Patient Intake Form Step 1 of 15 6% Patient InformationPatient First Name Patient Middle Initial Patient Last Name Patient D.O.B Patient Gender Patient Phone NumberPatient Alternate Phone Patient Email Patient Emergency Contact And Relationship Patient Emergency Contact And Phone NumberBy completing this portion of this form, you agree to receive automated phone and/ or text messages that will be made on behalf of our office to remind you of any and all future appointments. Standard text message rates may apply. Your email will be used to send out periodic newsletters and to keep you informed of updates going on within our office. Primary Care InformationPrimary Care Physician Name Primary Care Physician Phone NumberPrimary Care Physician Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Pharmacy InformationPharmacy Name Pharmacy Phone NumberPharmacy Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Insurance InformationHas there been any changes to your insurance since your referring physician sent over your information? Yes No Briefly describe the changes to your insuranceRegardless of your answer to the above question, please have your insurance card and photo ID with you at the time of your appointment. Receipt of Notice of Privacy Practices & Patient ConsentReceipt of Notice· of Privacy Practices & Patient Consent for Use and Disclosure of Protected Health Information(Required) I agree to the Receipt of Notice· of Privacy Practices & Patient ConsentI understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPP A) I have certain Patient Rights regarding my protected health information. I understand that Arthritis Autoimmune & Allergy, LLC may use and/or disclose my protected health information for treatment, payment or health care operations, which means for providing healthcare to me, the patient, handling billing and payment, and taking care of other health care operations. Unless required by law, there will be no other uses and disclosure of this information without my authorization. Arthritis, Autoimmune & Allergy, LLC has a detailed document called the "Notice of Privacy Practices." It contains a more complete description of my rights to privacy and how they may use and disclose my protected health information. The information is located at the front office and can be made accessible to me upon request,)(•. I understand that I have the right to read the full "Notice of Privacy Practices" document before signing this agreement. If I ask, Arthritis Autoimmune & Allergy LLC, will provide me with the most current "Notice of Privacy Practices." My signature below indicated that I have been given the opportunity to review such copy of the "Notice of Privacy Practices." My signature means that I agree to allow Arthritis Autoimmune & Allergy, LLC to use and disclose my protected health information to carry out treatment, payment, and health care operations. I have the right to revoke this consent in writing at any time, except to the extent that Arthritis, Autoimmune & Allergy, LLC has taken action relying on this consent.Signature - Receipt of Notice(Required)Date - Receipt of Notice(Required) MM slash DD slash YYYY Receipt of NoticeRelationship to Patient if signed by other party: *You may obtain a copy of our "Notice of Privacy Practices" including any revisions of our notice at any time by contacting our office: 1893 N Clyde Morris Blvd, Suite 110 Daytona Beach, FL 32117 (386) 676 - 0307 Office & Financial PoliciesOffice & Financial Policies I agree to the Office & Financial Policies1. All co-payments are due at the time of service. It is your responsibility as a patient, to be familiar with your individual insurance benefits prior to service. Please remember to have your insurance card with you at each appointment. 2. Your appointment time is reserved exclusively for you, if you are more than 15 minutes late to your appointment, we will need to reschedule the appointment. Please help us to serve you better by being on time for your scheduled appointments. 