Medical House Calls

United Medical House Calls

Narcotic/ Scheduled Medication Consent Form

I hereby consent to the use of Narcotic/ scheduled medications prescribed to me for the

means of achieving a higher level of daily functioning. I agree to be open, honest and

have regular communication with my provider to monitor my use of scheduled/

controlled medication

The potential risks of narcotic/scheduled medication include, but are not limited to

Addiction

Interference with Physical and/or Mental Functioning

Narcotics/ scheduled medications may interfere with driving, operating machinery or other

requirements of my job. I understand it is my responsibility to avoid these risks

Physical Dependence

I understand that abrupt discontinuation of a narcotic/ scheduled medication drug may cause

nausea, vomiting, suicidal thoughts and sweating

Tolerance

I understand that in the future, narcotics/ scheduled medications may no longer work to

manage my symptoms. It will be necessary to slowly taper from the medication and to develop

other behaviors for management (e.g., exercise, healthy diet, stress management, etc.)

Pregnancy Risk

I understand that narcotic/ scheduled drugs affect a developing fetus and may result in birth

defects. I agree to inform my provider if I am currently pregnant or should become pregnant

during the course of my treatment

Patient Agreement

1. I agree not to take scheduled medications from any other source, unless approved

2. I agree to inform my provider of any other medications I take during this time

3.1 agree to allow my provider to set the interval at which I may request narcotic/ scheduled

prescriptions

4.1 agree to practice pain management behaviors regularly.

5.1 agree to provide a urine sample for drug screening, upon request

6. I will not alter my prescription in any way

my prescription through one pharmacy, and will notify my doctor and both

pharmacies of any change

8.1 understand that prescriptions will be processed within 24- -48 hours

9.1 agree that I have been instructed to go to pain management but have states I am home

bound and unable to get to pain management for treatment

10. I understand that I am being treated with pain medication because I am home bound and

that if I become able to leave my home (FOR ANY REASON), I will start a pain management

program

11. 1 understand that I can be refused scheduled medications at any time

12. Iunderstand that violation of any of the above may result in the termination of my doctor/

patient relationship

13. I understand that stolen pills will require a police report, should any future refills be given. I

understand there is no guarantee they will be refiled and that lost pills will not be refilled

There may be specific risks that pertain to my illness. There is a small chance these risks have

gone undiagnosed. I have been given the opportunity to explore alternative methods for

evaluation and pain management. I have been allowed to ask any questions regarding my pain

control

I hereby give my consent freely, voluntarily and without reservation

HCP (If Applicable) Patients Name

Patient Signature Date

Witness Signature Date

Pharmacy Name and Address

Robert Bramante, MD Steven Templeton, MS PA-C

Gary Despres, DPT Steven Sattler, DO

United Philease Martin, MS PA-C Kimberly Schmidt, PA-C Medical House Calls Laura McDermott, FNP Danielle Willsey, MS PA-C

Kimberley Levy, PA-C Melissa Clem mens, FNP 9

Jessica Graff, PA-C Angela Baily- -Hardy, PT

Suffolk: 631- -626-1006 www. medicalhousecalls .com

Central New York: 607-222- -0628/315- -715-1698 Nassau: 516-736- -1510

info@medicalhousecalls .com Fax: 631 -477-6219

CO MPREH ENSIVE PATIENT INFORMATION Delivering medical care to patients in their home saves money, avoids unnecessary ambulance

trips, emergency department visits, hospitalizations and premature nursing home placement for

our elderly patients. Medical House Calls works closely with home health companies, nurses

and medical equipment companies, mobile imaging companies and pharmacies to assure that

care is coordinated and timely

Office Staff

Our providers are usually on seeing patients but our reception staff is always available

and look forward to assisting you in

Scheduling

Assisting with urgent matters

Prescription refills

Ordering Medical Equipment and Supplies

Any other questions you may have

Practitioners are easily reached by our office staff during operating hours for your

convenience

Fees, Billing and Co-Pays

We will gladly bill your insurance company for your house call visit and any associated charges

