New Pateint Paper Work form

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*

Captcha

Phone

This field is for validation purposes and should be left unchanged.

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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