3, Lab, X-rays and all diagnostic test results are NOT given over the phone but rather at your next visit. If there is an abnormal result that warrants immediate attention, the office will contact you. 4. Please advise our office staff if there are any changes to your phone number, address, email or insurance so all communications with you as a patient are easily made. a. Failure to provide updated insurance information in a timely manner may cause insurance denials and non-coverage for procedures including in-office infusion therapy. Any claims denied due to the lack of updated insurance information will then become the responsibility of the patient. If new insurance information is provided, we will file the claim under that plan if the effective date falls within the range of the date of service. If the claim is denied by the health insurance plan for timely filing, the patient will be responsible for payment of the claim. 5. This practice participates in filling out FLMA and disability claim forms; this includes short-term disability claim forms. Patients are required to be seen for an office visit to have these forms filled out and are required to pay a $ 25 fee. A co-pay for the appointment may also be required. 6. If you are to request products or documents, be sent via mail, you may be held responsible to pay the allotted shipping cost for the item. Otherwise, products or documents may be picked up at our office at your convenience at no cost. 7. If your account becomes past due, it is your responsibility to clear the debt in full before you may schedule future visits with our office or render any services.Patient Signature - Office & Financial Policies(Required)Date -Office & Financial Policies MM slash DD slash YYYY No Show Fee PolicyNo Show Fee Policy I agree to the No Show Fee PolicyEffective August 21, 2023 At Arthritis, Autoimmune, & Allergy, we strive to provide timely and efficient healthcare services to all our patients. In order to ensure that our resources are utilized effectively and to minimize the waiting time for other patients, we have implemented a No-Show Fee Policy. This policy applies to all patients who fail to show up for their scheduled appointments or do not cancel within 24 hours. 1. No Show Fee Charges: a. New Patients: A fee of $50 will be charged for all new patients who fail to show up for their scheduled appointments or do not cancel within 24 hours. b. Established Patients: A fee of $30 will be charged for all established patients who fail to show up for their scheduled appointments or do not cancel within 24 hours. 2. Settlement of Fees: a. No future appointments can be scheduled until the No Show Fee is settled. b. The No Show Fee is the sole responsibility of the patient and must be paid in full before any further appointments can be made. c. For the initial occurrence, provided there is a valid and justifiable reason, the fee may be waived. 3. Three Strikes Policy: a. If a patient accumulates three instances of no show or failure to cancel within 24 hours, they will be considered in violation of our policy. b. Patients who violate the policy will be notified in writing and will no longer be able to schedule appointments at Arthritis, Autoimmune, & Allergy. We understand that unforeseen circumstances may arise, and we encourage our patients to inform us as soon as possible if they are unable to keep their scheduled appointments. By adhering to this No- Show Fee Policy, we aim to ensure that all patients receive the care they need in a timely manner. Please note that exceptions to this policy may be made in cases of emergencies or extenuating circumstances, which will be evaluated on a case-by-case basis. Thank you for your understanding and cooperation in helping us provide the best possible care to all our patients.Patient Signature - Office & Financial Policies(Required)Date - No Show Fee Policy MM slash DD slash YYYY Authorization for Release of Medical InformationAuthorization for Release of Medical Information I AgreeI, hereby authorize the physicians at Arthritis, Autoimmune and Allergy, LLC to release any information acquired in the process of insurance claims. I, also, authorize this office to release my medical records to my primary care and referring physician. In the event I am not available or not reachable, I give permission for Arthritis, Autoimmune and Allergy, LLC to leave a voice message on a voice messaging device. I give permission for Arthritis, Autoimmune and Allergy, LLC to release information verbally regarding my medical records, test results, appointment details or additional information to person(s) listed below:1.NameContact NumberRelationship Add Remove2.NameContact NumberRelationship Add Remove3.NameContact NumberRelationship Add RemoveTo add additional