Your insurance coverage is an arrangement bet ween you and your unsurance company and, as

with most health policies, payment (including any deducibles or other balances not covered by

your insurance) is your responsibility. Your cooperation with co- -pays and any associated

insurance questions is greatly appreciated. Please contact our office immediately if your

insurance carrier changes at any ume. We follow Medicare Guidelines for visits. testing and

treatments. Patients with Private Insurance are responsible for any fees not covered by their plan

We do our best to keep any additional costs down

Patient Scheduling

Patients can contact our office for all scheduling matters. We do our best to see you in a fast

timely manner. Routine follow ups are scheduled according to the frequency dictated by the

provider. Other appointments are scheduled based on urgency. The scheduling department will

call with the approximate window of arrival via confirmation call the day before that

appointment. Please call back to confirn the appointment before 9: :00 AM otherwise we will

reschedule the appointment for a later date. Requested time slots may not be available due to

other appointments, and/or Continuing Medical Education (CME) for our Practitioners. We

thank you in advance for you understanding and cooperation In this manner

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Kimberley Levy, PA-C Melissa Clem mens, FNP


Sutfolk: 631- -626-1006 www. medicalhousecalls .com

Nassau: 516-736- -1510 Central New York: 607-222- -0628/315- -715-1698

Fax: 631-477- -6219 info@medicalhousecalls .com

On the First Visit

Please have the following information readily available

A list of prescription medications, over-the- -counter medications, and herbal or nutritional

supplements you are currently taking. Please also have all the bottles out

Immunization records (Last Pneumococcal (Pneumonia) vaccination, Flu shot and

Tetanus shot)

Insurance cards for verification (We will need a copy of both the front and back of your

insurance cards)

A list of all physicians along with their phone/fax numbers and address involved with

your care

A list of all medical equipment companies along with their phone/fax numbers and

address

Canceling an Appointment

Our physicians and staff are on the road" during regular business hours. Therefore a last minute (

cancellation means that a patient who could have been seen may not have that opportunity due to

prior scheduling

If you do need to cancel an appointment, please contact us 24 hours prior to your scheduled visit

This allows us to offer the time to another patient

*** appointment is not cancelled24 hours prior to scheduled visit a $50 fee may be charged**

Nursing Staff:

Nurses coordinate all the behind the scenes" activities that allow our Providers to see you! They

answer the phones, manage patient charts and medical records, schedule patient visits, and

perform numerous other activities that keep things running smoothly

Follows care plans designed and approved by the Practitioners

May set up home health or a physician house call in discussion with the physician

Coordinate orders for medical equipment, oxygen, diabetes supplies, etc

Order and facilitate outpatient testing

Conduct Annual Wellness Visits as well as Telephone counseling

Perform EKG Lab draws, collects urine specimen

Assist Practitioner with procedures

Ph Physical Therapists:

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(

Kimberley Levy, PA-C Melissa Clem mens, FNP


Suffolk: 631- -626-1006 www. medicalhousecalls. .com

Central New York: 607-222- -0628/315- -715-1698 Nassau: 516-736- -1510

info@medicalhousecalls .com Fax: 631 -477-6219

See patients both in home and at our facility

Work closely with your provider to tailor a regimen for you

Assist with choosing the proper equipment and or braces for your specific needs

Prescription Refills

Refills are generally written for a one- -month supply. If you would like a larger quantity to

decrease trips to the pharmacy please let us know (note, most insurance companies will only

cover a one month supply at a time). Please call the office during regular business hours for

preseription refills and not the doctor on call

Prior to your house call please review your medication bottles for any refills needed. The

physician will take care of the refills at the visit to ensure you do not run out of your medication

Your primary care provider must approve a prescription refill. Please allow 2 business days for

all refill requests

Please call and press the refill prompt with the following information

Name of medication

Patients Nane

Dosage

Pharmacy name and location

If mail-order pharmacy must specify

Phone Number or Insurance Change of Address

If your home or business address, telephone numbers, or insurance information changes, please

notify our reception promptly

Inclement Weather

During times of unsafe driving conditions, our providers will not be traveling. Should you need

immediate medical attention you should dial 911 during these times. If your house is inaccessible

due to snow or any other means we will reschedule your appointment until snow can be removed

or the situation remedied. There must be a clear, safe path to your home

Release of Medical Records

A signed statement is required for the release of medical records. Please allow two weeks to copy

the records. If paper copies are requested a minimal charge may be assessed for this service as

determined by state law

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www. medicalhousecalls .com (631) 626- -1006 Suffolk

info@medicalhousecalls com (516) 736 - -1510 Nassau

FAX: (631) 477 - - 6219 Central NY: (607) 222- 0628

(315) 715- -1698

New Patient Form

Date First Visit Date

** PATIENT INFORMATION ** ** PRIMARY INSURANCE

Name Insurance Company

Street Claim Address

Facility/Complex City/state/Zip

Group #:

Town/State/Zip Policy/ 1D#

Name on Card

Date of Birth Contact Information

Soc Security #: Phone

Effective Date Email

* SECONDARY INSURANCE *

Date of Birth

Insurance Company F Sex M

Soc Security # Claim Address

City/state/Zip **

**EmergencyContact Information **

Group #

Policy/ ID# Name

Name on Card Phone

Date of Birth Relationship

Soc Security #:

Effective Date

** ** **Other Physicians** Name

Name Phone

Phone Relationship

Specialty Fax

Responsible Party Billing address

Name (If not same as above)

Phone Name

Specialty Fax Street:

Page 1


(631) 626-1006 www. .medicalhousecalls com Suffolk

(516) 736- -1510 info@medicalhousecalls .com Nassau

Central NY: (607) 222- 0628 FAX: (631) 477 - - 6219

(315) 715-1698

Past Medical History

Have you ever been Hospitalized? If yes, why? DYes ONo

Have Have you ever been treated for Hepatitis A,B, orC OYes DNo If yes, which?

If yes, date complicated you been vaccinated for Hepatitis B? DYes ONo

If yes, date complicated DYes ONo Have you been vaccinated for Hepatitis A?

Positive ONegative Result of screening Last Tuberculosis (TB) Screening?.

Result of Chest Xray: Positive ONegative If positive TB screen, date of last chest x-ray:

Diagnosis Have you ever had a sexually Transmitted Disease? oYes oNo

Which of the following conditions are you currently being treated for or diagnosed within the past?Please

check)

DHigh blood pressure DHigh cholesterol DHeart disease / Murmur / Angina

Swollen OAnemia or blood problems Low blood pressure

DAsthma Shortness of breath OHeartburn (reflux)

Tonsillitis aSeasonal allergies DSinus problems

DEye disorder / Glaucoma DLung problems / cough DEar problems

DNeurological problems Head aches / Migraines Seizures

] Stroke DPsychiatric care Depression / Anxiety

Liver problems / Hepatitis DKidney / Bladder problems Diabetes

Ulcers/colitis Cancer OArthritis

OThyroid problems

Page 2


www. medicalhousecalls .com (631) 626-1006 Suffolk

info@medicalhousecalls. com (516) 736 - 1510 Nassau

FAX: (631) 477 - - 6219 Central NY: (607) 222- 0628

(315) 715-1698

Please Descrlbe any current or past medlcal treatment not Ilsted above

Please list your past surgeries

Allergies

Are you Allergic to penicillin or other drugs?

Please list:

Have you ever had to use an Epinephrine Pen? DYes DNo If Yes, date administered

Medications: (PLEASE LIST ALL MEDICATIONS)

Social and Preventive History

If no, have you in past? DYes DNo Do you currently smoke or chew tobacco?

