Personal Health Screen Form NHIMA Patient Name_ Age

Today's Date_ Date of Birth

Date of Last Exam

PAST MEDICAL OR CHRONIC ILLNESSES *Please Circle or Check Neatly* Skin Acne Eczema Psoriasis Skin Cancer Eyes, Ears, Nose, Throat Cataracts Glaucoma Loss of Vision Loss of Hearing Vertigo Tinnitus Hay fever Sinus Infection Hoarseness Polyps

Lungs Asthma Sleep Apnea Emphysema Chronic Bronchitis

Cardiac/Blood High Blood Pressure Irregular Heart Beat Swelling on Ankles/Legs

Varicose Veins Heart Attack Pacemaker Anemia Blood Transfusion (When): DVT(blood clots) Endocrine Diabetes Thyroid Disease Obesity Form B

Gastrointestinal Acid Reflux Hepatitis Irritable Bowel Disease Chronic Constipation Chronic Diarrhea Hemorrhoids Fatty Liver Disease Gallstones Stomach Ulcers Diverticulitis Colon Polyps

Urinary Chronic Kidney Disease Kidney Stones Urinary Incontinence

Neurologic/Brain ADD ADHD Anxiety Depression Migraine Headaches Sciatica Parkinsons Disease Multiple Sclerosis Seizure Disorder Anorexia/Bulimia Stroke Other: Men Only Enlarged Prostate Impotence Infertility Genital Herpes Genital Warts Prostate Cancer STD's(WhatKind):_

Immune Allergies Chronic Fatigue Hepatitis HIV Disease Lupus Rheumatoid Arthritis Lyme's Infection Mononucleosis Tuberculosis Cancer {What Kind):_

IVIuscle/Joint/Bone Arthritis Gout History of Fractures Fibromyalgia Osteoporosis/Osteopenia

Women Only PMS Extreme Menstrual Pain Irregular Menses Endometriosis Uterine Fibroids PCOS Infertility Genital Herpes Genital Warts Ovarian Cysts Breast Cysts Breast Cancer (When): Hysterectomy (When): Abnormal PAPs (When):_

Other medical illness you have had not listed here:

All information is strictly confidential

H^H Relation

Age

State of Health

Age of Death

Cause of Death

Check if your relatives have any of the following and what relationship to you, (eg. Aunt/Uncle etc.):

Father

Disease Arthritis, Gout

Mother

Asthma,

Mother's Side

Father's Side

Cancers Chemical Dependency Diabetes

Brothers

Heart Disease Stroke High Blood Pressure Kidney Disease Thyroid Disease

Sisters

Mental health disorder Other

Year

Hospitalization/Surgery Hospital Reason for hospitalization

List of medications currently taking:

Year

M/F

Pregnancy History Complications if any

List of supplements currently taking:

__ _ Who lives with you? Are you: (please circle the following) » Married Single Divorced Living together How many Children do you have? _ Do you drink? (please circle the following) • Water Coffee Alcohol o If so, how much per week? Do you smoke now? Yes No . If so, how long does a pack last you? If not smoking now, did you smoke in past? Yes No . How many years did you smoke?_ o When did you quit smoking? Do you exercise? Yes / No If yes, How long and how many times/ week? What kind of work Qob) do you do? Education: (please circle the following) Military (what branch) Grade School High School College

Shingles Vaccine

PPD(TB Test) Result: + or -

Tetanus

Hepatitis B

Hepatitis A

Pneumovax

Flu

HIV Test

Gardisil Vaccine

Colonoscopy

EKG

Vision/Eye Exam

Hearing Screen

Dental Check Up

Bone Density Test Mammogram

PAP Smear

Other:

'NUTRITION SCREEN

Breakfast:. AM Snack: Lunch: PM Snack: Dinner: Night Snack:

How many times do you eat out per week_

Printed Name:

. Signature of Patient:.

Date

NORTH HILLS INTEGRATWE MEDICINE ASSOCIATES

APPOINTMENT POLICY

We allocate our time to provide the care and attention our patients need. It is imperative that you give us no less than 24 hour notice by phone of an appointment cancellation so that we can provide that time to another patient. We will charge your account a $75 for less than a 24 hour notice or a missed appointment. Patients that have missed two scheduled appointments without appropriate notice must contact the Office Manager prior to future appointments. Patients with an account in arrears must contact the Office Manager prior to future appointments.

I have read this policy.

Signature

Patient/Parent/Guardian

4040 Barrett Drive, Raleigh, NC 27609

Date

NORTH HILLS INTEGRATIVE MEDICINE ASSOCIATES

Consent for medical treatment I hereby authorize North Hills Integrative Medicine Associates (NHIMA) to provide and administer diagnostic laboratory and X-Ray tests, medications and treatments as ordered by the physician. Signature of Patient / Parent or Legal guardian(if a minor)

Relationship

Authorization to release Medical Information I authorize that my medical information can be left on my answering machine at home. DYes D No I authorize that my medical information can be left on my voice mail at work. DYes DNo

I want to contacted by: Home

Work

Mail

Signature

Email Date

Patient/ Legal Guardian/Parent

Relationship

4040 BARRETTDRIVE RALEIGH, NC 27609, 919-783-5300

Date

NHIMA - NORTH HILLS INTEGRATIVE ASSOCIATES PATIENT INFORMATION Date Name

Soc. Sec#

Date of Birth

Apt.

