Page 1 of 15 New Patient Package Office Policies and Procedures We appreciate the confidence you have shown by choosing our office to provide medical care to you and your family. We make every effort to give you the best possible care. In order to achieve this, we ask for your assistance in the following clinic policies. APPOINTMENTS Appointments are required to address any/all issues and concerns. Regular office hours are Monday through Friday from 9:00 am – 6:00 pm with lunch from 12 pm – 1:00 pm (hours may vary from time to time). We reserve some appointment times for same day "sick" visits every day. We work hard to accommodate requests for same day appointments, but are not always able to do so. New patients must arrive 30 minutes prior to their appointment time. If you are an established patient, please arrive 10 minutes prior to your appointment time. If you arrive late, we may need to reschedule your appointment. If you are unable to keep your scheduled appointment, please call our office 24hrs hours ahead to cancel so that your appointment time can be made available to other patients. It is our policy that if you do not show for 3 appointments you will be notified by mail that you will be discharged from the practice. Phoenix Family Medical Clinic reserves the right to bill $25.00 for No-Show appointments. TEST RESULTS Our medical assistant will usually contact you by phone regarding your test results to schedule an appointment for follow-up. Due to HIPPA Law we are unable to disclose any medical information with you or any other member of your family. If you have not heard from our office within 15 business days, please contact our office. MEDICATION REFILLS We require 72 hours notification for all refill requests. Please do not allow yourself to run out of medication. Your provider requires advance notice, as he/she needs to evaluate your medical records. Narcotic medications will NOT be refilled without an office visit. REFERRALS All referrals require an office visit. When your provider wants you to be referred to a specialist, it will take up to 10 business days for completion. If it is an urgent referral, it will be completed within 48 hours. You will receive all the information you need by mail or phone so that you are then able to call and schedule your appointment. If your specialist requires additional visits, it is your responsibility to verify that the specialist is contracted with your insurance prior to your visit. MEDICAL RECORDS For all medical record requests, a release form will be provided and must be signed by the patient. Please allow 15 business days to process your request. Your records may be faxed to another physician's office OR made available for you to pick up in our office, Please note: If you are picking up records from our office there is a minimum charge of $15.00 for up to 30 pages. PHYSICIAN PHONE CONSULT Our providers do not usually consult patients over the phone. If this becomes a necessity which is not a medical emergency, we reserve the right to charge you a consultation fee (most insurance plans do not cover phone consultations, so therefore this charge will be your responsibility). INSURANCE It is the patient's responsibility to understand their insurance plan benefits. We will try to assist you when possible with what is and is not covered. The patient is responsible for services/items that the insurance does not cover. PAYMENTSThe patient is responsible for payment of each office visit. If you have insurance, our billing department will file the claim with them as a courtesy. Please have your insurance card with you at each visit. Co-payments and payments are always required on the day of service. If you do not bring your payment with you, we reserve the right to reschedule your appointment. Patients without insurance will need to pay for their service on the day it is rendered. Please pay with cash, credit or debit card. We do not accept checks. A 33% fee will be added to accounts that are sent over to collections. AFTER-HOURS EMERGENCIES If you have a true medical emergency, please call 911 or go to the nearest emergency room to receive medical assistance immediately. I have reviewed the policies listed above in their entirety. Patient Name(*) Please enter your full name Patient Information/Informacion del Paciente Date(*) Please enter today's date Email address(*) Please provide a valid email address Name/Nombre(*) Please enter your name SSN/Numero de Seguro Social(*) Please enter your SSN Age/Edad(*) Please enter your age Sex/Sexo(*) MaleFemalePlease select an option Marital Status/Estado Civil(*) Please enter your marital status DOB/Fecha de Nacimiento(*) Please enter your date of birth Home Phone/Numero de Casa(*) Please enter your home phone Cell Phone/Numero de Cellular(*) Please enter your cell phone Address/Direccion(*) Please enter your address Apartment/Apartamento Invalid Input City/Ciudad(*) Please enter your city State/Estado(*) Please enter your state Zip/Codigo Postal(*) Please enter your zip Occupation/Ocupacion(*) Please enter your occupation Employer/Empleador(*) Please enter your employer If need arises, the doctor/receptionist may leave a message on my / Si necesitan, el doctor/recepcionista puede dejar