fields click the + icon located on the right side of any field.Patient Signature - Release of Medical Information(Required)Date - Release of Medical Information MM slash DD slash YYYY If you wish to remove or add additional person(s) to this form you will need to fill out a new form and submit it to our office. Any revocation of consent is to be made in writing and submitted to Arthritis, Autoimmune, and Allergy, LLC. Initial Patient Health SurveyReason for your visit (chief complaint): Do you smoke? Yes No Are you a former smoker? If yes, how often do you smoke? If you are a former smoker, when did you quit (approximately)? Personal Past Medical HistoryDo you now or have you ever had the following conditions?AnemiaKidney Disease Add RemovePleurisyLupus Add RemovePsoriasisBlood Clots Add RemoveThyroid DiseaseAnxiety Add RemoveAlcohol/Drug AddctionChronic Headaches Add RemoveDepressionIrritable Bowel Syndrome Add RemoveFibromyalgia/ Chronic PainHeart Disease Add RemoveAsthmaChronic Obstructive Pulmonary Disease Add RemoveDiabetesStroke Add RemoveColitisHigh Blood Pressure Add RemoveTuberculosisHIV/ AIDS Add RemoveCovid-19Cancer Add RemoveTo add additional fields click the + icon located on the right side of any field.Other known conditions: Do you have any known drug allergies? Yes No If you do have drug allergies, please list: Medication HistoryName of MedicationStrength & Dosage Add RemoveTo add additional fields click the + icon located on the right side of any field. Surgical HistorySurgeryYearReason Add RemoveTo add additional fields click the + icon located on the right side of any field. Family HistoryPlease list what family member if any, has the following conditions:Osteoporosis Lupus Rheumatoid Arthritis Ankylosing Spondylitis Psoriasis Hay Fever Allergy HistoryPlease select all of the following you are or have been affected by: Environmental HistorySeasonal PerennialSymptoms Induced by Add RemovePetsAsthmaDust Add RemovePlantsRhinitisAnimals Add RemoveGrass/Trees (near home)ConjunctivitisCut Grass Add RemoveMattressOtitisSeason Change Add RemovePillowEczemaWeather Change Add RemoveBlanketsSinusitisInsecticides Add RemoveBlinds/ CurtainsNasal Spray UseSmoke/Fumes Add RemoveRugsAngioedemaOdors Add RemoveStuffed AnimalsUrticariaCold Add RemoveHeating SystemInsect AllergyFood Add RemoveAir ConditioningDermatitisAsprin Add RemoveHumidifierInsect AllergyExertion Add RemoveTo add additional fields click the + icon located on the right side of any field.Please list any other things you are affected by:List more details, if possible, to the items you selected under the "Symptoms Induced by" column Self EvaluationA. Dress yourself Including tying shoelaces and doing buttons? WITHOUT ANY DIFFICULTY WITHOUT SOME DIFFICULTY WITH MUCH DIFFICULTY UNABLE TO DO B. Get In and out of bed? WITHOUT ANY DIFFICULTY WITHOUT SOME DIFFICULTY WITH MUCH DIFFICULTY UNABLE TO DO C. Lift a full cup or glass to your mouth? WITHOUT ANY DIFFICULTY WITHOUT SOME DIFFICULTY WITH MUCH DIFFICULTY UNABLE TO DO D. Walk outdoors on flat ground? WITHOUT ANY DIFFICULTY WITHOUT SOME DIFFICULTY WITH MUCH DIFFICULTY UNABLE TO DO E. Walk outdoors on flat ground? WITHOUT ANY DIFFICULTY WITHOUT SOME DIFFICULTY WITH MUCH DIFFICULTY UNABLE TO DO F. Turn faucets on and off? WITHOUT ANY DIFFICULTY WITHOUT SOME DIFFICULTY WITH MUCH DIFFICULTY UNABLE TO DO G. Bend down to pick up clothing from the floor? WITHOUT ANY DIFFICULTY WITHOUT SOME DIFFICULTY WITH MUCH DIFFICULTY UNABLE TO DO H. Get In and out of a car, bus, or airplane? WITHOUT ANY DIFFICULTY WITHOUT SOME DIFFICULTY WITH MUCH DIFFICULTY UNABLE TO DO I. Walk two miles if you wish? WITHOUT ANY DIFFICULTY WITHOUT SOME DIFFICULTY WITH MUCH DIFFICULTY UNABLE TO DO J. Participate In recreational activities and sports as you would like, If you wish? WITHOUT ANY DIFFICULTY WITHOUT SOME DIFFICULTY WITH MUCH DIFFICULTY UNABLE TO DO K. Participate In recreational activities and sports as you wish WITHOUT ANY DIFFICULTY WITHOUT SOME DIFFICULTY WITH MUCH DIFFICULTY UNABLE TO DO L. Get a good night's sleep? WITHOUT ANY DIFFICULTY WITHOUT SOME DIFFICULTY WITH MUCH DIFFICULTY UNABLE TO DO M. Deal with feelings of a rudely or being nervous? WITHOUT ANY DIFFICULTY WITHOUT SOME DIFFICULTY WITH MUCH DIFFICULTY UNABLE TO DO N. Deal with feelings of depression or feeling blue? WITHOUT ANY DIFFICULTY WITHOUT SOME DIFFICULTY WITH MUCH DIFFICULTY UNABLE TO DO Δ