PATIENT INFORMATION Patient ID #: ______________ Sex [ ] Male [ ] Female

Name: ______________________________ Social Security #: ____________________ DOB: ________

Mailing Address: _____________________ Marital Status: [ ] Married [ ] Single [ ] Divorced [ ] Other

Street Address: _______________________ Email Address: _______________________________________

City, State, ZIP: ______________________ Primary: [ ]Home [ ]Work [ ]Cell: ______________________

Secondary: [ ] Home [ ] Work [ ] Cell: __________________

Primary Care Physician: ________________________ Phone Number: ____________________________________

Ethnicity: Hispanic Non-Hispanic Refused Race: ___________________ Religion: ___________________

PATIENT EMPLOYMENT PERSONAL / EMERGENCY CONTACTS

[ ] Employed [ ] Retired [ ] Unemployed [ ] Self Name Relationship Phone

Employer: _______________________________ __________________________________________________

Job Title: ________________________________ __________________________________________________

Phone: __________________________________ __________________________________________________

GUARANTOR/RESPONSIBLE BILLING PARTY RESPONSIBLE BILLING PARTY EMPLOYMENT

[ ] Same as Patient

Name: ___________________________________ Employer: _________________________________________

Address: _________________________________ Work Phone: _______________________________________

City, State, ZIP: ___________________________ Social Security #: ___________________________________

Phone: ___________________________________ Date of Birth: ______________________________________

PRIMARY INSURANCE Subscriber: [ ] Patient [ ] Responsible Billing Party [ ] Other

Subscriber Name: _____________________ Relationship to Patient: _______________________________

Subscriber DOB: _____________________ Subscriber Social Security #: __________________________

Insurance Co.: ________________________ Insured ID: _________________ Group #: _______________

SECONDARY INSURANCE Subscriber: [ ] Patient [ ] Responsible Billing Party [ ] Other

Subscriber Name: _____________________ Relationship to Patient: _______________________________

Subscriber DOB: _____________________ Subscriber Social Security #: __________________________

Insurance Co.: ________________________ Insured ID: _________________ Group #: _______________

ASSIGNMENT OF INSURANCE BENEFITS AND RELEASE OF MEDICAL INFORMATION:

I GIVE MY CONSENT FOR TREATMENT.

I herby authorize the release of any appropriate medical information to my insurance company; I assign all medical and/or

surgical benefits, including major medical benefits to which I am entitled, including Medicare, private insurance and other health

plans. This assignment will remain in effect until revoked by me in writing.

Signature: ____________________________________________________ Date: ___________________

We make every reasonable effort to obtain pre-approval, prior authorization and referral information. Your co-payment, co-insurance and/or

deductible are due in full at the time of service. We will bill your insurance as a courtesy to you. On denied worker compensation claims, the

patient’s private/group health insurance may be billed. Ultimate financial responsibility remains with the patient and if the insurance company

or worker compensation carrier denies payment, the bill is your responsibility. If you are unsure of any of these issues, please ask the staff before

you see the physician.

New Prim Drug EmeWha________

Last Age # of # of Any HaveAre ySexuMeth

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Menstrual pPeriods begDays of bleeDays betwechanges to e you ever hyou sexuallyual partners hod of contra

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period: ____gan: ______eding: _____

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PERSONAL MEDICAL HISTORY Please check box if you have or have had any of the following

Asthma Stroke Seizures /Convulsions Pneumonia / Lung disease Rheumatic Fever Bowel Problems Kidney infections/stone Blood Clots in Lungs of legs Broken Bones Tuberculosis Eating Disorders Hepatitis / Liver Disease Fibroids Autoimmune Disease (Lupus) Gallbladder Disease STD / Chlamydia Chicken Pox Headaches Infertility Cancer Bleeding Disorders HIV / AIDS Reflux / Hiatal Hernia / Ulcers Thyroid Disease Heart Attack / Disease Depression / Anxiety Diabetes Anemia High Blood pressure Blood transfusion Other__________________________________________________________________________

MEDICATIONS

Name Dose Frequency Reason

Example: Synthroid 100mcg Daily Low thyroid

SURGICAL HISTORY

SURGERY/HOSPITALIZATION Date

SOCIAL HISTORY

Married Single Civil Union Divorced Widow(er) Separated Sexual Orientation: ____________ Occupation: ______________________ Current Former Never Alcohol use Drinks/wk: _________ Type: _____________ Tobacco use Packs/day: _________ # of years: _________ Drug use Type: _____________ # of years: __________ Yes No Do you wear a seat belt? Have you been sexually abused, threatened or hurt by anyone? Advance Directive? Yes No If Yes, Date: _________________ Education: Junior HS HS College Graduate Education _________________

FAMILY MEDICAL HISTORY

Mother: Living Deceased, Age: _____ Father: Living Deceased, Age:_______ Siblings: Number living: _______ Number deceased: ________ Cause/Age(s):______________________

Please indicate if there is a family history of any of the following medical illnesses or cancers

Example: Colon cancer Brother 36 yrs Aunt 44years Grandfather 65 yrs Cousin 58yrs Siblings/ Children

(age at diagnosis) Mother’s side

(age at diagnosis) Father’s side

(age at diagnosis) Breast Cancer

Colon Cancer

Ovarian Cancer

Uterine Cancer

Stomach or Bowel Cancer

Prostate Cancer

Melanoma

Pancreatic Cancer

Other

High blood pressure

Heart Disease/Stroke

Blood Clots

Diabetes

Osteoporosis

C SIG REV

breast pain nipple dischbreast lumpabnormal blpainful periopremenstruapelvic or abvaginal drynpainful interabnormal vablood in urinpain with urvery frequenchronic couleg swellinginvoluntary coughing upenlarged lymOther_____

Currently I a

GNATURE:

VIEWED BY

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harge ps leeding ods al syndromedominal pain

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fevers muscle weasignificant wsignificant wexcessive fasleep disturbchange in hvision changdepression significant ahearing probsinus problechest pain orapid or irregnausea/vominvoluntary lconstipationheat or cold __________

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W OF SYMPxperiencing

akness weight loss weight gain atigue bance eight ges

anxiety blems ems or pressure gular heartb

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___________

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_________

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_________

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Preferred Lab If we send out specimens from our office, i.e., pap smears, blood draws, pathology, etc., your insurance company may have a preference and your benefits could be affected. Please indicate which lab is contracted with your insurance company. If you do not know, please ask one of our receptionists. _______ Barton _______ Lab Corp _______ Quest Diagnostics _______ OTHER - Lab Name & Address:____________________________ Pharmacy: _____________________________________________________________ Print Name: __________________________________________________________ Signature: __________________________________________________________ Date: ________________________

Patient Record of Disclosures **Please fill out completely**

Patient Name:

Date of Birth:

Who may we release medical information to: Name: ___________________________________________ Relationship to you:_________________________ Name: ___________________________________________ Relationship to you: _________________________ Name: ___________________________________________ Relationship to you: _________________________

I wish to be contacted in the following manner (check all that applies):

Home Telephone ___________________________________________ o Okay to leave message with detailed information o Leave message with call back number and name of Barton

Women’s Health only

Work Telephone ___________________________________________ o Okay to leave message with detailed information o Leave message with call back number and name of Barton

Women’s Health only

Cellular Phone ____________________________________________ o Okay to leave message with detailed information o Leave message with call back number and name of Barton

Women’s Health only

Other ______________________________________________________ Signature ___________________________________ Date ________________

 

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P.O. Box 9578-South Lake Tahoe, CA 96158

Phone (530) 543-5900 – Fax (530) 544-1458

Date: 4/03/03 Revision Date: 5/19/10; 11/15/17; 5/2018

ACKNOWLEDGMENT OF RECEIPT OF JOINT

NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGMENT OF RECEIPT OF JOINT NOTICE OF PRIVACY PRACTICES

I acknowledge that I received a copy of Barton Healthcare System’s Joint Notice of Privacy

Practices.

Patient Name: _________________________________________________________________

(please print)

Signature of Patient/Legally Authorized or Personal Representative:

(Signature)

Date: ______________________________

If not signed by the patient, please indicate the relationship to patient/authority of person:

FOR BARTON USE ONLY:

Signed acknowledgment received by: ___________________________________________

(BMH staff print name)

Acknowledgement refusal received by:___________________________________________

(BMH staff print name)

Describe good faith efforts to obtain acknowledgment:

______________________________________________________________________________

Describe reasons why acknowledgment was not obtained:

Employee Signature: ________________________________________________________________________

2175 South AvenueSouth Lake Tahoe CA 96150 530.543.5711 TELbartonhealth.org

ANNUAL WELLNESS AND OFFICE VISIT Charging

Today you are scheduled for an Annual Wellness visit. If additional services are being provided relating to adiagnosis outside of a wellness diagnosis you may becharged an office visit in addition to your wellness visit.This includes medication refills. By signing this form youacknowledge you have been notified of this.

Patient Name: ________________________________________________ DOB: _____________________

Signature: ____________________________________________________ Date: _____________________

Women's Health