mensaje en mi(*) Home phone/Numero de CasaCell Phone/Numero de CellularPlease select an option Family Name/Nombre de Familiar Invalid Input Spouse or Emergency Contact Information (or Parent/Guardian if Patient is Child) Name/Nombre(*) Please enter your name SSN/Numero de Seguro Social(*) Please enter your SSN Age/Edad(*) Please enter your age Sex/Sexo(*) MaleFemalePlease select an option Marital Status/Estado Civil(*) Please enter your marital status DOB/Fecha de Nacimiento(*) Please enter your date of birth Home Phone/Numero de Casa(*) Please enter your home phone Cell Phone/Numero de Cellular(*) Please enter your cell phone Address/Direccion(*) Please enter your address Apartment/Apartamento Invalid Input City/Ciudad(*) Please enter your city State/Estado(*) Please enter your state Zip/Codigo Postal(*) Please enter your zip Occupation/Ocupacion(*) Please enter your occupation Employer/Empleador(*) Please enter your employer Medical Insurance Information/Informacion del Seguro Medico Primary Insurance Company Name/Nombre del Seguro Medico Primario(*) Please enter your insurance details Member ID #/ # de ID de Miembro(*) Please enter your insurance details Group Number/Numero de Grupo(*) Please enter your insurance details Subscriber Name/Nombre del Encargado(*) Please enter your insurance details DOB/Fecha de Nacimiento(*) Please enter your date of birth Secondary Insurance Company Name/Nombre del Seguro Medico Primario(*) Please enter your insurance details Member ID #/ # de ID de Miembro(*) Please enter your insurance details Group Number/Numero de Grupo(*) Please enter your insurance details Subscriber Name/Nombre del Encargado(*) Please enter your insurance details DOB/Fecha de Nacimiento(*) Please enter your date of birth Please make sure you update your information with us if there are any changes. Thank you.Por favor de informarnos si ay algun cambio en su informacion. Gracias. Health History Questionnaire All questions contained in this questionnaire are strictly confidential and will become part of your medical record. Name(*) Please enter your name DOB(*) Please enter your date of birth Marital Status(*) Please enter your marital status Previous or referring Doctor(*) Please enter your previous or referring doctor Date of last physical exam(*) Please enter the date of your last physical exam Personal Health History Childhood Illness MeaslesMumpsRubellaChickenpoxRheumatic FeverPolioInvalid Input List any medical problems that other doctors have diagnosed Invalid Input Surgeries (enter Year, Reason & Hospital) Invalid Input Other Hospitalizations (enter Year, Reason & Hospital) Invalid Input Have you ever had a blood transfusion?(*) YesNoPlease select an option List your prescribed drugs and over the counter medication, such as vitamins and inhalers (enter Name of the Drug, Strength & Frequency Taken) Invalid Input Allergies to Medications (enter Name of the Drug & Reaction you had) Invalid Input Health Information and Personal Safety All questions contained in this questionnaire are strictly confidential and will become part of your medical record. Exercise Mild exercise (i.e., climb stairs, walk 3 blocks, golf)Occasional vigorous exercise (i.e., work or recreation, less than 4/week for 30 min.)Regular vigorous exercise (i.e., work or recreation 4/week for 30 min.)Invalid Input Are you dieting? YesNoInvalid Input Caffeine NoneCoffeeTeaColaInvalid Input No. of cups/cans per day? Invalid Input Do you drink alchohol? YesNoInvalid Input How many drinks per week? Invalid Input Do you use tobacco? YesNoInvalid Input Do you currently use recreational or street drugs? YesNoInvalid Input Are you sexually active? YesNoInvalid Input If yes, are you trying for a pregnancy? YesNoInvalid Input Any discomfort with intercourse? YesNoInvalid Input Would you like to speak with your provider about your risk of HIV/AIDS? YesNoInvalid Input Family Health History Father Age Invalid Input Significant Health Problems Invalid Input Mother Age Invalid Input Significant Health Problems Invalid Input Siblings MaleFemaleInvalid Input Significant Health Problems Invalid Input MaleFemaleInvalid Input Significant Health Problems Invalid Input MaleFemaleInvalid Input Significant Health Problems Invalid Input MaleFemaleInvalid Input Significant Health Problems Invalid Input MaleFemaleInvalid Input Significant Health Problems Invalid Input MaleFemaleInvalid Input Significant Health Problems Invalid Input Children MaleFemaleInvalid Input Significant Health Problems Invalid Input MaleFemaleInvalid Input Significant Health Problems Invalid Input MaleFemaleInvalid Input Significant Health Problems Invalid Input MaleFemaleInvalid Input Significant Health Problems Invalid Input Grandfather (Maternal) Age Invalid Input Significant Health Problems Invalid Input Grandmother (Maternal) Age Invalid Input Significant Health Problems Invalid Input Grandfather (Paternal) Age Invalid Input Significant Health Problems Invalid Input Grandmother (Paternal) Age Invalid Input Significant Health Problems Invalid Input Other Problems Check if you have, or have had, any symptoms in the following areas to a significant degree SkinChest/HeartHead/NeckBackEarsIntestinalNoseBladderThroatBowelLungsCirculationInvalid Input