If no, have you in past? dYes ONo DYes ONo Do you drink alcohol, beer, or wine?

If yes, how many cups per day? Do you currently drink coffee or tea?

Do you exercise weekly? UYes ONo DYes ONo Do you wear a helmet when riding bike?

dYes ONo Do you wear seatbelt when driving?

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(631) 626-1006 Suffolk www. medicalhousecalls. com

(516) 736 - -1510 Nassau info@medicalhousecalls .com Central NY: (607) 222- 0628

FAX: (631) 477 - - 6219

(315) 715- -1698

List of serious illness LivingAge (or age of death) Family History

Mother DYes DNo

Father Yes ONo

Sisters

DYes ONo

Brothers

OYes DNo

Has any member of your family (including children and parents) had any of the following illness

Which family member $ llness

Anemia or blood disorder

Cancer

Diabetes

Glaucoma

Heart Disease

High Blood Pressure

HIV disease/ AIDS

Mental Status/ Depression

Stroke

Other serious illness

Do you routinely see OBGYN? Females

Date of last Pap Smear: How many times have you been pregnant?,

Diagnosis Have you had an abnormal Pap smear? DYes ONo

Mammogram results Date of last Mammogram

Biopsy results Yes ONo Have you ever had a breast biopsy?

Page 4


www. medicalhousecalls .com (631) 626- -1006 Suffolk

info@medicalhousecalls com (516) 736- -1510 Nassau

FAX: (631) 477 - - 6219 Central NY: (607) 222- 0628

(315) 715-1698

By signing below, I certify that to the best of my knowledge all the information I have furnished on this form is

complete, true, and accurate, I hereby give consent for medical treatment. I also give consent for Clinical Care

Management conducted by nursing and provider staff. I have read the comprehensive patient information and I agree

as per company guidelines, Medical House Calls of the North Fork reserves the right to begin the immediate

discharge of any patient if any of the following occur; abuse including physical and/or verbal, sexual innuendo

threatening communications, or assault by the patient or any family members

Patient/ Legal Guardian Signature Date

PATIENT MEDICAL INFORMATION RELEASE

Patient Name DOB

Address

Medical House Calls of the North Fork Is authorized to

()Furnish ( )Receive (check which applies)

Medical records to/from any Hospital, Facility, or Doctor

OR Specific Recipient/ Discloser:

IAUTHORIZE RELEASE OF THE FOLLOWING MEDICAL RECORDS

()I GIVE PERMISSION TO THE RELEASE OF MY MEDICAL RECORDS including information and

records or copies of records relating to the history, diagnosis, treatment, or services rendered to me in

connection with any condition or disease. This includes permission to release POTENTIALLY

SENSITIVE INFORMATION which may include information concerning my treatment of mental illness

Human Immunodeficiency Virus (HIV), alcoholism, drug use/ dependency, venereal disease, sexual

assaults, abortion, illegitimacy of birth, communications to social workers and/or psychotherapies

psychologists, if any

()I GIVE PERMISSION TO RELEASE ONLY RECORDS specifically described below

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(United Medical House Calls

(631) 626- -1006 Suffolk www .medicalhousecalls. .com

(516) 736 - -1510 info@medicalhousecalls com Nassau

Central NY: (607) 222- 0628 FAX: (631) 477 - - 6219

(315) 715- -1698

I release Medical House Calls of the North Fork and the Recipient/ Discloser listed above, and any of their

providers and staff from all responsibility or liability that may arise from this authorization. I may withdraw

this authorization at any time by giving written notification to Medical House Calls of the North Fork

provided that I do so in writing and to the extent that you already disclosed the information in reliance on

this authorization

(optional) if no expiration date is given, then this authorization This authorization expires /I shall remain in effect for 12 months from date of signature

Date Patient Signature (Legal Representative)

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