Address City, State

Zip Code

Cell Phone

Telephone

E-Mail Address

Marital Status

EMPLOYER INFORMATION Employer_

Patient Occupation

Employer address

City, State

Zip Code_ Fax

Ext

Telephone

FINANCIALLY RESPONSIBLE PERSON (IF OTHER THAN PATIENTS Relationship

Name Address

f

City, State_

Phone#

FINANCIAL RESPONSIBLE EMPLOYER INFORMATION Employer

Employer Address

City, State,

Zip Code

Phone#

Name

EMERGENCY CONTACT Relationship _

Home Phone

Bus Phone#

Cell#

INSURANCE INFORMATION Subscriber Name & Date of Birth_ Address

Primary Ins. Carrier

.Grp#_

ID#

Effective Date Plan#

Soc Sec#

^Secondary Ins Carrier_

Grp#_ ASSIGNMENT & RELEASE OF INFORMATION STATEMENTS

I hereby authorize and direct NHIMA having treated me, to release to government agencies, insurance carriers or others who are financially liable for my hospitalization and/or medical care, all information needed to substantiate payment for such services rendered during my care and to permit representatives thereof to examine and make copies of all records related to such care and treatment. These agencies will be expected to maintain my confidentiality in accordance with standard practices. I hereby assign, transfer and set over to the above named Medical group sufficient monies and/or benefits to which I may be entitled from government agencies, insurance carriers or other who are financially liable for my medical care to cover the cost of such care and treatment rendered to me or my dependents by assignment

Names of Patient /Authorized Representative

Patient (Representative) Signature

Date

MORTH HILLS JISiTECRATIVE MEOICIME ASSOCIATES FINANCIAL POLICY Thank you for choosing us as your health care provider. We are committed to giving you the best care available. We hope the following will answer any questions you may have about oair insurance and billing procedures and policies in relation to yoor appointment and procedures, Insurance: Your insurance policy is a contract between you and your insurance company. We are not a part of that contract- We cannot guarantee to you mat your insurance will pay all, or any part, of your claim. It is your responsibility to verify with your insurance company, prior to treatment, your policy., coverage, benefits, and any deductible and/or co-insurance responsibilities. If your insurance company denies payment of your claim, you should contract your insurance company directly. If your company denies, or only pays a portion of your claim, please understand that you are personally and fuliy responsible for your total outstanding account balance(s). We will allow your insurance company a period of sixty (60) days to pay your insurance claim. If they have not paid by the 61 ** day, you will be held entirely responsible for any balance due, and you will be billed accordingly. Dissatisfaction with your insurance company does not constitute reason to withhold pajireient of your account with North Hills Integrative Medicine Associates. We do accept assignment of your benefits, however, please be aware that some or all of the services provided may be a non-covered service under your plan. You will be responsible for these non-covered charges. It is your responsibih'ty to: > Ensure that we actively participate with your insurance carrier/plan > Know your benefit coverage > Ensure that all pre-approval requirements are met to avoid denials or out-of-network benefits. Please remember that we must receive your billing information at the time of each visit in order to meet claims submission guidelines set by your insurance plan. If either the practice or the plan fails to receive accurate information necessary to process your claim, you will be held responsible. We must have a copy of your current insurance card to file for you or your family member. If you do not have your insurance card, we will ask for payment in full at the time of visit. Regarding insurance plans where we are a participating provider, all co-pays, deductibles and co-insurance are due at the time of treatment. In the event that your insurance coverage relates to a plan where we are not a participating provider, you will be 100% responsible for all charges incurred. In summary, your financial responsibility pertains to: > Denied and Non-covered services > Services deemed not medically necessary by your insxarance company > Co-payments, deductibles, co-insurance > Pending claims due to lack of patient and/or guarantor information > Non-insurance and/or out of network benefit > Self pay patients must pay in mil at time of service. Please be advised that you may receive a separate bill for Lab services. This is dependent upon your insurance benefits. Esrimates: Please remember that any charges you were provided when you scheduled your procedure were ESTIMATES only. Due to medical evaluation required for your complaints, we have no way of stating exactly what the charges will be prior to a visit, Collections: Any past due balances not paid may be turned over to a collection agency after 90 days. We accept all credit cards, cash,, money orders and checks. A service charge of $25.00 will be applied to your account for all returned checks or any stopped payment on an issued check, Refunds: It is our policy to not issue refunds unless your account has a credit balance and all claims have been paidMissed Appointments: Please provide us with a 24 hour notice of cancellation so that we mayviitilize our schedule to provide better patient care. If you don't offer at least 24 hours advance notice, we may charge you a $75.00 missed appointment fee. This charge will not be billed to your insurance company. Authorization: I agree to be responsible for any medical expenses incurred with NHIMA, therefore., I authorize my insurance company, attorney., or other parties to pay directly to NHIMA, and/or provide any information regarding payment of my bill. I have read, understood, and agreed to the financial policy stated above and I accept responsibility for any balance not covered by my insurance company. X

Signature of Patient or Responsible Party

Date:

North Hills Integrative Medicine Associates

RECEIVE YOUR LABS ELECTRONICALLY!

It's easy. Just fill out the information below and return to the front desk. We'll send you and email invite with all the information you need to set up your secure account.

This allows you to securely receive copies of certain lab results using the internet. We've partnered with Lab Corp and Relay Health to help keep you healthier and better informed.

EMAIL ADDRESS: NAME: DOCTOR: D. Sutherland-Phillips MD

DATE: