Praxis Medical Group dba Family Health Associates

Praxis Medical Group
dba Family Health Associates (FHA)
Patient Information
page 1
(Informacion del Paciente)
Date (Fecha): ___________
Social Security (Seguro Social) #: _______________
Name (Nombre): _____________________________________________________________
First
Middle
Birth date (Fecha Nacimiento): __________
Male / Female
Last (Apellido)
Masculino/Femenino
Marital Status (Estado Civil): _____________
Race (Raza): ___________
Ethnicity(Etnicidad): __Latino/Hispano __Other(Otro) __Refused(Rechaza) Preferred Language(Idioma Preferido): ___________
Employer’s Name: _____________________________ Phone# _______________
Unemployed / Retired
Nombre del Empleador
Desempleado
Telefono
/
Retirado
Patient’s (Paciente)
Street Address: _____________________________ City____________________ State _____ Zip Code __________
Direccion
Ciudad
Estado
Codigo
Mailing Address: ___________________________ City____________________ State______ Zip Code ___________
Direccion de Envio
Ciudad
Estado
Codigo
Email: _________________________________ Home Phone___________________ Cell Phone__________________
Correo Electronico
Telefono de Casa
Which is your preferred phone? Home / Cell / Work
Cual es su telefono preferido?
Casa
/
Celular
Referral by(Referido Por):__________________________
Cell / Trabajo
Patient’s Identification (Identificacion del Paciente)
Driver’s License (Licencia)# _______________ State (Estado): _____
or another form of ID (otra forma de Identificacion):
What is it (Que es)? ______________________________
ID (Identificacion) # ________________________________
Guarantor’s Information (Informacion del Garantor)
Who is responsible for this account? _________________________________ Relationship to patient _______________
Ouien es responsable por esta cuenta?
Relacion al Paciente
Mailing Address: ___________________________ City____________________ State______ Zip Code ___________
Direccion de Envio
Ciudad
Estado
Codigo
Home Phone ___________________ Cell Phone _________________ Work Phone _________________ Male / Female
Telefono de Casa
Cell
De Trabajo
Masculino/Femenino
Social Security# _______________ Birth date _______________ Employed by: _______________________________
Seguro Social
Fecha de Nacimiento
Marital Status: _________________________
Nombre del Trabajo
Name of Spouse: ______________________________________
Estado Civil
Nombre del Conyuge
_______________________________________________________________________________________________________________________________________
List other family members who have been seen by FHA ____________________________________________________
Lista de otros miembros de la familia que han sido vistos por la clinica
_________________________________________________________________ Are you a veteran? ___ Yes ___ No
Es un Veterano?
Si
No
Emergency Contact (Contacto del Emergencia)
In case of emergency, who should be notified? ____________________ Relationship_________ Phone#___________
En caso de Emergencia A quien Notifican?
Relacion
Telefono
Praxis Medical Group
dba Family Health Associates (FHA)
Insurance Information (Informacion de la Aseguranza)
page 2
Do you have Medical insurance (TieneAseguranza medica)? __ Yes (Si) __ No (No)
Name of primary Insurance Company ___________________________ Employer ______________________________
Nombre de aseguaranza primaria
Empleador
Subscriber’s Name _____________________________________ SSN __________________ DOB _______________
Nombre de los suscriptores
Seguro Social
Fecha de Nacimiento
Patient’s relationship to subscriber (Relacion del Paciente al Asegurado) _______________________
Name of Secondary Insurance Company _____________________________ Employer __________________________
Nombre de la aseguranza secundaria
Empleador
Subscriber’s Name _____________________________________ SSN _________________ DOB _______________
Nombre de los suscriptores
Seguro Social
Fecha de Nacimiento
Patient’s relationship to subscriber (Relacion del Paciente al Asegurado) ________________________
Name of Pharmacy (Nombre de la farmacia) ____________________ City (Ciudad) ________________
Do you have Medicare ___ Yes
Tiene Medicare
Si
___ No Medicare# ______________ Medicare Part D Provider ________________
No
Numero
Medicare Parte D y Proveedor
Authorization for Treatment (Autorizacion para el tratamiento)
By signing below I am requesting Praxis Medical Group dba: Family Health Associates to provide health care related
treatment and consultation to the previously-named patient and that I may refuse treatment or services at any time. I
understand Praxis Medical Group dba: Family Health Associates does not guarantee any outcome for any services or
treatment either stated or implied.
Signed (Firma) _________________________________________
Date (Fecha): ___________
Relationship to patient (Relacion al Paciente): ________________________________________________________
Assignment, Release and Authorization (Asignacion y Autorizacion)
I request Praxis medical Group dba: Family Health Associates to bill my insurance and authorize payment from such
billing to be paid to Praxis Medical Group dba: Family Health Associates. I understand that I am financially
responsible for all charges whether or not paid by insurance. I authorize the release of information relevant to secure
payment of benefits on all insurance submissions to the insurer or agency shown to have responsibility whether actual
or implied.
In Medicare assigned cases, Praxis Medical Group dba: Family Health Associates agrees to accept the charge
determination of the Medicare carrier as the full payment and the patient is responsible only for deductible,
coinsurance and non-covered services. Coinsurance and the deductible are based upon the charge determination of the
Medicare carrier.
Signed (Firma)__________________________________________
Date (Fecha): ____________
Relationship to patient (Relacion al Paciente): _________________________________________________________
Praxis Medical Group
dba Family Health Associates (FHA)
page 3
My health information may be created or received by Family Health Associates and may be in the form of written or
electronic records or spoken words. My health record may include information of my health history, health status, test
results, diagnoses, treatments, procedures, prescriptions, and similar types of health related information.
I understand that I have the right to receive and review a written description of how Family Health Associates will
handle my health information. This written description is known as a Notice of Privacy Practices and describes the
uses and disclosures of health information made and the information practices followed by the employees, staff, and
other office personnel of Family Health Associates and my right regarding my health information.
I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a
copy of any revised Notice of Privacy Practices. I also understand that a copy or summary of the most current
version of Family Health Associates’ Notice of Privacy Practices in effect will be posted in the waiting/reception
area.
Patient’s Name (Nombre del Paciente) (Please Print (Imprima)) ____________________________________________________
Patient’s Signature (Firma del Paciente) ______________________________________________
Date (Fecha): __________
By signing, I agree that I have reviewed and understand the information above and that I have received a copy of the
Estoy de acuerdo con la firma que he revisado y entiendo la informacion anterior que he recibido una copia del aviso de practicas de privacidad.
Notice of Privacy Practices.
SPECIAL PERMISSION REQUEST (Solicitud de Permiso especial)
I give my permission for FHA to leave messages regarding appointments on my preferred phone message system.
Doy mi permiso a FHA a dejar mensajes con respeto a los nombramientos en mi contestador automatico.
Patient’s Signature (Firma del Paciente) __________________________________________________ Date (Fecha): _________
I give my permission to have messages regarding treatment, billing, and/or appointment status left with my
Doy permiso para que los mensajes y la facturacion con respeto al tratamiento o nombramiento sea dejado con
spouse/partner/family member/caregiver ____________________________________________
conyuge/socio/miembro de la familia/o cuidador
Patient’s Signature (Firma del Paciente) _________________________________________________ Date (Fecha): _________
This release will be revoked by written permission only.
Esta version sera revocada por autorizacion escrita solamente.
I understand that I must send a written request to FHA in order to revoke this release.
Entiendo que tengo que enviar una solicitud por escrito a FHA con el fin de revocar esta version.
Patient’s Signature (Firma del Paciente) _________________________________________________ Date (Fecha): _________