Initial Intake - New Patient
Name
*
First Name
Last Name
Patient (Date of Birth)
*
-
Month
-
Day
Year
Date
Patient's Gender
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MALE
FEMALE
Patient's Phone Number
*
Please enter a valid phone number.
Patient's Email
*
example@example.com
Patient's Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Emergency Contact Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Patient Allergies
*
Current Medications including over-the-counter medications and supplements:
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Preferred Pharmacy Name
*
Pharmacy Phone Number
*
Please enter a valid phone number.
Please describe your concern or goal for today's visit?
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Patient's Medical History
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Past Surgeries & Hospitalization including mental health, Detox and Rehabs
*
Family Medical History: Please provide any known medical conditions/diagnosis for any family members (state relationship)
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Name of last Primary Care Provider and date last seen
*
Do you see any Specialty Providers? (Cardiologist, Psychiatrist, psychotherapist, MAT clinics etc.) If yes, please list provider and clinic name below, and the date of your last visit
*
General/Constitutional:
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YES
NO
Unexplained Weight Changes
Difficulty Sleeping
Frequent Antibiotic Use
Frequent Infections
Fever/Chills
Anemia
Autoimmune Disorder
Excessive Thirst/Hunger
Fatigue
Night Sweats
NONE OF THE ABOVE
OTHER - Please List
Eyes, Ears, Nose, Throat
*
YES
NO
Glasses/Contact Lens Use
Vision Changes
Cataracts
Glaucoma
Poor Hearing
Recurring Ear Infections
Running Nose
Dental Problems
Difficulty Swallowing
NONE OF THE ABOVE
OTHER - Please List
Respiratory
*
YES
NO
Asthma - Currently
Asthma - Past
COPD
Chronic Cough
History Pneumonia or Bronchitis
History COVID-19
Shortness of Breath/Difficulty Breathing
Sleep Apnea
NONE OF THE ABOVE
Other - Please List
Cardiovascular
*
YES
NO
Chest Pain/Tightness
Palpitations
History of Heart Attack
High Blood Pressure
Heart Disease/CHF
Irregular Hearbeat
Murmur
Tachycardia
Low Blood Pressure
Dizziness on Standing
DVT/Blood Clots
Pacemaker
Bypass/Stent Placement
HIgh Cholesterol
NONE OF THE ABOVE
OTHER - Please List
Gastrointestinal
*
YES
NO
Nausea/Vomiting
Acid Reflux/Heartburn
Hernia
Ulcer, Gastric/Duodenal
H Pylori
Hypoglycemia
Eating Disorder, Anorexia/Bulimia
Constipation
Diarrhea
Hepatitis/Liver Disorder
Gallbladder Disease/Stones
HIV or Hep C
Kidney Stones
Frequent Urinary Tract Infections
Crohn's Disease or Ulcerative Colitis
NONE OF THE ABOVE
OTHER - Please List
Musculoskeletal
*
YES
NO
Joint Pain
Sciatica
Back Pain
Carpal Tunnel
Osteoarthritis
Rheumatoid Arthritis
Osteoporosis/Osteopenia
Degenerative Joint Disease
Fibromyalgia
NONE OF THE ABOVE
OTHER - Please List
Psychological/Behavioral
*
YES
NO
Excessive Guilt
Depressed Mood
Risky Behaviors
Lack of Interest/Unable to Enjoy Activities
Racing Thoughts
Impulsivity
Crying Spells
Decreased Libido
Anxiety Attacks
Avoidance
Hallucinations
Suspiciousness
Childhood Behavioral Concerns
NONE OF THE ABOVE
OTHER - Please List
Neurologic
*
YES
NO
Dementia
Memory Problems
Seizures
Head Trauma
Concussion
Vertigo/Dizziness
Neuropathy
Numbness/Tingling
Headaches
Migraines
Fainting
Tremors
Parkinson's
Stroke/CVA/TIA
NONE OF THE ABOVE
OTHER - Please List
Skin
*
YES
NO
Rashes
Hives
Easy Bleeding or Bruising
Eczema/Atopic Dermatitis
Psoriasis
New or Changed Moles
Fungal Infection Skin/Nails
NONE OF THE ABOVE
OTHER - Please List
Have you received immunization for COVID-19? If so, date of last injection.
*
Women Only
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YES
NO
Irregular Menses
PCOS
Breast Cancer
Cervical Cancer
History of Abnormal PAP
Hormone Replacement Therapy
Menopause
Hot Flashes
Hysterectomy
NONE OF THE ABOVE
Pregnancies - vaginal delivery/C-section (include dates)
OTHER - Please List
Birth Control Method
*
Last Menstrual Period
*
-
Month
-
Day
Year
Date
Are you currently pregnant of breast feeding?
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YES
NO
Men Only
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YES
NO
Prostate Cancer
Erectile Dysfunction
Prostate Concerns
Abnormal PSA
Low Testosterone
Increased Urinary Frequency
OTHER - Please List
Social History:
Marital Status:
*
Please Select
Married
Widowed
Separated
Divorced
Single
Children:
Please Select
YES
NO
, if yes how many?
Number
Employment Status:
*
Please Select
Unemployed
Part-time
Full-time
Other
Occupation:
*
How many alcoholic beverages do you consume, on average, in a week?
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None
1 - 2
3 - 4
5 or more
How many people live in your household?
What type of living space do you live in?
What is your faith?
Tell us about any legal history:
Tobacco Use
*
YES
NO
Currently
Former Smoker
Never Smoked
Cigarettes
1/2 PPD of Less
1 PPD
2 PPD
Vape
Smokeless Tobacco
Chewing Tobacco
How many alcoholic beverages do you consume, on average, in a week?
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YES
NO
None
1-2
3-4
5 or more
Substance Use
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YES
NO
Heroine/Fentanyl
Oxycodone/Percocet/Morphine/Oxycontin/Methadone
Cocaine
Illicit Benzodiazepines (Xanax or Klonopin)
Methamphetamine (Crystal Meth)
Stimulant (Adderall or Ritalin)
LSD or Hallucinogens
Marijuana - Recreational or Medical Use
Bath Salts/Ketamine/Kratom
Ecstasy
Alcohol
OTHER - Please List
Any Outpatient Treatment Centers including rehabs and inpatient detox
*
YES
NO
PHQ-9: Over the last 2 weeks, how often have you been bothered by any of the following problems? Please type your name to verify you are completing the below questions
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First Name
Last Name
0-Not at all
1-Several Days
2-More than half the days
3-Nearly Every Day
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
Trouble falling or staying asleep, or sleeping too much?
Feeling tired or having little energy?
Poor appetite or overeating?
Feeling bad about yourself or that you are a failure or have let yourself or your family down?
Trouble concentrating on things, such as reading the newspaper or watching television?
Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual?
Thoughts that you would be better off dead or hurting yourself in some way?
Total Score
Past suicide/homicide attempts?
*
YES
NO
Active thoughts of suicide or homicide?
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YES
NO
History of being abused sexually, physically, emotionally or by neglect?
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YES
NO
WellCare Medical Clinic Consent: We are committed to providing you with quality and affordable health care. Financial Agreement Our prices are representative of the usual charges for our area, and the way we determine the level of each visit charge is set by national standards. 1. Insurance: We participate in most insurance plans and will submit your claims for you. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays on your claim. You also understand & acknowledge that you are personally responsible to pay us in full for services that your health insurer will not cover due to non-payment of your health insurance premiums. It is your responsibility to assure that providers participate with your insurance panel. Knowing your insurance benefits is your responsibility. 2. Discounts: If you are not insured by a plan we do business with, payment in full is expected at each visit. We offer a cash discount on some services and lab tests if paid in full at the time the service is provided. 3. Co-payments, deductibles and non-covered services: All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. You must also pay at the time of visit for services your insurance does not cover. We accept cash, checks, and major credit cards. 4. Nonpayment: If a balance remains unpaid, we may refer your account to a collection agency. Consent for Use and Disclosure of Protected Health Information hereby give my consent for WellCare Medical Clinic to receive, use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). The Notice of Privacy Practices describes such uses and disclosures more completely. I acknowledge receiving the Notice of Privacy Practices. With this consent, WellCare Medical Clinic may call, email or mail my home, cell phone or other alternative location and leave a message in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, billing issues and any calls or letters pertaining to my clinical care, including test results, among others. I understand that email is not a secure form of communication. Before email is used extensively, I will be asked to agree to a separate email consent statement. Authorization for Treatment: I authorize treatment and accept the financial agreement, and assign WellCare Medical Clinic all of the insurance benefits due to me to the full extent of my financial obligation. When referred to a facility for a diagnostic test or health care treatment or service, I am responsible for determining the extent of coverage or the limitation on coverage, and I may receive the service at a facility of my choosing. My provider may not deny, limit or withdraw a referral solely based on my choice of facility. Consent for Use of Telehealth: You may need to have a clinic encounter using telehealth, which can be a telephone call of a video/voice call. You will be able to see and hear the provider and if using video she/he will be able to see and hear you just as if you were in the same room. This information may be used for diagnosis, treatment, therapy, follow-up and education. Expected Benefits: Improved access to care by enabling a patient to remain within the facility and obtain services from provides at distant sites. Patient remains closer to home and local healthcare providers can maintain continuity of care. Reduced need to travel for the patient or other providers. Possible Risks: A provider may determine that the telemedicine encounter is not yielding sufficient information to make an appropriate clinic decision, requiring additional in-person visit. Technology problems may delay medical evaluation and treatment of today’s encounter. Rarely, security protocols could fail, causing a breach of privacy or personal medical information. You will be notified promptly. By signing this form, I am authorizing treatment and accepting financial responsibility for all treatment provided. I am also consenting to allow WellCare Medical Clinic to receive, use and disclose my PHI to carry out treatment, payment and health care operations. A scanned copy of this document is as valid as the original.
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I Agree
I disagree
Request to Limit Confidential Communication Consent: At times our office may need to contact you regarding your care. Please read, sign, and date below. You have the right to revoke this authorization at any time. I hereby authorize WellCare Medical Clinic and their staff to contact me on my preferred contact number, email, or mail listed on file. I hereby authorize WellCare Medical Clinic and their staff to leave a detailed VM on my preferred contact number. I will contact the office to notify of any changes to my preferred contact information.
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I Agree
I disagree
Appointment Cancel, Late Arrival and No Show Policy: New Patients: All forms must be completed prior to your appointment. If you have not completed the Intake Form online, please arrive 15 minutes before your scheduled appointment and bring in a photo ID and all insurance cards. Late Arrival: We encourage you to show up 5 - 10 minutes prior to your appointment. If you are 15 minutes or more later than your scheduled time, your appointment may be canceled or rescheduled. No Shows: Our policy at WellCare Medical Clinic for services rendered here is that all patients notify us 24 hours prior to their appointment if cancellation is necessary. If you have two no-shows in six months, you will be notified by text message and email. Your care may be terminated if you have three no-shows in a year.
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I Agree
I disagree
Authorization to Receive Appointment Text Reminders: Do you wish to receive appointment reminders via text message, automated phone call and via email?
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I Agree
I disagree
WellCare Medical Clinic - Notice of Privacy Practices: This notice describes how health information about you may be used and disclosed and how you can get access to your individually identifiable health information. Please review this notice carefully. Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you, and we must let you know how we may use and disclose your PHI, your privacy rights in your PHI, and our obligations concerning the use and disclosure of your PHI. The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices, and any revision or amendment will be effective for all of your records that we create or maintain. You may request a copy of our most current Notice at any time. If you have questions about this Notice, please contact any of our team members. We may use and disclose your PHI in the following ways: 1. Treatment. The people who work for our practice may use or disclose your PHI in order to treat you or to assist others in your treatment. We may also disclose your PHI to others who may assist in your care, such as your spouse, children or parents, and we may disclose your PHI to other health care providers and pharmacies for purposes related to your treatment. 2. Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us, and we may disclose your PHI to other entities to assist in their billing and collection efforts. If you choose to pay the full charge out-of-pocket you have the right to restrict your health plan's access to certain information. 3. Health care operations. Our practice may use and disclose your PHI to operate our business such as in quality of care and business planning activities and we may disclose your PHI to other entities to assist in their health care operations. 4. Disclosures required by law. Our practice will use and disclose your PHI when we are required to do so by law. 5. Use and disclosure of your PHI in certain special circumstances to entities authorized by law to collect it: Our practice may disclose your PHI to public health authorities, health oversight agencies, law enforcement officials, and workers' compensation and similar programs. We may also disclose your PHI in response to a court or administrative order, or when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public, or for intelligence and national security activities. 6. Your rights regarding your PHI: You have the following rights regarding the PHI that we maintain about you. Confidential communications: You have the right to request in writing that our practice communicate with you about your health and related issues in a particular manner or at a certain location. Our practice will try to accommodate reasonable requests. Requesting restrictions: You have the right to request in writing a restriction in our use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. Inspection and copies: You have the right to inspect and obtain an electronic copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy and SOAP notes. You must submit your request to inspect and/or obtain a copy of your PHI in writing to us. Copies to others: You may request in writing a that we share your pH I with other types of third parties, such as employers. We will not share your PHI with these other types of third parties without your written consent. Amendment: You may ask us in writing to amend your health information if you believe it is incorrect or incomplete. Accounting of disclosures: You have the right to request in writing an "accounting of disclosures." An "accounting of disclosures" is a list of certain non-routine disclosures our practice has made of your PHI for purposes not related to treatment, payment, or operations. Use of your PHI as part of our routine patient care is not required to be documented. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint in writing with our practice or with the Offices for Civil Rights - U.S. Dept of Health and Human Services. You will not be penalized for filing a complaint. 1. Right to provide an authorization for other uses and disclosures: Our practice will obtain your written authorization for uses and disclosures for marketing or sale, or that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. 2. Right to notification: You have the right to receive notifications whenever a breach of your unsecured PHI occurs. Again, if you have any questions regarding this notice or our health information privacy policies, please let us know. You may also request a more detailed version of this notice which includes examples of uses and disclosures, and further details about making written submissions.
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I Agree
I disagree
HIPAA INFORMATION and CONSENT FORM: The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov. We have adopted the following policies: 1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information. 2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative. 3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA. 4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties. 5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or healthcare provider. 6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services. 7. We agree to provide patients with access to their records in accordance with state and federal laws. 8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.
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I Agree
I disagree
CRISP is the State Designated Health Information Exchange (HIE) for Maryland. WellCareMedical Clinic uses different services of CRISP such as PDMP for medications and medical health updates and history. I understand and gives permission to WellCare Medical Clinic to utilize these services for my medical and medication history.
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I Agree
I Disagree
Appointment Followups: Each patient is responsible for scheduling his/her follow up appointment to go over the treatment as discussed in the previous(initial) visit such as lab results, radiology results, correspondence, etc. WellCare Medical Clinic is not responsible to call patients for follow-up visits to review lab results, radiology results, correspondence, treatment follow-ups, etc. WellCare Medical Clinic will offer to schedule a follow-up visit at the end of each visit, but ultimately it is the patient’s responsibility to make and follow through with all appointments for continuity of care.
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I Agree
I Disagree
Unpaid Visits: If the office has two or more unpaid visits by the insurance company, then the patient’s services will be terminated with the clinic. Patients will be notified via email, call, or letter in the mail.
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I Agree
I Disagree
Patient's Name:
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First Name
Last Name
Date
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Month
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Day
Year
Date
Submit
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