Colorado Fibromyalgia Center At South Pointe Healthcare

Colorado Fibromyalgia Center

At South Pointe Healthcare
** Items Necessary For Your Visit **

- Current Valid Photo ID

- Current Valid Insurance Card

- Updated Medication List (If You Do Not Know What You Take, Bring The Bottles, And We'll Help You Make A Current Medication List)

- Facial Mask Required To Be Worn Throught Entire Appointment
Name: *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate:
S.S. #:
Home Phone:
Cell Phone:*
Email:*
example@example.com
Gender:
Marital Status:
How did you hear about us?:*
How did you hear about us?*

GoogleFriend / FamilyDoctor ReferralInsurance CompanyFibromyalgia Group (Facebook or other community group)
Referring Doctor / Provider Name*
Pharmacy of Choice (Name & Address):

NameAddress
Primary Care Physician Name:*
Primary Care Physician Phone #:

Insurance And Responsible Party Information

Part I
Check this Box if you are a Self-pay patient that is not using Insurance:

I am a self-pay patient who is not using insurance.
Insurance Information:
Secondary Insurance Information:
Uninsured Patient Provider Agreement

Please fill out if you are not using insurance.
Patient Name:

First NameLast Name
Date of Birth:
MM/DD/YYYY
I confirm that I DO NOT have any Government issued or Commercial insurance.
Initial Per Government guidelines and our contractual agreement with the insurance
Companies, South Pointe Healthcare must bill insurances before accepting self-pay
Initials*
I understand that if I withhold any active insurance information I may be discharged or reported for fraud
Initials*
I understand that all payments for services rendered are due at the time of my
Initial appointment or my appointment may be rescheduled.
Initials*
Signature of Patient or Personal Representative:*

Clear
Date:
MM/DD/YYYY
Name of Patient or Personal Representative:

First NameLast NameMM/DD/YYYY

Consent And Understanding

Part II
This consent is required by the Health Insurance Portability and Accountability Act of 1996 to inform you of your rights for privacy with respect to your health care information.

Consent Related to Privacy Notice:

I have had a chance to review the Practice Privacy Notice as part of this registration process. I understand that the terms of the Privacy Notice may change and I may obtain these revised notices by contacting the practice by phone or in writing. I understand I have the right to request how my protected health information (PHI) has been disclosed. I also have the right to restrict how this information is disclosed, but this practice is not required to agree to my restrictions. If it does agree to my restrictions on PHI use, it is bound by that agreement.

Consent for Care:

I, with my signature, authorize South Pointe Healthcare, and any employee working under the direction of the physician, to provide medical care for me, or to this patient for which I am the legal guardian. This medical care may include services and supplies related to my health (or the identified person) and may include (but not limited to) preventative, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body and the sale or dispensing of drugs, devices, equipment or other items required and in accordance with a prescription. This consent includes contact and discussion with other health care professionals for care and treatment.
By Signing this I agree that I have read and understand the Consents as stated above:*

Clear
Date:
MM/DD/YYYY
Patient Name If Different From Responsible Party:

First NameLast Name

General Information

Part III
What is your Occupation?:
Does the onset of your symptoms effect your ability to perform your job duties?
Amount of Children:
# children:
Do your symptoms have an effect on your Children/Family?:
What are the top three symptoms that you would like to focus on most to try and help improve your quality of life?:
How much have your symptoms decreased your overall function?:
When did you first start to notice your symptoms? (Approx. Year):
What Stresses (physical, mental and/or emotional) were occurring in your life when your symptoms began (IE: Injury, Illness, Life Event)?:
Have you had chronic, widespread pain for more than three months in all four quadrants of the body and axial pain? (IE: above and below the waist, and on both sides of the body. Headaches or pain around the spine or chest.) These sources of pain do not all have to be at the same time.

YesNo

Medical History / Information

Part IV
Please Attach A List If There Are More Medications:

Browse Files

Cancelof
Allergy:
Reaction:
Family History

Part V
Mother:

LivingDeceased
Relevant Health History:
Cause of Death:
Father:

LivingDeceased
Relevant Health History:
Cause of Death:
Sibling:

LivingDeceased
Relevant Health History:
Cause of Death:

Psychological Health

Part X
Compared to your colleagues or friends, do you consider yourself happier than most of them?

YesNo
How often do you feel lonely?
How often do you feel depressed?
How often do you experience anxiety?
I am content with the current state of my life.
Currently, I don’t need to worry about the finances in my life.
I am satisfied with my life.
I am happy with the relationships in my life.
I am happy with my professional life.
If I could get my pain under control, my life would be wonderful.
Do you have any other concerns that you would like to mention? (Please write below about your experiences with Fibromyalgia or Chronic Fatigue Syndrome illness. Such as, How does this effect your life? Your mental and emotional state?