Recent changes in WeightEnergy levelAbility to sleepInvalid Input Other pain/discomfort Invalid Input Health Information and Personal Safety Women Only Age at onset of menstruation Invalid Input Date of last menstruation Invalid Input Period every (days) Invalid Input Heavy periods, irregularity, spotting, pain, or discharge? YesNoInvalid Input Number of pregnancies Invalid Input Number of live births Invalid Input Are you pregnant or breastfeeding? YesNoInvalid Input Have you had a D&C, hysterectomy, or Cesarean? YesNoInvalid Input Any urinary tract, bladder, or kidney infections within the last year? YesNoInvalid Input Any blood in your urine? YesNoInvalid Input Any problems with control of urination? YesNoInvalid Input Any hot flashes or sweating at night? YesNoInvalid Input Do you have menstrual tension, pain, bloating, irritability or other symptoms at or around time of period? YesNoInvalid Input Experienced any recent breast tenderness, lumps, or nipple discharge? YesNoInvalid Input Date of last pap and rectal exam? Invalid Input Health Information and Personal Safety Men Only Do you usually get up to urinate during the night? YesNoInvalid Input If yes, number of times Invalid Input Do you feel pain or burning with urination? YesNoInvalid Input Any blood in your urine? YesNoInvalid Input Do you feel burning discharge from penis? YesNoInvalid Input Has the force of your urination decreased? YesNoInvalid Input Have you had any kidney, bladder, or prostate infections within the last 12 months? YesNoInvalid Input Do you have any problems emptying your bladder completely? YesNoInvalid Input Any difficulty with erection or ejaculation? YesNoInvalid Input Any testicle pain or swelling? YesNoInvalid Input Date of last prostate and rectal exam? Invalid Input Health Information and Personal Safety Mental Health Is stress a major problem for you? YesNoInvalid Input Do you panic when stressed? YesNoInvalid Input Do you have problems with eating or your appetite? YesNoInvalid Input Do you cry frequently? YesNoInvalid Input Have you ever seriously thought about hurting yourself? YesNoInvalid Input Do you have trouble sleeping? YesNoInvalid Input Have you ever been to a counselor? YesNoInvalid Input Do you feel depressed? YesNoInvalid Input Have you ever attempted suicide? YesNoInvalid Input Acknowledgement of Receipt of Notice of Privacy Practices (HIPAA) You may refuse to sign this AcknowledgementI have received a copy of this Notice of Privacy Practices. Patient Name(*) Please enter your full name Patient Record of Disclosure In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's home. I wish to be contacted in the following manner (check all that apply): Home Telephone Please enter your full address including zip Okay to leave message with instructionsOkay to leave message with call-back number onlyInvalid Input Work Telephone Please enter your date of birth Okay to leave message with instructionsOkay to leave message with call-back number onlyInvalid Input Written Communication Okay to mail to home addressOkay to mail to work/office addressInvalid Input SSN Please enter your telephone no. Patient Authorization to Disclose Personal Information Phoenix Family Medical Clinic/ Phoenix Clinica Familiar is authorized to(*) Furnish toReceive fromPlease select an option Physician(*) Please enter the name of your physician Phone #(*) Please enter your physician's phone no. Fax #(*) Please enter your physician's fax no. Address(*) Please enter your physician's address I authorize release of the following medical records(*) I GIVE PERMISSION TO RELEASE ALL MY MEDICAL RECORDS including information and records or copies 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, 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 belowPlease select an option Invalid Input I released Phoenix Family Medical Clinic/ Phoenix Clinica Familiar and the Recipent/Disclosure 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 Phoenix Family Medical Clinic/ Phoenix Clinica Familiar, provided that I do so in writing and to the extent that you have already disclosed the information in reliance on this authorization. This Authorization expires on Invalid Input (Optional) If no expiration date is given, then this authorization shall remain in effect for a period reasonably needed to complete the request. Oxycodone/Narcotic Pain Medication Guidelines From: Dr. Napoleon Ortiz, MD This clinic follows strict rules on prescribing Narcotic Pain medication. We discourage all long term use of narcotic pain medication including Oxycodone. If you are here just to seek narcotic pain medication or Oxycodone, please be aware that this clinic will not prescribe those medications. All Oxycodone/ narcotic pain medication prescriptions are FINAL. There will be no refills at all, under no circumstances. We believe that Narcotics Pain killers like Oxycodone do not heal or cure anything. If you do not agree with these guidelines, we request that you let the front office person know, so she cancels your appointment. We thank you for your patience in reading this memo. Patient Name(*) Please enter your full name Preferred clinic location(*) PhoenixLaveenSurpriseIndian SchoolAhwatukeePlease select your preferred clinic location