New Patient Documents - Physicians` House Calls

Physicians’ House Calls
115 Roesler Road
Glen Burnie, MD 21060-1088
Phone: 410-766-8009
Fax: 410-766-8022
Thank you for choosing Physicians’ House Calls as your Home Health Care Provider. Attached you will find
the New Patient Information Packet, Health History Forms and a Medication List that are needed from each potential
patient. We will begin the new patient process immediately after receiving the completed forms, along with photo
copies of the patient’s identification and insurance cards (front and back), via fax email or USPS. You will receive
a phone call after all information is verified, and given an estimated date for your home visit. The Physicians’ House
Calls provider’s visits their patients according to geographical locations, therefore scheduling a patient could
possibly take up towards two (2) weeks after receiving and verifying all completed forms. Should you have any
questions and or concerns please do not hesitate to call.








Patient Information
New Patient Consent
Authorized Account Users
Authorization for Release of Medical Records
Patient Medication List
Health History
Family History
Copies of Identification & Insurance Cards
Thank you
Physicians’ House Calls
Physicians’ House Calls
115 Roesler Road
Glen Burnie, MD 21060-1088
Phone: 410-766-8009
Fax: 410-766-8022
I would like to personally welcome you to Physicians’ House Calls. Since 1999, Physicians’ House Calls has
demonstrated an ability to reduce emergency room visits and hospital admission rates by providing physicians to
deliver high quality comprehensive, at home medical services.
Our practice benefits our patients by:

Providing excellent patient care, done exclusively by our physicians.

Working in coordination with all home health agency providers.

Utilize hospitals to manage any necessary inpatient care.

We participate with the Medicaid and Medicare program

Strong bedside medical services, including:
1. Blood Draws
2. Wound Care
Research studies have determined that homebound patients prefer to be seen by only physicians. We try to achieve
consistency with all of our patients and physicians in scheduling our house calls, however, due to the unique nature
of our mobile practice we may need to rotate physicians to you, but don’t worry, you will always have a high
qualified doctor.
With Physicians’ House Calls home based evaluation, management, and testing capabilities, specialized home health
nursing agencies are readily available to assist us. Regular visits by our physicians can detect and address subtle
features of advancing disease.
Thank you for your time, we appreciate the fact that you chose our practice and we hope our doctors become your
doctors.
Dr. Jeffrey Katz MD
Naketa Brown/ Assistant
**********PATIENTS INFORMATION**********
Patients
Last Name
:_________________________________ First Name
:_______________________MI: ______
Assisted Living Facility Name:____________________________________Owner:__________________________
(If applicable)
Home Address:_______________________________________________________________________________
City
:_________________________________ State:_________ Zip Code:_______________________
Birthday
:______/_____/_____
Social Sec
:_________________________________ Home Phone :________________________________
Emergency Contact
Race_______________
Sex (M/F)_______ Status:________ (S M D W )
:_____________________________Relationship:__________________________________
Emer Phone :__________________________________ Cell/Work Phone:______________________________
Name and address for all
Correspondence and Bills:_______________________________________________________________________
****************************************************INSURANCE*********************************************************
Member ID#: ____________________________
Referral Date: ______________________________
PCP: __________________________________
PCP Phone#: ______________________________
Case Mgr/Nurse: _________________________
Office #: _______________ Cell #: _____________
Email: _________________________________
Fax #: ____________________________________
Care Coordinator: ________________________
Phone #: __________________________________
MA#: __________________________________
Special Instructions: _________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
**********GUARANTOR INFORMATION / POWER OF ATTORNEY**********
Name
:________________________________________________________________________________
Address
:________________________________________________________________________________
City
:__________________________________ State :________
Telephone
:__________________________________ Miscellaneous :________________________________
Zip Code :____________________
PATIENT’S AUTHORIZATION
I authorize Physicians House Calls to apply for benefits on my behalf for services rendered by Physicians House
Calls. I request payment from my insurance company be made directly to Physicians House Calls. I certify that the
information I have reported with regard to my insurance coverage is correct and further authorize the release of any
necessary information, including medical information for this or any related claims. I permit a copy of this
authorization to be used in place of the original. I may revoke this authorization at any time in writing. I understand
that nothing herein relieves me of the primary responsibility and obligation to pay for medical services provided,
when a statement is rendered.
_____________________________________________
Signature of Subscriber or Beneficiary
____________________________________
Date
PHYSICIANS’ HOUSE CALLS
New Patient Consent to the Use and Disclosure of Health Information for
Treatment, Payment or Healthcare Options
I, ___________________________, understand that as part of my health care, Physicians’ House Calls, originates
and maintains paper and/or electronic records describing my health history, symptoms, examination and test results,
diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as:





A basis for care plan oversight and treatment.
A means of communication among the many health professionals who contribute to my care.
A source of information for applying my diagnosis and other information to my bill.
A means by which a third-party can verify that services billed were actually provided, and
A tool for routine healthcare operations such as assessing quality and reviewing the competence of
healthcare professionals.
I understand and have been provided with a Notice of Information Practices that provides a more complete
description of information uses and disclosures. I understand that I have the following rights and privileges.



The right to review the notice prior to signing this Consent
The right to object to the uses of my health information for directory purposes, and
The right to request restriction as how my health information may be used or disclosed to carry out
treatment, payment or health operations
I understand the Physicians’ House Calls, is not required to agree to the restriction requested. I understand that I may
revoke this Consent in writing, except to the extent that the organization has already taken action in reliance thereon.
I also understand that by refusing to sign this Consent or revoking this Consent, this organization may refuse to treat
me as permitted by Section 164.520 of the Code of Federal Regulations.
I further understand that Physicians’ House Calls, reserve the right to change their notice and practices prior to
implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should Physicians’ House
Calls, make any significant changes in their policy, we will change our notice and post a new notice in the waiting
area and in each examination room. You can request a copy of our notice any time.
I wish to have the following restriction to the use or disclosure of my health information.
__________________________________________________________________________________________
__________________________________________________________________________________________
I understand that as part of this organization’s treatment, payment or healthcare operations, it may become necessary
to disclose my protected health information to another entity, and I consent to such disclosure for these permitted
uses, including disclosures via fax.
I fully understand and ACCEPT / DECLINE the terms of this Consent
_____________________________________
Patient’s Signature
________________________
Date
Physicians’ House Calls
115 Roesler Road
Glen Burnie, MD 21060-1088
Phone: 410-766-8009
Fax: 410-766-8022
NOTICE OF INFORMATION PRACTICES
This notice describes how medical information about you may be used, disclosed
And how you can get access to this information.
USES AND DISCLOSURE OF HEALTH INFORMATION
Physicians’ House Calls may seek your consent to use health information about your treatment to obtain payment for
treatment, for administrative purposes and to evaluate the quality of healthcare that you receive. You can revoke
your consent.
Physicians’ House Calls may use or disclose identifiable health information about you without your authorization for
public health purposes, for auditing purposes, for research studies and for emergencies. We provide information
when otherwise requested by law, such as for law enforcement in specific circumstances. In any other situation, we
will ask for your written authorization before using or disclosing any identifiable health information about you. If
you choose to sign an authorization to disclose information, you may later revoke the authorization to stop any future
uses or disclosures.
INDIVIDUAL RIGHTS
In most cases, you have the right to look at or get a copy of health information about you that Physicians’ House
Calls uses to make decisions about you. If you request copies, we will charge you’re for a retrieval fee, copying and
postage. You also have the right to receive a list of instances where we disclosed health information about you for
reasons other than treatment, payment or related administrative purposes. If you believe that the information in your
record is incorrect or if important information is missing, you have the right to request that we correct the existing
information or add the missing information.
COMPLAINTS
If you are concerned the Physicians’ House Calls has violated your privacy rights or you disagree with a decision we
made about access to your records, you may contact our office or the U.S. Department of Health and Human
Services.
OUR LEGAL DUTY
Physicians House Calls is required by law to protect the privacy of your information, provide this notice about out
information practices and follow the information practices that are described in this notice.
Physicians’ House Calls
115 Roesler Road
Glen Burnie, MD 21060-1088
Phone: 410-766-8009
Fax: 410-766-8022
AUTHORIZED ACCOUNT USERS
Please help us maintain your privacy. Please list below the names, addresses, and phone numbers of the
person/persons that we can speak to directly about your healthcare, account status or general information.
NAME
ADDRESS
PHONE
______________________
____________________________
________________________
____________________________
______________________
____________________________
________________________
____________________________
______________________
____________________________
________________________
____________________________
______________________
____________________________
________________________
____________________________
___________________________________
Patient’s Signature
________________________
Date
Physicians’ House Calls
115 Roesler Road
Glen Burnie, MD 21060-1088
Phone: 410-766-8009
Fax: 410-766-8022
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
Patient Information
Request Release From
___________________________________
Name
___________________________________
Address
___________________________________
City, State
___________________________________
____________________________________
Date of Birth:
_____________________
____________________________________
Social Security: _____________________
____________________________________
____________________________________
____________________________________
____________________________________
I hereby authorize you to release to _Physicians’ House Calls_ a copy of my medical records to be used for
continuing medical care. I reserve the right to revoke this authorization in writing at any time. Further, I understand
that this Protected Health Information may be re-disclosed by the recipient and thus, no longer protected under
privacy rules.
___________________________________
Patient/Guarantor Signature
____________________________________
Date
Please include the FOLLOWING ITEMS:
_________ Admission Notes
_________ Progress Notes
_________ Discharge Summary
_________ Pathology Reports
_________ Operative Reports
_________ Consultation Notes
_________ EKG’s
_________ Laboratory Notes
_________ X-Ray Reports
_________ Stress Tests
_________ Other _____________________
Remarks: _____________________________________________________________________
_____________________________________________________________________________
Patient’s authorization will expire on _______________________________________________