Patient Registration - University Internal Medicine

REGISTRATION

The patient claims there are no changes to their current demographic information.

Print their demographic sheet from Cerner and have them verify their information.

MRN*

MRN is required so Formstack can send all data to Cerner

FIN (Visit Encounter)*

FIN is required so Formstack can send all data to Cerner

Appointment Date

Save & Complete Registration Later

Click the box to save and hold submission in the Formstack queue to finish at a later date

Result Date

Result Time

:

University Internal Medicine Visit Information

Office Location

Patient Name*

First Name

Initial (optional)

Last Name

Date of Birth*

SSN

Social Security Number

Who is filling out this form?*

Patient Spouse Parent Child Authorized Patient Representative

Your Name*

First Name

Last Name

Your Phone Number*

Visit Type*

New Patient Annual Wellness Visit (Yearly Physical) Sick Visit Follow-up Appointment

Other:

Reason for your visit?*

List in order of importance to you

In the past 3 years, have you been seen by a physician at the University Internal Medicine Office?*

Yes No I'm not sure

Has any of your personal information changed since your last visit?*

Yes No I'm not sure

Example: Insurance info, Address, Phone Number, etc.

Do you have any Allergies?*

Yes No

Please list all know allergies and associated reaction*

Please list all prescription and ‘over the counter’ medications you are currently taking

Pharmacy Name

Pharmacy Phone

COVID-19 Screening Questionnaire

Have you recently been exposed to COVID-19?*

Yes No I'm Not Sure

Are you experiencing any symptoms of COVID-19?*

Yes No I'm Not Sure

Have you been tested for COVID-19 in the past 2 weeks?*

Yes No

Where were you tested?*

Date of Test*

Results of COVID-19 Test*

Positive for COVID-19 Negative for COVID-19 Test Results Pending I never received the results

Patient Demographics

Birth Gender*

Male Female

Gender Identity

Male Female

Other:

Home Address*

Address Line 1

City

State

ZIP Code

Primary Phone number*

Phone Type (Primary)*

Cell Phone Home Phone Work Phone

Secondary Phone Number

Phone Type (Secondary)

Cell Phone Home Phone Work Phone

Email

Race

American Indian / Alaska Native Asian Black / African American Native Hawaiian / Pacific Islander White Decline to Answer

Ethnic Group

Hispanic / Latino Not Hispanic / Latino Decline to Answer

Employment Status

Employed Retired Student Unemployed Disabled Active Military Duty

Employer

Occupation (past or present)

Marital Status*

Single Married Legally Separated Divorced Widowed

Do you have Healthcare Insurance?*

Yes No

Self

Spouse's Information

Spouse's Name*

First Name

Middle Name (optional)

Last Name

Spouse's Date of Birth*

Spouse's SSN

Social Security Number

Address

Address Line 1

City

State

ZIP Code

Spouse's Phone Number*

Spouse's Phone Type*

Cell Phone Home Phone Work Phone

Spouse's Employment Status

Employed Retired Student Unemployed Disabled Active Military Duty

Spouse's Employer

Spouse

Responsible Party / Guarantor of Payment

This is the person who will be responsible for any payment owed to the medical practice

Guarantor's Name

First Name

Middle Name (optional)

Last Name

Relationship to Patient

Guarantor's Date of Birth

Guarantor's SSN

Social Security Number

Guarantor's Email Address

Guarantor's Address

Address Line 1

City

State

ZIP Code

Guarantor's Phone Number

Guarantor's Phone Type

Cell Phone Home Phone Work Phone

Guarantor's Employment Status

Employed Unemployed/Disabled Student Retired

Guarantor's Employer

Emergency Contact Outside The Home

Contact Name*

First Name

Middle Name (optional)

Last Name

Relationship to Patient*

Contact Phone Number*

Contact Phone Type*

Cell Phone Home Phone Work Phone

Primary Insurance Information

Policy Holder Name*

First Name

Middle Name (optional)

Last Name

Relationship To Insurance Policy Holder*

Policy Holder Date of Birth*

Policy Holder SSN*

Social Security Number

Primary Insurance Provider

Name of Insurance Company

Insurance Member ID

Group Number

Insurance Claims Address

Address Line 1

Address Line 2

City

State

ZIP Code

Photo of Insurance Card - Front Side

No File Chosen

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Photo of Insurance Card - Back Side

No File Chosen

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Do You Have Secondary Insurance?*

Yes No

Secondary Insurance Information

Policy Holder Name*

First Name

Middle Name (optional)

Last Name

Relationship To Insurance Policy Holder*

Policy Holder Date of Birth*

Policy Holder SSN

Social Security Number

Secondary Insurance Provider*

Name of Insurance Company

Insurance Member ID*

Group Number

Insurance Claims Address

Address Line 1

Address Line 2

City

State

ZIP Code

Photo of Insurance Card - Front Side

No File Chosen

File uploads may not work on some mobile devices.

Photo of Insurance Card - Back Side

No File Chosen

File uploads may not work on some mobile devices.

AUTHORIZATION TO RELEASE INFORMATION AND PAY BENEFITS TO PHYSICIAN

I hereby authorized the physician to release any information acquired in the course of my treatment necessary to process insurance claims. I also authorize payment directly to the Physician for the surgical and/or medical benefits, if any, otherwise payable to me for his/her services as described, realizing I am responsible to pay non-covered charges.

Signature*

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Date/Time*

:

Insurance Payment Policy

Thank you for choosing us for your healthcare needs. We commit to provide you with quality and affordable healthcare. Please read this Policy. Ask us any questions you may have. A copy of this can be given to you upon asking.

Insurance Plans. Our providers accept Medicare and most major plans. If you are not insured by a plan we contract with, you must pay in full at each visit. If you are insured by a plan we contract with, but do not have a current insurance card, you must pay in full for each visit until you give us a current copy of your insurance. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions that you may have about your coverage.

Co-payments. All co-pays must be paid at the time of service.

Non-Covered Services. Please be aware that some of the services you receive may not be covered or considered reasonable or necessary by your insurance. Our office will file each visit with your insurance company. If your insurance company determines a service is not reasonable or necessary, we ask that you pay for that item right away.

Proof of Insurance. All patients must complete our patient information form before seeing a doctor. We will also ask that you complete this form once a year. You must give us a copy of your current valid insurance card to provide proof of insurance. If you do not provide us with the correct information in a timely manner, you may need to pay the balance of the claim.

Claim Submission. We will submit your claims and help you in any way we can, within reason, to help get your claims paid. Your insurance company may need you to supply them with certain information. It is your responsibility to fill their requests. Please be aware that the balance of your claim is your responsibility. This includes whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company. If your insurance company does not pay your claim in 45 days, the balance will be billed to you. If you have Medicare, we will bill you for any money owed after we receive the payment from Medicare and/or a secondary policy that you might have.

Coverage Changes. If your insurance changes, please let us know before your next visit. We will make the changes to help you receive your maximum benefits. We will also need a copy of your new insurance card.

Non-payment. If your account is over 90 days past due, you will get a letter from our billing department. Partial payments will not be accepted, unless otherwise stated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency.

Our practice is committed to providing the best treatment to our patients. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.

I have read and understand the payment policy. I agree to follow its guidelines.

Signature*

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Date/Time*

:

Patient Privacy Questionnaire

May we leave messages about your healthcare and treatment on your voicemail or answering machine when you are not available?*

Yes; may leave messages as specified below May leave messages with a call back number only No messages; Only leave information with me

What is your preferred contact phone number?*

Primary Phone Number Secondary Phone Number Other Phone

Please make sure that you provided your phone number in the designated field in the "Patient Demographics" section above

Other Preferred Phone Number*

May leave messages about appointment schedule and reminders*

On my voicemail or answering machine With a call back number only Only with me (no message)

May leave messages about lab & test results*

On my voicemail or answering machine With a call back number only Only with me (no message)

May leave messages about billing & payment information*

On my voicemail or answering machine With a call back number only Only with me (no message)

May leave messages with questions & general information*

On my voicemail or answering machine With a call back number only Only with me (no message)

Is there another person that we may contact to talk about your healthcare and treatment?*

Yes No: Only leave information with me

Please list anyone that we may contact to get or disclose personal information on your behalf.

Authorized Person #1*

First Name

Last Name

Phone Number*

Person #1

Relationship*

Person #1

May leave appointment reminders with the person above May discuss lab / test results with the person above May discuss billing information with the person above May leave questions and information with the person above I prefer that all healthcare messages be given to the person above

Authorized Person #2

First Name

Last Name

Phone Number

Person #2

Relationship

Person #2

May leave appointment reminders with the person above May discuss lab / test results with the person above May discuss billing information with the person above May leave questions and information with the person above I prefer that all healthcare messages be given to the person above

Patient Privacy Disclosure Information

You may obtain a copy of the University Health Systems (UHS) Notice of Information Practices at any time by clicking here, calling (865) 305-9118, or by requesting one at the UHS or UHSV office. This document describes how your health information maybe used or disclosed by UHS, UHSV Facilities and it should read it carefully. Be aware that this document may be changed at any time.

If we are not able to reach you by telephone, we will send information through the U.S. Postal Service to your home address. We keep a record of each of your visits to this practice. This record may include your test results, diagnosis, medications, and your response to medications or other therapies. This allows your doctors and other clinical staff to provide proper care to meet your medical needs. The information in your record is called protected health information. We may disclose your protected health information to other healthcare providers or beings involved in your care.

I understand that my protected health information may be used to manage my treatment as stated above. I have been offered a copy of the University Health System, Inc. (UHS) Notice of Information Practices. I understand that this Notice describes how my health information may be used or disclosed by this practice, UHS, UHS Ventures Inc. (UHSV), doctors, and other providers that practice at UHS or UHSV facilities. I should read it carefully. I am aware that the Notice may be changed at any time.

By giving my home phone number, cell phone number, email address, and any other personal contact information, I authorize my health care provider to employ a third-party automated outreach and messaging system. The system will use my contact information, the name of my care provider, and other limited information, for the purpose of letting me know of balances due, when needed.

Patient Signature*

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Date/Time*

:

Past Medical History

The information you provide today is very important in regards to your healthcare.

Please answer the following questions carefully and thoroughly to the best of your ability.

Please list any other physicians that your are currently seeing

Do you see any of the following

Chiropractor Massage Therapist Cognitive Therapist Faith Healer Practitioner of Homeopathy

Other:

Check all that apply

Please list any hospitalizations with associated dates for medical and surgical problems, including childbirth

Menstrual History

Date of last PAP/pelvic exam

Where was this performed?

Have you ever had an abnormal pap smear?

Yes No

When was your last abnormal pap smear?

Date of last period?

Do you have irregular menstrual bleeding?

Yes No

Do you have painful periods?

Yes No

Do you have vaginal discharge?

Yes No

Have you been through menopause yet?

Yes No

Have you had bleeding after Menopause?

Yes No

Number of pregnancies

Number of live births

Number of living biological children

Have you had a Hysterectomy?

Yes No Partial

When was your hysterectomy?

Reason for the Hysterectomy?

Do you still have your ovaries

Yes No I don't know

Date of last mammogram

Do you perform monthly self-breast exams?

Yes No Sometimes

Do you have any new breast problems?

Breast Lumps Nipple Discharge Pain N/A

Other:

Vaccinations

Do you get a yearly Flu shot?*

Yes No Sometimes

When was your last Tetanus Shot?

Have you had the pneumonia vaccine?*

Yes No

Year you received the pneumonia vaccine

Have you ever been exposed to TB?*

Yes No

Year you were last tested for TB

TB skin test results*

Positive Negative

Have you received a 2nd MMR vaccine?*

Yes No

Year you received the MMR vaccine

Have you received the Hepatitis A vaccine?*

Yes No

series of 2

Year you received the Hepatitis A vaccine

Have you received the Hepatitis B vaccine?*

Yes No

series of 3

Year you received the Hepatitis B vaccine

Have you received the Chickenpox vaccine?*

Yes No

series of 3

Year you received the Chickenpox vaccine

Have you received the Shingles vaccine?*

Yes No

Year you received the Shingles vaccine

Have you received the HPV (Gardasil) vaccine?*

Yes No

Year you received the HPV (Gardasil) vaccine

Social History

Highest level of education completed?

Religious or Spiritual considerations / preferences

Optional

Do you currently smoke?*

Yes No

Have you ever smoked?*

Yes No

Age started smoking

Age stopped smoking

How many packs a day?

Are you interested in stopping?

Yes No

Do you use Dip/Snuff/Chew?*

Yes No

Do you drink alcohol?*

Yes No

How many drinks per week?

Do you feel that you need to cut down on drinking?

Yes No Sometimes

Do you currently use prescription or street drugs for non-medicinal purposes?*

Yes No

examples: opioids, cocaine, marijuana, heroin

Have you ever used prescription or street drugs for non-medicinal purposes?*

Yes No

examples: opioids, cocaine, marijuana, heroin

Do you examine your skin?*

Yes No

Do you use sun protection?*

Yes No

Do you currently exercise?*

Yes No

Do you use a seat belt?*

Yes No

Type of exercise, frequency, and duration

Hobbies or recreational activities

Have you ever been hurt or threatened by someone?

Yes No

Please explain the situation

Family History

Is your Father living?*

Yes No Unknown

Father's Current Age

Father's Age at Death

Father's cause of death

Does your Father have any of the following illnesses or health conditions?

Diabetes Colon Disease Kidney Disease Thyroid Disease Prostate Cancer Heart Attack (prior to age 60) Stroke (prior to age 60) Other Cancer

Other:

Check all that apply

Is your Mother living?*

Yes No Unknown

Mother's Current Age

Mother's Age at Death

Mother's cause of death

Number of Brothers*

Number of Sisters*

Age range of your siblings

Sibling deaths and cause of death

Do you have any children?*

Yes No

Age range of children

Any chronic health problems?

Review of Systems

Do you have any physical disabilities?

No disabilities Difficulties Walking / Paralyzed Hearing Impaired Vision Impairment

Other:

Do you use any of the following

Cane Walker Wheelchair None

Other:

Please describe these disabilities

Do you wear dentures (including partials)?

Yes No

How many meals do you eat per day (on average)?

Date of last hospital admission

Location of last hospital admission

Date of last ER visit

Location of last ER visit

Date of most recent doctor visit

Location of last doctor visit

Date of last complete eye exam

Location of last eye exam

aaaaand...YOU'RE DONE!

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