New Pateint Paper Work form

New Patient Paper Work

Your Contact Information
First Name*
Last Name*
Date of Birth*
E-mail Address
Phone*
Home Address*
Social Security Number*
Emergency Contact Name
Emergency Contact Phone Number
Medical Insurance Information
Medicare number (if applicable)
Medi-cal number (if applicable)
Primary Insurance Name*
Name of Insured*
Policy Number*
Group Number
Secondary Insurance Name
Name of Insured
Policy Number
Group Number
What is the reason for your visit?
What are you current or past medical issues?
Past surgeries?
Medications (please list the name, strength and how often you take each medication)
Medication Allergies (please list the name of the medication and type of allergic reaction)
Pharmacy Name
Pharmacy Phone Number
Pharmacy Address
Social History
Any past or current history of Tobacco, alcohol or drug abuse?
Family History
Please list any family medical history
Review of systems (Are you experiencing any of the following? Please check all that apply)
General
- Fever
- Chills
- Weight gain
- Weight loss
- Fatigue
- Dizziness
HEENT
- Vision Changes
- Dry eyes
- Dry mouth
- Double Vision
- Oral Ulcers
Cardiac
- Chest pain
- Palpitations
- Irregular heartbeat
- High blood pressure
Pulmonary
- Shortness of breath
- Wheezing
- Cough
Gastroenterology
- Stomach pain
- Reflux
- Nausea
- Vomiting
- Diarrhea
- Constipation
Musculoskeletal
- Joint pain
- Joint swelling
- Muscle pain
- Muscle weakness
Neuro
- Headaches
- Loss of sensation
- Tingling
- Tremors
Skin
- Rashes
- Hives
- Tight skin
- Ulcerations
Other symptoms
THIS PATIENT CONSENT FORM IS FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION, FOR TREATMENT, PAYMENT AND/OR HEALTHCARE OPERATIONS.
I understand that as part of my health care, Dr.Chandrakant Mehta, Dr.Amal Mehta, Dr.Dharmarajan Ramaswamy, Lisa Garcia, FNP, Southland Arthritis & Osteoporosis Medical Center, C.V.Mehta MD Medical Corporation and their affiliates originates and maintains paper and/or electronic medical records describing my health history, symptoms, examination, test results, diagnosis, treatment, and any plans for the future care of treatment. I understand that this information serves as:
A basis for planning my care 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 surgical information to my bill
- A means by which a third-party payer can verify that the services billed were actually provided.
- 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 the consent,
- The right to object to the use of my health information for directory purposes
- The right to request restrictions as to how my health information may be used or disclosed to carry
out treatment, payment, or health care options.
I understand that Dr.Chandrakant Mehta, Dr.Amal Mehta, Dr.Dharmarajan Ramaswamy, Lisa Garcia, FNP, Southland Arthritis & Osteoporosis Medical Center, C.V.Mehta MD Medical Corporation and their affiliates are not required to agree to the restrictions requested. I understand that they may revoke this consent in writing. I also understand that by refusing to sign this consent, this organization may refuse to treat me as permitted by section 164:506 of the code of Federal Regulations. I understand that Dr.Chandrakant Mehta, Dr.Amal Mehta, Dr.Dharmarajan Ramaswamy, Lisa Garcia, FNP, Southland Arthritis & Osteoporosis Medical Center, C.V.Mehta MD Medical Corporation and their affiliates reserves the right to change this notice and practices in accordance with section 164:520 of the code of Federal Regulations. Should this organization change the notice, they will send me a copy of any revised notice to the address I have provided (whether by U.S. mail or by Email).
I understand that as part of this organization’s treatment, payment, or health care options, 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, answering machine, or a family member. I fully understand and accept the terms of this consent.
Signature*
Full Name*
Date*
Missed appointments Fees and Rescheduling
Our physicians want to be available for your needs. Unfortunately when a patient does not show for their scheduled appointment, another patient loses an opportunity to be seen. So if you are not able to make your appointment, please call us before 10 am on the business day prior to your appointment, otherwise a fee of $25.00 will be billed. Schedules fill up quickly, if you miss an appointment without calling, we may not be able to reschedule as soon as you would like. This policy enables us to better utilize available appointments for our patients in need of medical care.
Copays and other charges due at time of service?
Copayment is expected at the time of service. Services provided which are not a covered benefit of your health plan will be your financial responsibility.
How to refill a prescription
If you need a prescription refilled please plan ahead. Many Rheumatology medications should not be discontinued or stopped unexpectedly. Complete the online medication refill request form on the Southland Arthritis website for the fastest response time. Call your pharmacy to request a refill 5 working days in advance. Do not call our office. If you already have refills authorized, the pharmacist will be able to fill your prescription quickly. If you do not have refills then the pharmacist will notify our office. It will take 3-5 working days to complete the authorization for your prescription and inform the pharmacy. Mail order prescriptions will also need 5 working days to complete.
Forms/Record Requests
There is a charge for most forms, such as Jury Duty excuse, DMV placard, disability exam form, FMLA form.
If you are coming from another Medical Group or Doctor's office you can request your records be sent here. A signed medical release by you will initiate that a copy of your records be sent. The form will need your signature and to be mailed to your previous physician's office. If you are already an existing Southland Arthritis patient and an outside physician is requesting your records, a signed release is also needed. On the average most facilities require about 15 working days to have the records copied and sent.
Signature*
Full Name*
Date*
Authorization For Release of Medical Records
I hereby authorization the following health care organization to release my medical records:
Patient Name*
Patient Date of birth*
Electronically to our HIPAA complaint email address: records@southlandarthritis.com
Fax: (855) 306-0135
Offices Addresses:
- Hemet Office: 949 Calhoun Pl, Suite F, Hemet, CA 92543
  Phone (951)652-5000; Fax (855) 306-0135
- Menifee Office: 29798 Haun Rd, Suite 301, Menifee, CA 92586
  Phone (951) 672-1866; Fax (855) 306-0135
- Temecula Office: 31515 Rancho Pueblo Rd, Suite 203, Temecula, CA 92592
  Phone (951) 303-1500; Fax (855) 306-0135
- Moreno Valley Office: 23100 Eucalyptus Ave, Moreno Valley, CA 92553
  Phone (951) 924-6500; Fax (855) 306-0135
Medical Information Release
If you would like to authorize the providers of Southland Arthritis to discuss your medical conditions with a relative, friend or health care surrogate, please complete the information below.
Providers:
Chandrakant Mehta, MD
Amal Mehta, MD
Dharmarajan Ramaswamy, MD
Lisa Garcia, FNP
Signature*
Full Name*
Date*
Medical Information Release
If you would like to authorize the providers of Southland Arthritis to discuss your medical conditions with a relative, friend or health care surrogate, please complete the information below.
Providers:
Chandrakant Mehta, MD
Amal Mehta, MD
Dharmarajan Ramaswamy, MD
Lisa Garcia, FNP
Patient Name
Patient Date of birth
Health care Surrogate's Name
Relationship to the patient
Signature*
Full Name*
Date*
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New Patient Paper Work

Your Contact Information

Medical Insurance Information

Social History

Family History

Review of systems (Are you experiencing any of the following? Please check all that apply)

Missed appointments Fees and Rescheduling

Copays and other charges due at time of service?

How to refill a prescription

Forms/Record Requests

Authorization For Release of Medical Records

Medical Information Release

Medical Information Release

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