birth: _______________________
Notice of Privacy Practice/clinics.
________ (Patient/Representative initials) I acknowledge that I have received the practice/clinic’s Notice of Privacy
Practice/clinics, which describes the ways in which the practice/clinic may use and disclose my healthcare
information for its treatment, payment, healthcare operations and other described and permitted uses and
disclosures, I understand that I may contact the Privacy Officer designated on the notice if I have a question or
complaint. I understand that this information may be disclosed electronically by the Provider and/or the Provider’s
business associates. To the extent permitted by law, I consent to the use and disclosure of my information for the
purposes described in the practice/clinic’s Notice of Privacy Practice/clinics.
Disclosures to Friends and/or Family Members
DO YOU WANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM THE
PROVIDER MAY DISCUSS YOUR MEDICAL CONDITION? IF YES, WHOM?”
I give permission for my Protected Health Information to be disclosed for purposes of communicating results,
findings and care decisions to the family members and others listed below:
Name Relationship Contact Number
1:
2:
3:
Patient/Representative may revoke or modify this specific authorization and that revocation or modification must be in writing.
Consent for Photographing or Other Recording for Security and/or Health Care Operations
I consent ____ (Patient/Representative Initials) to photographs, digital or audio recordings, and/or images of me
being recorded for patient care, security purposes and/or the practice/clinic’s health care operations purposes
(e.g., quality improvement activities). I understand that the facility retains the ownership rights to the images
and/or recordings. I will be allowed to request access to or copies of the images and/or recordings when
technologically feasible unless otherwise prohibited by law. I understand that these images and/or recordings will
be securely stored and protected. Images and/or recordings in which I am identified will not be released and/or
used outside the facility without a specific written authorization from me or my legal representative unless
otherwise permitted or required by law.
-OR-
I do not consent ____ (Patient/Representative Initials) to photographs, digital or audio recordings, and/or images
of me being recorded for patient care, security purposes and/or the practice/clinic’s health care operations
purposes (e.g., quality improvement activities).
Consent to Email, Cellular Telephone, or Text Usage for Appointment Reminders and Other Healthcare
Communications:
We want to stay connected with our patients. Patients in our practice/clinic may be contacted via email,
calls to your cellular telephone (including prerecorded/artificial voice messages and/or calls from an
automatic dialing device), and/or text messaging to confirm an appointment, to obtain feedback on your
experience with our healthcare team, and to be provided general health reminders/information. If at any
time, you provide an email, cellular telephone number, address or text number below, you understand that you
may get these communications from the Practice/clinic. You may opt out of these communications at any time
(see next page).The practice/clinic does not charge for this service, but standard text messaging rates or cellular
telephone minutes may apply as provided in your wireless plan (contact your carrier for pricing plans and details).
I authorize to receive text messages and/or cellular telephone calls for appointment reminders, feedback, and
general health reminders/information and the cell phone number is __________________________.
I authorize to receive email messages for appointment reminders and general health
reminders/feedback/information and the email that is______________________________.
-OR-
I decline ______ (Patient/ Representative Initials) to receive communication via text.
I decline ______ (Patient/ Representative Initials) to receive communication via cellular telephone call.
I decline ______ (Patient/ Representative Initials) to receive communication via email.
Updated: January 2018 v6 replacing 122016, 042216, 102815, 061215, 112113
A photocopy of this consent shall be considered as valid as the original.
Note: This clinic uses an Electronic Health Record that will update all your demographics and consents to the information
that you just provided. Please note this information will also be updated for your convenience to all our affiliated clinics
that share an electronic health record in which you have a relationship.
Release of Information.
I hereby permit practice/clinic and the physicians or other health professionals involved in the inpatient or outpatient
care to release healthcare information for purposes of treatment, payment, or healthcare operations.
• Healthcare information regarding a prior service(s) at other HCA affiliated providers may be made available to
subsequent HCA-affiliated providers to coordinate care. Healthcare information may be released to any person
or entity liable for payment on the Patient’s behalf in order to verify coverage or payment questions, or for any
other purpose related to benefit payment. Healthcare information may also be released to my employer’s
designee when the services delivered are related to a claim under worker’s compensation.
• If I am covered by Medicare or Medicaid, I authorize the release of healthcare information to the Social Security
Administration or its intermediaries or carriers for payment of a Medicare claim or to the appropriate state
agency for payment of a Medicaid claim. This information may include, without limitation, history and physical,
emergency records, laboratory reports, operative reports, physician progress notes, nurse’s notes,
consultations, psychological and/or psychiatric reports, drug and alcohol treatment and discharge summary.
• Federal and state laws may permit this facility to participate in organizations with other healthcare providers,
insurers, and/or other health care industry participants and their subcontractors in order for these individuals
and entities to share my health information with one another to accomplish goals that may include but not be
limited to: improving the accuracy and increasing the availability of my health records; decreasing the time
needed to access my information; aggregating and comparing my information for quality improvement
purposes; and such other purposes as may be permitted by law. I understand that this facility may be a member
of one or more such organizations. This consent specifically includes information concerning psychological
conditions, psychiatric conditions, intellectual disability conditions, genetic information, chemical dependency
conditions and/or infectious diseases including, but not limited to, blood borne diseases, such as HIV and AIDS.
Prescription Order Pick-up. There may be times when you need a friend or family member to pick-up a prescription
order (script) from your physician’s office. In order for us to release a prescription to your family member or friend, we will
need to have a record of their name. Prior to release of the script, your designee will need to present valid picture
identification and sign for the prescription.
•
I do want ____ (Patient/Representative Initials) to designate the following individual to pick up a
prescription order on my behalf:
o Name: __________________________________________ Date: ___________________
o Name: __________________________________________ Date: ___________________
• I do not want ____ (Patient/ Representative Initials) to designate anyone to pick-up my prescription order.
Patient/Parent/Guardian/Patient Representative Signature ___________________________ Date: _____________
Patient/Parent/Guardian/Patient Representative Name (Printed) _____________________
Patient Name (Printed): _________________________ Date of Birth: _______________________
Only If you have previously consented to receive communication via text/cellular telephone call/email and wish
to remove the consent/Opt Out/Revocation of communications via email and/or text or cellular telephone call.
In other words, I do not want my email address or cell number to be used any longer for the above mentioned
communications.
__I hereby revoke my request to receive any future appointment reminders, feedback, and general health via text.
__I hereby revoke my request to receive any future appointment reminders, feedback, and general health via cellular
telephone call.
__I hereby revoke my request to receive any future appointment reminders, feedback, and general health via email.
Patient Name: ________________________________________________________
Patient/Patient Representative Signature: _______________________________________________
Date: ____________________________ Time: ____________________
Updated: January 2018 v6 replacing 122016, 042216, 102815, 061215, 112113
A photocopy of this consent shall be considered as valid as the original.
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Welcome to the department of General Surgery at (Pinnacle Medical Group)

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Completed 1 March 2021

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