NEW PATIENT MEDICAL HISTORY FORM

Name: (First)______________________________ (Last) ______________________________ (MI)

Previous Doctor Name: _____________________ Phone Number:

Past medical history (check all that apply):

Last Pap smear: _____________ History of abnormal pap (explain):

Last mammogram: ___________ History of abnormal mammogram (explain):

Last colonoscopy: ___________ History of abnormal colonoscopy (explain):

History of varicella vaccine or chickenpox? (y/n) __________ When:

History of shingles or shingles vaccine? (y/n) __________ When: History of MMR vaccine? (y/n) __________ When: History of flu vaccines? (y/n) __________ When: Other:

Allergies:​ (Medications)____________________________ (Food)

Current smoker (_____ packs/day)□ Past smoker (quit _____ years ago) Infrequent□ Regularly (_____ times per week)

Family History (please list medical problems of each family member)

Mother: ________________________________ Father:

Brother(s): ______________________________Sister(s)

Paternal Grandfather:______________________Paternal Grandmother:

Maternal Grandfather:_____________________Maternal Grandmother:

Review of Systems ​(Check all that apply, please review list carefully)

Chest pain □ Irregular heartbeat □ Difficulty breathing when lying flat

As a courtesy to our patients, we will gladly file the forms necessary so that you receive the full benefits of your medical coverage. We ask that you read your insurance policy to be fully aware of any limitations of the benefits provided. If you are concerned about coverage for any of our services, please contact your insurance company prior to your visit. If your insurance company denies coverage, or we otherwise do not receive payment 60 days from filing your claim, the amount will then become due and payable by you. Remember that your coverage is a contract between you and your insurance company and/or your employer and your insurance company. Although we will make a good faith effort to assist you in obtaining your benefits, we cannot force your insurance company

to pay for the services we have provided to you. ​PLEASE NOTE: if your insurance changes it is the patient’s responsibility to verify

that ​VITALITY WEIGHT LOSS AND WELLNESS INSTITUTE PLLC is contracted with the new insurance plan. Copays, deductibles, and

coinsurance are due at the time of service, NO EXCEPTIONS will be made.

We do NOT accept cash or checks, the only form of payment accepted is credit/debit cards as noted below.

Appointments/Cancellations​: We gladly reserve appointment times for you and appreciate that you have chosen Vitality for your care. As a courtesy, we will remind you of your appointment by calling and/or text/emailing you prior to your scheduled date and time. However, in the event your mailbox is full, or your line is busy, our efforts to contact you may be unsuccessful. An appointment is a contract of time reserved for your treatment. We respect our patient’s valuable time, and we request the same courtesy from our patients. Please extend this courtesy should you need to cancel and/or reschedule your appointment. We reserve the right to charge $75 for regular appointments cancelled or broken without advance notice of 2 business days.

I authorize payment to be made directly to Vitality by my insurance company, and I accept financial responsibility for all services not covered by my insurance. I authorize the release of any medical care information requested by my insurance company. My signature below acknowledges that I have read and understand this information.

Vitality is committed to making our billing process as simple and easy as possible. We require that all patients provide a credit card on file with our office. We will store your card number in a secure, compliant location in your electronic medical record. For security reasons only the last four digits will be visible to our staff. Credit cards on file will be used to pay copays when you are seen in our office, including account balances, after your insurance processes your claim.

You will be notified by email of pending charges 5 days before the charges occur, and again when the credit card is charged. You will also receive an email receipt when the card is charged.

I have read and agree to the above policies.

Signature____________________________________________Date

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; THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.

The law requires us to keep your protected health information (PHI) private in accordance with this Notice of Privacy Practices (Notice) as long as this Notice remains in effect. We are also required to provide you with a paper copy of this notice, which contains our privacy practices, our legal duties, and your rights concerning your PHI.

From time to time, we may revise our privacy practices and the terms of our Notice at any time, as permitted or required by applicable laws. Such revisions to our privacy and our Notice may be retroactive. Our Notice will be updated and made available to our patients prior to any significant revisions of our privacy practices and policies.

Use and Disclosure: We may use or disclose your PHI for treatment, payment or health care operations. For your

convenience, we have provided the following examples of such potential uses or disclosures.

Treatment​: ​Your PHI may be used by or disclosed to any physicians or other health care providers involved with the

medical services provided to you.

Payment: ​Your PHI may be used or disclosed in order to collect payment for the medical services provided to you.

Health Care Operations​: Your PHI may be used or disclosed as part of our internal health care operations. Such health

care operations may include among other things, quality of care audits of our staff and affiliates, conducting training programs, accreditation, certification, licensing or credentialing activities.

Authorizations: ​We will not use or disclose your medical information for any reason except those described in this

Notice, unless you provide us with a written authorization to do so. We may request such an authorization to use or disclose your PHI for any purpose, but you are not required to give us such authorization as a condition of your treatment. Any written authorization from you, may be revoked by you in writing at any time, but such revocation will not affect any prior authorized uses or disclosures.

Patient Access​: We will provide you with access to your PHI, as described below in the Individual Rights section of this

Notice. With your permission, or in some emergencies, we may disclose your PHI to your family members, friends, or other people to aid in your treatment or the collection of payment. A disclosure of your PHI may also be made if we determine it is reasonably necessary

Disasters​: We may use or disclose your PHI to any public or private entity authorized by law or by its charter to assist in

Required by Law: We may use or disclose your medical information when we are required to do so by law. For

example, your PHI may be released when required by privacy laws, workers’ compensation or similar laws, public health laws, court or administrative orders, subpoenas, certain discovery requests, or other laws, regulations or legal processes. Under certain circumstances, we may make limited disclosures of PHI directly to law enforcement officials or correctional institutions regarding an inmate, lawful detainee, suspect, fugitive, material witness, missing person, or a victim or suspected victim of abuse, neglect, domestic violence or other crimes. We may disclose your PHI to the extent reasonably necessary to avert a serious threat to your health or safety or the health or safety of others. We may disclose your PHI when necessary to assist law enforcement officials to capture a third party who has admitted to a crime against you or who has escaped from lawful custody.