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: