Pediatric Welcome Packet - Today Integrative Healthtodayhealthandwellness.com/.../2014/08/Pediatric-Welcome-Packet.pdf · Hepatitis2 2 2 2 2 2 ... Physical Medicine, Therepeutic Exercise,

www.TodayHealthandWellness.com (503) 746-‐5889 14535 Westlake Drive, Suite B, Lake Oswego, Oregon 97035

Welcome!

Welcome to Today Integrative Health + Wellness! The trust and confidence you have placed in us as a part of your healthcare team is appreciated. As you begin your journey with us to better health there are a few things to keep in mind.

We are located at 14535 Westlake Dr., Suite B., Lake Oswego, OR 97035.

To make or change your appointment please call the office at 503-746-5889. Alternatively you can schedule online at todayhealthandwellness.com.

To better serve our patients who may be waiting to see their provider we require 24 hours notice if you need to change or cancel your appointment. You can do this by phone or on our website. Violations of this policy incur a $30 cancellation fee. If you find yourself 15 minutes or more late for your visit please call the office to reschedule.

Please bring this completed welcome packet to your first visit. If you intend to use insurance for services we must receive your insurance information at least 2 business days prior to your appointment. You will be asked to pay the out of pocket expenses for all services performed if insurance information cannot be obtained.

If you have a medical emergency please call 911.

Our clinic is not equipped with an on-call physician. If you have non urgent requests of your provider please contact our office staff at 503-746-5889 and a message will be promptly relayed to your provider who will respond when they are next in clinic, typically within 2-3 business days.

Thank you for choosing Today Integrative Health + Wellness. We look forward to working with you to meet your healthcare goals!

~ The team at Today Integrative Health + Wellness


Pediatric New Patient Information W e l c o m e t o o u r c l i n i c ! W e l o o k f o r w a r d t o h e l p i n g y o u a c c o m p l i s h y o u r h e a l t h g o a l s . P l e a s e t a k e a m o m e n t t o f i l l o u t t h i s i n t a k e f o r m . Legal Name Preferred Name (if different) Date of Birth

Email Preferred Phone Alternate Phone

OK to leave a detailed message? YES NO

Address City, State: Zip

Emergency Contact and Phone

Mother’s Legal Name Preferred Name (if different)


Address (if different from above) City, State: Zip

Father’s Legal Name Preferred Name (if different)


Address (if different from above) City, State: Zip

How did you hear about us? _____________________________________________________ Referral from another Physician? Health Fair, Internet Search, Insurance Website, Farmers Market? If this was a referral let us know, so that we may thank them!


Your Personal Insurance Information

Primary Insurance Co Member ID Group No Customer Service Phone No

Secondary Insurance Co Member ID Group No Customer Service Phone No

Insurance Assignment and Release I, the undersigned, certify that I (or my dependent) have insurance coverage with the above-‐listed companies and assign directly to the provider, Oswego Progressive Medicine LLC, payment of all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges for all services provided, whether or not paid by insurance. In the event that my insurance company denies benefits or makes a partial payment, I am responsible for any balance due.

I hereby authorize the provider to release any medical or other information necessary to secure the payment of benefits. This may include intake forms, chart notes, reports, correspondences, billing statements and any other information to my attorneys, health care providers and insurance case managers. I authorize the use of this signature on all insurance submissions.

Signature _______________________________________ Date _____________


What are your most important health concerns?

Ongoing Concerns (prioritized) Concern Headaches

Started when? June 2010

How often? 4 per week

How severe? mild/mod/severe

You may list more later on the Health Systems Check-‐list

Tell us about your prior medical history

Hospitalizations or Surgeries and Dates Allergies to Medications Type of Reaction

Illness Past Now Family Who? Other Important Information? Asthma ○ ○ ○ Cancer ○ ○ ○ Diabetes ○ ○ ○ Digestive Concerns ○ ○ ○ Heart Disease ○ ○ ○ Hepatitis ○ ○ ○ High Blood Pressure ○ ○ ○ Lung Disease ○ ○ ○ Seizures ○ ○ ○ Thyroid Condition ○ ○ ○ Chicken pox ○ ○ ○ Scarlet fever ○ ○ ○ Tonsillitis ○ ○ ○ Frequent colds ○ ○ ○


What medications are you currently taking? (Both prescriptions and OTC)

Medication and Dose Albuterol 2 puffs as needed

Reason Asthma

Started? 11/2008

Prescribed By Alan James, MD

If you would like, we can provide you with a longer medication and supplement form

Supplement, Brand and Dose Super Vitamin C (Thorne) 500mg / day

Reason Immune Support

Started? 11/2008

Recommended By Self

Other Healthcare Providers?

What prior experiences have you had with healthcare in general?

Measles ○ ○ ○ Pneumonia ○ ○ ○ Ear infections ○ ○ ○ Rheumatic fever ○ ○ ○ Mumps ○ ○ ○ Rubella ○ ○ ○ Strep throat ○ ○ ○


What prior experiences have you had with alternative therapies?

Additional Prior Medical History that you would like to share:

Tell us about how you eat

Sodas, oz/day Food Sensitivity Coffee, oz/day Food Restrictions Water, oz/day Food Ethics □ Vegan □Vegetarian □Kosher □Other: Juice, oz/day

Food Cravings

Do you eat? □ In the car □ Watching TV □ Standing □ With others □ On the go □ In a hurry □ After 11pm □ In your sleep □ On waking

Snack Foods

Typical Breakfast How often do you eat out? Where?

Typical Lunch

Typical Dinner Bowel movements per day ________ □ Constipated?

Any Bowel Concerns?

Tell us about your home life

With whom do you live? (including family, pets, roommates)?

Name Age Relationship Name Age Relationship


How is your sleep? When do you go to sleep and wake up?

What do you do to relax? What are your hobbies?

What types of physical activity do you do?

Do you have a religious or spiritual affiliation? ______ What type?

Prenatal history Previous pregnancies, miscarriages or complications? ____________________________________________________________________________________________Mother’s age at child’s birth: __________ Mother’s health during pregnancy: ___ bleeding ___ nausea ___ physical or emotional trauma ___ illnesses ___ hypertension ___ cigarettes, alcohol, drug consumption ___ medications ___ diabetes ___ thyroid problems Birth History Term: ___ Full ___ Premature ___ Late Child’s birth weight:________ Length of labor: ____________________ ___ vaginal birth ___ C-‐section Complications:__________________________________________________________________ Did your child have any of the following problems shortly after birth? ___ Rashes ___ Birth injuries ___ Blue baby ___ Jaundice ___ Seizures ___ Cerebral palsy ___ Colic ___ Fever ___ Birth Defects ___ Other: _____________________________________________________________________ Breast fed: Y / N How Long:___________ Formula: Y / N Type (milk, soy):________________ Age began solids: ___________ Which foods:_________________________________________ Age began: Sitting ________ Crawling ________ Walking ________ Talking ________


Vaccinations MMR: Y / N History of contracting this disease: Y / N DPT: Y / N History of contracting this disease: Y / N Chicken Pox : Y / N History of contracting this disease: Y / N Measles: Y / N History of contracting this disease: Y / N Mumps: Y / N History of contracting this disease: Y / N Rubella: Y / N History of contracting this disease: Y / N Polio: Y / N History of contracting this disease: Y / N Influenza: Y / N History of contracting this disease: Y / N Pneumococcal: Y / N History of contracting this disease: Y / N Tetanus: Y / N History of contracting this disease: Y / N HIB: Y / N History of contracting this disease: Y / N Rotavirus: Y / N History of contracting this disease: Y / N Hep A: Y / N History of contracting this disease: Y / N Hep B: Y / N History of contracting this disease: Y / N Others (list):___________________________________________________________________ Any Adverse reactions? Y / N If yes please describe: __________________________________


GENERAL CLINIC POLICIES

It is not the policy of our office to manage medical care via email. While email can be an efficient method of communicating we believe we can best serve you face to face or over the phone if necessary. To that end our providers do not typically communicate over email. For non-medical issues our office staff can be reached at [email protected]

It is not our policy to conduct phone consults or otherwise give medical advice over the phone. If such a consult is requested you will be responsible for a telephone visit fee, which is not covered by insurance. From time to time your provider may contact you by phone for a brief exchange of medical information. There is no fee for such a service.

Payment is due at the time of service. After your visit, you will checkout with our staff and be asked for copays or co-insurance for the visit and some labs ordered. As a courtesy Today will contact your insurance and have a quote of your benefits prepared. You are responsible for your portion of any fees at the time of the visit, minus portions covered by insurance. Additional fees for outside labs will be billed to you.

Your initial visit will include a complete discussion of your health history and current symptoms. Physical exams relating to your symptoms will likely be performed in this visit. Your provider will make a treatment plan tailored to you. Your provider may order labs in this appointment, which will be released and discussed with you in a follow-up office visit. It is not the policy of our clinic to release labs without interpretation by your provider.

If you need a prescription refill please call your pharmacy. They will fax us your request or send it electronically. In order for your provider to make an informed decision with ample time to review your history please provide 2-3 business days notice for your refill.

For records requests for other providers we will do our best to get these processed within 7 business days. However, please keep in mind that common standards allow for 30 days to fulfill these requests.

Letters of medical necessity for supplements will be completed within 7 business days.

I acknowledge that I have read and understand the general clinic policies for Today Integrative Health + Wellness and have discussed any concerns or questions I have with the office staff.

Signature _____________________________________________________________________________ Date ______________________


CONSENT FOR TREATMENT

General Information: Today Integrative Health + Wellness is an Integrative Medical Clinic which integrates a number of medical modalities. Due to the diversity of modalities offered at Today, your treatment may include any or all of the following general modalities: Naturopatic Medicine, Physical Medicine, Therepeutic Exercise, Homeopathy, Psychological Counseling, Nutrional Counseling, and Intravenous Therapies. Methods, Procedures, and Therapeutic Approaches: Clinicians may perform any of the following procedures as necessary to give proper assessments, determine treatment approaches, treat or otherwise address your health concerns. General Diagnositc Procedures: Including but not limited to venipuncture, pap smears, radiography, blood labwork, urine labwork, general physical exams, neurological and musculoskeletal assessments. Herbs/ Natural Medicines: Prescribing of various therapeutic substances including plants, minerals, and animal materials. Substances may be given in the form of teas, pills, powders, tinctures (may contain alcohol), topical creams, pastes, plasters, washes, suppositories, or other forms. Homeopathic remedies, often highly dilute quantities of naturally occurring substances, may also be used.

Dietary Advice and Therapeutic Nutrition: The use of foods, diet plans, or nutritional supplements for treatment (may include intramuscular injection or intravenous therapies). Soft Tissue and Osseous Manipulation: The use of massage, neuro-muscular techniques, muscle energy stretching, visceral manipulation, as well as manipulations of the extremities and spine including traction and cranio-sacral therapy. Electromagnetic and Thermal Therapies: Including the use of ultrasound, low and high-volt electrical muscle stimulation, transcutaneous electrical stimulation, microcurrent stimulation, diathermy, and infrared and ultraviolet therapies. Pharmaceutical Medication: Your physician may prescribe medication for your care that is within the scope of practice. Potential Benefits: Restoration of health and the body’s maximal functional capacity, relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or its progression. Potential Risks: Pain, discomfort, blistering, discoloration, infection, burns, loss of consciousness or deep tissue injury from needle insertions, topical procedures, heat or frictional therapies ,electromagnetic, and hydrotherapies; allergic reactions to prescribed herbs or supplements; soft tissue or bone injury from physical manipulations; and aggravation of pre-existing symptoms. Notice to Women: All female patients must alert the doctor if they know or suspect that they are pregnant, since some of the therapies used could present a risk to the pregnancy or during breast feeding.

I understand that I may ask questions regarding my treatment before signing this form and that I am free to withdraw my consent and to discontinue participation in these procedures at any time. With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been giving to me by Today or any of its personnel regarding cure or improvement of my condition. I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by my representative or me or as otherwise permitted or required by law.

_________________________________________________ ________________________________________ Patient Name (PRINT) Guardian/Personal Representative (PRINT)

_________________________________________________ _________________________________________ Patient Signature Guardian/Personal Representative Signature

_________________________________________________ _________________________________________ Date Relationship/ Representative Authority


PATIENT FINANCIAL POLICY

Payment for Services: Patient or patient’s responsible party is responsible for all charges. Full payment is due at the time of service for all provided services, lab tests, telephone appointments, supplements and other supplies, postage, shipping and handling, and any additional charges incurred in connection to your healthcare.

Insured Patients

• Payment in full is due at the time of service for all deductibles, coinsurance, copays, and services not covered or not paid by your insurance carrier.

• Patients are responsible for all charges resulting from services provided whether or not your insurance pays your claim. Your insurance policy is a contract between you and your insurance company. Today Integrative Health + Wellness and its physicians are not party to that contract.

• Patient is fully responsible for being aware of insurance coverage, limitations, and exclusions. If you have questions about your plan’s coverage and exclusions, we encourage you to contact your insurer directly.

• Patient is responsible for providing in a timely manner all accurate, current and thorough information and documentation required to verify your insurance coverage and/or bill your insurance carrier, including all primary and secondary insurance, Medicare, Medicaid, auto carriers, and workers’ compensation carriers; referrals required from insurers or other providers; and most current address, phone, and other contact information.

• Verification of health, motor vehicle accident, or workers’ compensation insurance is used to determine if there is coverage for services through your insurance carrier and is NOT a guarantee of payment of your claims by your insurance carrier.

• As a courtesy, we will submit your claims to your primary and secondary insurance carriers for covered charges, provided that we have received your plan information and verified coverage PRIOR TO rendering services.

• In the event that your insurance claim is returned unpaid because the services are not covered, you will be billed for the remaining balance for the non-‐covered services.

Non-‐Insured Patients (Self-‐Pay)

• Payment in full is due at the time of service. • A Time-‐of-‐Service discount of 30% will be applied to eligible services and labs. • Time-‐of-‐Service and other courtesy discounts do not apply to supplements, diagnostics, telephone appointments, and most IV or injection therapies, or if there is another discount being honored at time of service.

Labs: Payment for ordered labs is due at the time of specimen draw or provision of take-‐home lab kits. Medications / Supplements / Supplies: Full payment is due for all medications, supplements, and other products prescribed from our office at the time they are provided.

Appointment Cancellations: Appointments must be cancelled with at least 24 hours’ advance notice. A $30 fee will be charged to your account for appointments missed or cancelled with less than 24 hours’ notice.

Product Return / Refund: Unopened and unused pre-‐packaged products may be returned and refunded for the original amount paid. Refrigerated products, customized formulas, herbs, teas and other non-‐pre-‐packaged items are not refundable.

Returned Checks: A Returned Check fee of $25 will be added to your account if your check is returned by your bank for insufficient funds, in addition to the amount of the check.

I have read and fully understand the above agreement. _____________________________________________________ _________________________________________ Patient Name (18 years or older) Parent, Guardian, Responsible Party Name

_____________________________________________________ _________________________________________ Signature of Patient or Responsible Party Date

Copy of your signed Financial Policy available upon request


NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Uses and Disclosures Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members. Payment. Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated. Health care operations. Your health information may be used as necessary to support the day-today activities and management of Today Integrative Health + Wellness. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality. Law enforcement. Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting. Public health reporting. Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department. Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization. Additional Uses of Information Appointment reminders. Your health information will be used by our staff to send you appointment reminders. Information about treatments. Your health information may be used to send you information that you may find interesting on the treatment and management of your medical condition. If you do not want to receive information via e-mail about events and lectures being offered at Today Integrative Health + Wellness, please initial here ______. E-mails are sent only monthly or every two months. Individual Rights. You have certain rights under the federal privacy standards. These include: (1) The right to request restrictions on the use and disclosure of your protected health information. (2) The right to receive confidential communications concerning your medical condition and treatment (3) The right to inspect and copy your protected health information (4) The right to amend or submit corrections to your protected health information (5) The right to receive an accounting of how and to whom your protected health information has been disclosed (6) the right to receive a printed copy of this notice Today Integrative Health + Wellness Duties We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice. Right to Revise Privacy Practices As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain. Requests to Inspect Protected Health Information You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting the Receptionist or the Privacy Officer/Administrator. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request.

Initial Here:______


Complaints If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to: Privacy Officer/Administrator Today Integrative Health + Wellness 14535 Westlake Drive, Suite B Lake Oswego OR 97035 If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint. Contact Person The name and address of the person you can contact for further information concerning our privacy practices is: Privacy Officer/Administrator Today Integrative Health +Wellness 14535 Westlake Drive, Suite B Lake Oswego OR 97035 Effective Date This Notice is effective on or after February 01, 2011. With this Signature I acknowledge that I have received this Notice of Privacy Practices.

Patient Signature:___________________________________________ Date:_____________________ If you would like a copy of this form, once signed, please ask the receptionist.

Page 2 of 2

14535 Westlake Drive, Suite B, Lake Oswego, OR 97035

Tel: (503)-‐746-‐5889 Fax: (503) 746-‐5944

Documents

Pediatric Welcome Packet - Today Integrative Healthtodayhealthandwellness.com/.../2014/08/Pediatric-Welcome-Packet.pdf · Hepatitis2 2 2 2 2 2 ... Physical Medicine, Therepeutic Exercise,