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Caswell Cares
Patient Registration Form
Please Note: Before starting this form, please be sure you have approximately 10 minutes to complete. You cannot save your work and return later.
Patient Registration Form
Please Choose Your Preferred Medical Center
*
Caswell Family Medical Center, Yanceyville
James Austin Health Center, Eden
CFMC Urgent Care
Caswell Senior Services
Caswell County Health Department
Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Middle
Last
Email Address
Address
*
Street Address
Address Line 2
City
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Armed Forces Americas
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ZIP Code
Home Phone
*
Work Phone
Cell Phone
Do you have a preference for a specific provider? If so, which one?
No Preference
Dr. Stephen Kikel (Family Medicine, Yanceyville)
Dr. Denise Hunter (Internal Medicine, Yanceyville)
Dr. Serena Zhou-Talbert (Family Medicine, Yanceyville)
Dr. Douglas Browning (Sports & Family Medicine, Eden)
Beth DeKoninck, FNP-C (Family Medicine, Eden)
Meredith Harris, FNP-C (Family Medicine, Yanceyville)
Jason Vaughn, FNP-C (Family Medicine, Eden)
Lindsey Strader, FNP-C (Family Medicine, Yanceyville)
Kristen Price, FNP-C (Family Medicine, Yanceyville)
Connie Robinette, PMHNP-BC (Psychiatric Nurse Practitioner, Yanceyville)
Tania Hyppolite, LCSW (Behavioral Health, Yanceyville)
Sara Laws, LCSW (Behavioral Health, Caswell Senior Center/Health Department)
Teneka Striblin, LCSW (Behavioral Health, Eden)
If your Primary Care Provider (PCP) is not CHC, please list the PCP/Practice name and Phone Number:
PCP Name
First
Last
Practice Name
PCP Phone Number
Social Security Number
*
Date of Birth
*
MM
DD
YYYY
Gender
*
Female
Male
Transgender M
Transgender F
Sexual Orientation
*
Lesbian/Gay
Straight
Bisexual
Something Else
Don't Know
Not Disclosed
Marital Status
*
Married
Single
Divorced
Widowed
Legally Separated
Partner
Employment Status
*
Full Time
Part Time
Not Employed
Self Employed
Retired
Active Military
Employer Name (If Applicable)
Student Status
*
Full Time
Part Time
Not a Student
Race
*
American Indian/Alaska Native
Asian
Native Hawaiian/Pacific Islander
Black/African American
White
Other
Declined
Ethnicity
*
Hispanic/Latino
Not Hispanic/Latino
Declined
Language
*
English
Spanish
Indian
Japanese
Chinese
Korean
Other
Email Address
*
What pharmacy do you use?
*
Housing Status
*
Homeless
Doubling Up
Private Residence
Group Home
Nursing Home
Are You Disabled?
*
Yes
No
Are You a Veteran?
*
Yes
No
Do you have an Advanced Directive (living will, DNR, etc.)?
*
Yes
No
Emergency Contact
Name
*
First
Last
Phone
*
Relationship to Patient
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Caregiver's Information (if applicable)
Name
First
Last
Phone
Caregiver's Relationship
Legal Guardian
Power of Attorney
Other
Certification
I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge.
Patient or Guardian Name
*
First
Last
Date
*
MM
DD
YYYY
NOTICE OF AUTHORIZATIONS & ASSIGNMENT OF BENEFITS
Assignment of Insurance Benefits:
I HEREBY AUTHORIZE DIRECT PAYMENT OF INSURANCE BENEFITS TO COMPASSION HEALTH CARE, INC. or the physician individually for services rendered to my dependents, or me, by the physician or those under his/her supervision. I understand that it is my responsibility to know my insurance benefits and whether or not the services I am to receive are a covered benefit. I understand and agree that I will be responsible for any co-pay or balance due that Compassion Health Care, Inc. is unable to collect from my insurance carrier, for whatever reason.
Authorization to release non-public information:
I certify that I have read and been offered a copy of the Compassion Health Care, Inc. “HIPAA Notice of Privacy Practices”, as well as receipt of Compassion Health Care, Inc.’s Office Practices and Patient Rights & Responsibilities. I hereby authorize Compassion Health Care, Inc. and/or the physician individually to release any of my or my dependent’s medical or incidental nonpublic personal information that may be necessary for medical evaluation, treatment, consultation, or the processing of insurance benefits. Compassion Health Care, Inc. reserves the right to revise its Notice of Policy Practices, Office Practices, and Patient Rights and Responsibilities at any time. A copy of such revisions will be available upon request.
Medicare/Medicaid Information:
I certify that the information given by me in applying for payment under these programs is correct. I authorize the release of any of my or my dependent’s records that these programs may request. I hereby direct that payment of my or my dependent’s authorized benefits may be made directly to Compassion Health Care, Inc., or the physician on my behalf.
Lab Testing:
I understand that I may receive a separate bill if my medical care includes lab services. I further understand that I am financially responsible for any co-pay or balances due for these services if they are not reimbursed by my insurance for whatever reason.
Prescriptions:
I acknowledge that my treating physician/medical provider may obtain a prescription history if it is deemed necessary.
Consent to Treatment:
I hereby consent to the evaluation, testing, and treatment as directed by my Compassion Health Care, Inc. physician or those under his/her supervision.
My signature below certifies that I have read and agree to all of the information stated above.
Name
*
First
Last
Date
*
MM
DD
YYYY
Do you wish to enroll for access to your medical records via CHC’s patient portal?
*
Yes
No
*Note: When you enroll, you will receive an email message at the address you gave us at the beginning of this form. You are strongly encouraged to use an email address that only you have access to.
PATIENT MEDICAL HISTORY INFORMATION
Please list all allergies, including medicines, foods, environmental and betadine:
Do you have, or have you had, any of the following health conditions?
Check all that apply
Diabetes (Sugar)
High Blood Pressure
Asthma/Emphysema
Heart Attack
Heart Disease
Stroke
Tuberculosis
Cancer
Seizures
Glaucoma
Kidney Disease
Kidney Stones
Arthritis
Osteoporosis
Mental Illness
Alcoholism
Check all that apply
Hay Fever
Pneumonia
Broken Bones
Phlebitis
Skin Disease
Gout
Rheumatic Fever
German Measles
Chicken Pox
Hepatitis
Peptic Ulcer
Vaginal Infection
Sexually Transmitted Disease (STD)
Anemia
High Cholesterol
Blood Transfusion
Other (Please Describe):
Have any family members had the following health problems?
Diabetes (Sugar)
High Blood Pressure
Asthma/Emphysema
Heart Attack
Heart Disease
High Cholesterol
Stroke
Tuberculosis
Cancer
Seizures
Glaucoma
Kidney Disease
Kidney Stones
Arthritis
Osteoporosis
Mental Illness
Alcoholism
List the family member who has had any of the health problems.
Have you had any of the following surgeries?
Tonsils/Throat
Gall Bladder
Bone
Lung
Tubal Ligation
Thyroid
Appendix
Prostate
Breast
Ear
Colon
Circumcision
Hysterectomy
Eye
Kidney
Vasectomy
C-Section
Stomach
Hernia
Heart
Ovaries
Other Surgery (Please Explain)
Social History (Please check all that apply)
Alcohol Use (Any Type)
Tobacco Use (Any Type)
"Street" Drug Use (Any Type)
Female Patients Only
What year was your last delivery?
Period/Menstrual Cycle
Regular
Irregular
First Day of Last Period
MM
DD
YYYY
Total # Pregnancies
Total # Live Births
Total # Miscarriages/Stillbirths
Total # Abortions
Please list all medications, including birth control and over-the-counter medications
Do you have any of the following symptoms or conditions? (Please check all that apply)
General Symptoms
Fatigue
Fever/Chills
Headaches
Loss of Appetite
Eyes
Discharge
Burning/Itching
Eye Pain
Loss/Blurred Vision
Ears, Nose & Throat
Ear Pain
Sinusitis
Nasal Discharge
Sore Throat
Cardiovascular
Chest Pain at Rest
Stress Pain During Strenuous Activities
Shortness of Breath While Lying Down
Swelling of Ankles
Palpitations
Respiratory
Coughing
Wheezing
Shortness of Breath
Snoring
Gastrointestinal
Nausea
Vomiting
Diarrhea
Constipation
Blood in Stool
Abdominal Pain
Heartburn
Genitourinary
Painful Urination
Frequency Urination
Blood in Urine
Musculoskeletal
Back Pain
Neck Pain
Joint Pains
Muscle Pain
Integumentary
Skin Rashes
Changes in Moles
Neurological
Blackouts
Tingling
Paresthesia/Numbness
Local Weakness
Seizure Activity
Psychiatric
Anxiety
Depression
Moodiness
Endocrine
Excessive Thirst
Change in Weight
Hematologic/Lymphatic
Abnormal Bleeding
Anemia
DISCLOSURE OF PROTECTED HEALTH INFORMATION
Patient Name
*
First
Last
Date of Birth
*
MM
DD
YYYY
HIPAA (The Health Insurance Portability and Accountability Act) gives you the right to request that we communicate financial and/or medical information to you in confidence by a particular method. In order to protect the privacy and confidentiality of your information, please complete the following. This form will tell us how you wish to be contacted and with whom we may discuss your healthcare, insurance, and billing questions.
CHC may contact me at the following phone numbers:
Home
Cell
Work
CHC has my permission to leave a fully detailed message at:
Home
Cell
Work
CHC has my permission to leave a ‘minimum necessary’ message at:
Home
Cell
Work
This authorization permits the disclosure of protected health information that includes, but is not limited to, test results, diagnosis, treatment, and billing information. This information includes mental illness or developmental disability, psychotherapy notes, HIV/AIDS testing or treatment (including information regarding test order, performance, or results, regardless if the results were positive or negative), sexually transmitted disease, substance abuse, abused of an adult with a disability, sexual assault, child abuse or neglect, genetic testing.
I hereby authorize that the protected health information regarding the above-named person may be discussed with me or the following person(s):
Name
First
Last
Relationship
Name
First
Last
Relationship
CHC will continue to communicate with you according to your above response(s) until you change your preferences. We will continue to leave appointment confirmations on your primary phone number. You can make a change by completing a new form. By signing below, you grant permission to the communication outlined above.
Patient Name
*
First
Last
Date
*
MM
DD
YYYY
Signature of Parent/Legal Guardian/Personal Representative (Required if patient is not legally authorized to sign this form).
First
Last
Relationship to Patient
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