Emergency Contacts

Part XI
Emergency Contact Name:*

First NameLast Name
Emergency Contact Phone Number:*
Emergency Contact Address:
Next of Kin Name:*

First NameLast Name
Next of Kin Phone Number:*
Next of Kin Address:

HIPAA Release Form

Part XII
I, First Name Last Name give my permission for South Pointe Healthcare, South Pointe Physical Rehab, and/or Colorado Fibromyalgia Clinic, to release the information listed in Section II of this document with the person(s) or organization(s) I have specified in Section II of this document.
Section II:
I would like to give the above healthcare organization permission to:
Check off as appropriate:
I do not wish to disclose any of my health information.ONLY Disclose the following (fill in after selection):Disclose my complete health record including, but not limited to, diagnoses, lab test results, treatment, and billing records for all conditions.Disclose my complete health record EXCEPT for the following information (fill in after selection):
Only disclose the following: List here
Disclose my complete health record except the following: List here
Who Can Receive My Health Information:
I give authorization for the health information detailed in section II of this document to be shared with the following individual(s) or organization(s)
Full Name(s) :     Phone number:   Area Code   Phone Number
Organization(s) or relationship to patient:

I understand that the person(s)/organization(s) listed above may not be covered by state/federal rules governing privacy and security of data and may be permitted to further share the information that is provided to them. I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to:
Name: _South Pointe Healthcare:
Address: 150 Old Laramie Trail suite 210, Lafayette, CO. 80026

In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data.

I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.

Please not that South Pointe Healthcare's email address has changed. All emails received will be forwarded to "frontdesk@southpointehealthcare.com".

Name:   First Name   Last Name   Date:   Date
Signature

Clear
If this form is being completed by a person with legal authority to act an individual’s behalf, such as a parent or legal guardian of a minor or health care agent, please complete the following information:
Name of person completing this form: First Name Last Name
Signature

Clear

Financial Policy

Part XIII
Patient Responsibility: Patient understands that it is his/her obligation to know his/her insurance requirements and ensure that they have been fulfilled, including having a valid authorization for service in place prior to his/her Medical services South Pointe Healthcare will check for eligibility as a courtesy, however this is not a guarantee of payment/coverage by the insurance company. Insurances that fail to pay for claims filed, regardless of the reasoning, will lead to the Patient and/or Guarantor being responsible for payment of the remaining uncovered charges. Insurance has to be present and active at the time of service, along with a valid U.S issued photo identification. If insurance information is presented after treatment we will file a claim to your insurance company on your behalf. However, you will be held liable for the charges if the insurance denies the claim because of late presentation of coverage or for lack of timely authorization due to late presentation of coverage.

Insurance Payments: We participate with most insurance plans in the area. Some services may not be covered by your insurance policy. Your insurance coverage is a contract between you and your insurance plan. Co-payment, deductibles, co-insurances and services are not covered by your insurance plan or outstanding balances are all patient's responsibility to pay in full.

Co-Payments are due at the time of service: It is your contractual obligation with you insurance company to pay the copay portion of the visit at time of service. Patients unable to pay their copay, will have their appointment rescheduled.

Missed Appointments: We charge a $50.00 fee for any office appointments missed or cancelled under 24 hour's notice. Late appointments and same day reschedules are considered missed appointments and are subjected to a missed appointment fee. These fees are patient responsibility and will not be submitted through insurance or liens.

Medical Records: We offer patient free electronic records via a secure email. You will be subjected to a fee for any printed records. We wll fax all records for free to any Physician's office or other medical facility as a courtesy. A signed HIPAA authorization will be required to send your records to any third party requester.

Past Due Balances: After 90 days your account will be considered past due and can be turned over to a third-party collection agency. If it becomes necessary to turn your account over to a third-party collection agency due to your non-payment you will be dismissed from the practice. We ask that you handle any outstanding balances within 90 days. Please reach out to our billing department or Practice Manager for needed payment arrangements.

Self-Pay: Patients who are not billing a third party or health insurance must pay in full at the time of service.

Your signature on this page constitutes as an acknowledgement and understanding of this policy.

I have read and agree to the above policies and authorize payment directly to South Pointe Healthcare.
Date: Date
Signature*

Clear
Should be Empty:

	Check box if treatment helped	Year
Stroke
Multiple Sclerosis
Glaucoma
Lupis
Heart Attack
Heart Issues
Diabetes
Emphysema
Hypoglycemia
Rheumatoid Arthrits
Osteoarthritis
Hypothyroidism
Hyperthyroidism
Asthma
Blood Pressure Issues
I. B. S.
Crohn's Disease
Cirrhosis of Liveer
Kidney Failure
Mononucleosis
Hepatitis

	Yes / No	Year	Did Treatment Help?	Details Provider Should Know
Pain Management
Rheumatology
Chiropractor
Neurologist
Naturopathic Doctor
Nutritionist
Physical Therapy

	Yes or No ?	Amount per Day ?
Coffee
Tea
Juice
Regular Soda
Diet Soda
Water
Milk (Whole)
Milk (2%)
Milk (1%)
Milk (Nonfat)
Alcohol

Colorado Fibromyalgia Center

Insurance And Responsible Party Information

Uninsured Patient Provider Agreement

Consent And Understanding

General Information

Medical History / Information

Family History

Social History

For Females

For Males

Pain & Energy Levels

Nutrition and Health Habits

Psychological Health

Emergency Contacts

HIPAA Release Form

Financial Policy