THClinicians - New Patient Intake

THClinicians - Registration Information

HOSPICE Agencies: You may text us with the patient's qualifying diagnosis

DO NOT - FILL THIS OUT UNTIL

1: YOU ARE APPROVED BY US AS LIKELY QUALIFIED

2: YOU HAVE UPLOADED DOCUMENTS INCLUDING LAST PROGRESS NOTE AND RELEVANT TESTING FROM PHYSICIAN

3: YOU RECEIVED TEXT CONFIRMATION FROM US YOU ARE APPROVED TO REGISTER

We do not wish to waste your or our time if not approved.

If you have not yet been approved, or your condition is not yet qualified in Texas, you may consider ordering CBD which does not require special approval.

11007 Northpointe Blvd Phone: 832-345-3926

Tomball, TX 77375 Fax: 888-840-6973

www.thclinicians.com
Full Name*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Last 5 Numbers of Social Security #:*
Necessary to Register with CURT Program
Approximate Weight*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Main Phone Number*
This number is:*
Medical Durable Power of Attorney*

Name

Relationship to Patient

Main Phone NumberSecondary Phone Number

Email of DPOA
Other People Permitted to Discuss Care: Name / Relation / Phone Number
You will be requested to list again and sign HIPAA consent later in this form
Medical History: Does the patient now or has ever had

ArthritisOsteoporosisDementiaDepressionHigh Blood PressureHigh CholesterolLow ThyroidDiabetesHeart BlockageAtrial FibrillationCHF/Heart FailureAnemiaEmphysemaAsthmaKidney DiseaseHip/Pelvic FractureStroke / TIABlood ClotsCataractGlaucomaBPH / Prostate EnlargedSeizureCancer - LungCancer - BreastCancer - UterineCancer - ProstateOther
Other Medical Concerns

Recent weight lossRecent weight gainIncreased FatigueFeverFrequent Urine InfectionsRecent Falls/ImbalanceMacular DegenerationHearing ImpairedHeartburn/GERDConstipationDiarrheaNauseaTrouble Falling AsleepTrouble Staying AsleepAgitation / AggressiveAnxiety / WorryingChest PainShortness of BreathLeg SwellingHallucinationsNumbnessSkin RashSkin BreakdownOther
Specialists: Please list type, name, contact info, and any ongoing issues (If needed, we have a team of many specialists who can provide care by telehealth or at facility) Please sign Release of Information if you would like to give us permission to send or receive records.
Allergies or Intolerance to Medications: Please list all names and type of reaction
Medications: Please list any medications that you are now taking. Include vitamins, non-prescription medications, and supplements. Name of drug, Dose (strength & number of pills per day), Reason for taking, Concerns?
Preferred Hospital:
if there is one
Current Home Health:
if there is one
Preferred Pharmacy:
Specify if long term meds, or for new/urgent issues
Any additional information to keep in mind, social or family dynamics, past or future issues to consider, things the patient relates to well or prefers to avoid.
Hospice/Palliative Care: Please contact us to discuss further if you feel your family member is at the point where hospitalization is likely to cause more stress, suffering, and they are unlikely to recover to a reasonable quality of life. Problems and infections are still treated, but we will focus on comfort rather than hospitalization if they continue to worsen. Hospice can be revoked at any time. Dr. Valdez is one of few who are also Board-Certified in Hospice and Palliative Care. We will only continue as primary care for company he is associated as medical director. If another company is involved, they may have an excellent director, but it is similar to having to great chefs for one recipe. If things go wrong, we are not familiar with the other company's team or director, and we cannot properly address problems. If a patient or family chooses another company, Dr. Valdez will turn over all care to that company’s medical director to avoid any confusion in care. As medical director, he receives a flat fee, and there is no financial incentive to refer patients. When working with his team, he has clearer communication with the care team members, as well as closer oversight of quality of care.
Signature of Patient or Durable Power of Attorney*

Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
HIPAA Consent and Acknowledgment

Notice of Privacy Practices. I acknowledge that I have received the practice’s Notice of Privacy Practices, which describes the ways in which the practice may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the Privacy Officer designated on the notice if I have a question or complaint. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice’s Notice of Privacy Practices.

Release of Information. I hereby permit practice and the physicians or other health professionals involved in the inpatient or outpatient care to release healthcare information for purposes of treatment, payment, or healthcare operations. Healthcare information may be released to any person or entity liable for payment on the Patient’s behalf in order to verify coverage or payment questions, or for any other purpose related to benefit payment. If I am covered by Medicare or Medicaid, I authorize the release of healthcare information to the Social Security Administration or its intermediaries or carriers for payment of a Medicare claim or to the appropriate state agency for payment of a Medicaid claim. This information may include, without limitation, history and physical, emergency records, laboratory reports, operative reports, physician progress notes, nurse’s notes, consultations, psychological and/or psychiatric reports, drug and alcohol treatment and discharge summary. Federal and state laws may permit this facility to participate in organizations with other healthcare providers, insurers, and/or other health care industry participants and their subcontractors in order for these individuals and entities to share my health information with one another to accomplish goals that may include but not be limited to: improving the accuracy and increasing the availability of my health records; decreasing the time needed to access my information; aggregating and comparing my information for quality improvement purposes; and such other purposes as may be permitted by law. I understand that this facility may be a member of one or more such organizations.
Disclosures to Friends and/or Family Members: I give permission for my Protected Health Information to be disclosed for purposes of communicating results, findings and care decisions to the family members and others listed:Name, Relationship, Contact Number
Signature of Patient or Durable Power of Attorney:

Clear
Authorization To Obtain/Release Medical Information

Disregard this section and click 'Submit' if there are no relevant medical records to request.

Please complete this section if you would like to give permission for us to request or send information to other physicians who are or have been involved in the patient's care.

Conditions Of Authorization

I may revoke this authorization in writing. If I do, it will not affect any previous actions already taken in reliance upon my authorization. I may not be able to revoke this authorization if its purpose was to obtain records. I may revoke this authorization by writing a letter and mailing it certified, return receipt requested, to the Privacy Officer at the health provider listed above. Information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and longer protected by Federal Privacy Regulations.

This authorization is valid for the release of information as indicated above. Only records from this facility can be legally released. Any record for other physicians must be obtained from them.
Patient's Name

First NameLast Name
Date of Birth
Month / Day / Year
Patient Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician(s):
Name / Specialty / Address / Phone / Fax
Should be Empty: