Addiction Therapy Intake
PATIENT INFORMATION FORM
For the best results, please use the latest version of Chrome or Firefox browser to submit your results.Primary Care Physician: Primary Care Physician Telephone Number:
Patient Name: Date of Birth: Sex:
Marital Status: Social Security Number: E-mail Address: Home Address: City: State: Zip: Home Number: Work Number: Cell Number: Emergency Contact: Relationship to Emergency Contact: Home Number: Work Number: Cell Number:
Primary Insurance: Telephone Number: Claim Submission: City: State: Zip: ID Number: Group Number: Effective Date: Subscriber’s Name: Subscriber’s Date of Birth: Relationship to Subscriber:
Secondary Insurance: Telephone Number: Claim Submission: City: State: Zip: ID Number: Group Number: Effective Date: Subscriber’s Name: Subscriber’s Date of Birth: Relationship to Subscriber:
QUESTIONNAIRE TO BE FILLED IN BY ALL NEW PATIENTS Name: Date: Age: Sex
Disabled/Reason for Disability: Occupation:
What providers have you seen for treatment of your addiction?
What treatment options have you tried?
What medication(s) have you tried ?
Do you engage in physical activity daily/weekly? If so, explain:
What are your expectations of how we can help you?What are your expectations of how we can help? Select the corresponding number (1-10) to show how far from normal toward the worst possible situation your pain has caused you to be. The lower numbers are the “best” or “normal” situation and the higher numbers are the “worst” it could be. What is the effect of the addiction on your work (please take into account absence from work or interfering with work abilities, etc.)?None12345678910Unable to workHow does the addiction affect your need for help with daily activities (household chores and personal care?)None12345678910Need total assistanceEffect of your addiction on your mood (depression/anxiety):None12345678910SevereHow much does the addiction interfere with your sleep?None12345678910Cannot sleep at allEffect of addiction on your lifestyle (i.e. social, sports, hobbies, etc.):None12345678910SevereHow much do you feel your addiction has changed your relationships with others?No change12345678910Drastic changeDo you have allergies to medications?
REVIEW OF SYSTEMS & MEDICAL ILLNESSES Please select either Yes or No to the following: Constitutional Symptoms Weight changes
Fever or chills
Cancer or tumors
Genitourinary Frequent urine infections
Loss of urine control
How often do you get up at night to void? Eyes, Ears, Nose, Mouth, and Throat Visual changes
Chest pain (Angina)
Irregular heart beat
Blood clots in legs
Chronic obstructive disease
Shortness of breath
Gastrointestinal Frequent heart burn/reflux
Nausea and vomiting
Hepatitis or cirrhosis
Change in bowel movements
Bloody bowel movements
Loss of appetite
Difficulty with work
Attention Deficit Disorder
Obsessive Compulsive Disorder
Endocrine Thyroid disease
When was your last menstrual period: Musculoskeletal Joint pain
Hair and/or nail changes
Loss of consciousness
Other Illnesses Do you smoke cigarettes?
If yes, how many packs per day? Do you consume alcoholic beverages?
If yes, how many per day? Do you use illicit drugs?
Have you abused narcotic drugs?
CLINIC RULES: 1. Refills will be made only in person during regularly scheduling office visits. We request that all non-controlled medications be refilled by requesting a refill from your pharmacy. In turn the pharmacy will fax us with a request which will be returned within 48 hrs. 2. No refills will be done after 5 pm MST, on holidays, nor on weekends. Please get your refills in prior to Fridays as we are short staffed on this day. You must bring your pain medication bottles with you when you come in for your office visit. Changes in medication (Strength, quantity, directions) are by follow up appointment only. 3. If you are experiencing any side effects, feel the need for changes in your regimen or have recently incurred a new trauma please speak with our staff nurse Whitney. (You must not take it upon yourself to change the medications you are taking!) She will speak with your provider and instruct you on what to do until you can be seen. 4. We do understand that deaths in the family, vacations and other unforeseen circumstances do occur which may cause you to need an earlier than usual refill. This may be done at our discretion rarely. Early refills for vacations will require a copy of your flight itinerary for verification purposes. The following month the next script will be given accordingly late. 5. Medication refill appointments will occur if you are stable on your current medications and do not need any changes or have new issues to discuss. These appointments are a quick check of your status and may occur via telemedicine. 6. Follow up appointments are required for more in-depth matters such as medication side effects, possible need for change in medications, radiography results, procedural scheduling or further management of care. 8. All future appointment should be made prior to leaving the office. If you must call in to make an appointment we must have at least 8-9 days notice for medication refills. If you violate this rule there is no guaranty that your medications can be filled in a timely manner. 9. If you are more than 10 minutes late for your appointment time you will have to be rescheduled. 10. Your Co-pay or full payment (self pay patients only) is required at the time of your appointment and must be paid before you will be seen. We accept personal checks, cash, visa, master card and American express.
METAMORPHOSIS NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY. METAMORPHOSIS understands and agrees that patient confidentiality can be an integral part of patient care. Under the Health Insurance Portability and Accountability Act (commonly, HIPAA), all health care providers must maintain as confidential your protected health information, or PHI. Your PHI can include your name, address, social security number, email address, telephone number, date of birth, driver’s license number, and medical record number. Health care providers must also provide patients with notice of the legal duties incumbent upon health care providers and their privacy practices so that the health care providers avoid any accidental or inappropriate disclosure of your PHI. In February 2009, The American Recovery Reinvestment Act (ARRA or more commonly, the “Stimulus Bill”) made some significant modifications to the HIPAA Privacy and Security Rules dealing primarily with the protection of your PHI in all media (meaning paper files and electronic storage). In addition, the Stimulus Bill introduced some new terminology – “Personally Identifiable Information” or “PII” along with penalties and mitigation associated with any violations and/or breaches of PHI or PII. Personally Identifiable Information (again, the PII) is defined as any patient’s first name or first initial and the last name in combination with any one or more of the following data elements belonging to that patient: social security number; driver’s license number of ID card number, account number or credit/debit card number in combination with any required security code or access code or password that would permit access to the patient’s financial account. Metamorphosis uses health information about you for treatment purposes, to obtain payment for treatment it has provided to you, for internal administrative purposes, and to evaluate the quality of care you receive. In addition, as part of your ongoing treatment, health information may be shared with other health care providers (for example, certain medical specialists) to whom you are referred or from whom you were referred. Such information may be shared by paper mail, electronic mail, facsimile or other methods. Further, Metamorphosis may disclose your PII (in whole or in part) without your authorization under certain circumstances. For example, subject to specific requirements, we may disclose your PII without your authorization for public health purposes such as reporting communicable diseases, birth, death, injury, child abuse or neglect; for auditing purposes; for research studies; for worker’s compensation claims; and for emergencies. We will also provide information when required to do so by law enforcement authorities or by court authorities. Contact with you may also take place in the form of appointment reminder, prescription refills, test results, etc. When other situations arise we will ask you for your written authorization before using or disclosing any of your PII. If you choose to sign an authorization to disclose some or all of your PII, you may later request to revoke either all or part of the authorization. As the patient, you have the right to see and receive a copy of all information that is contained in your medical record (chart) at this office, with the following exceptions: psychotherapy notes; information compiled in reasonable anticipation of civil, criminal or administrative litigation or enforcement proceedings; and protected health information if it is subject to protection under other applicable law. If Metamorphosis denies your right of access, you are entitled to have that determination reviewed if the reason for the denial was one of the following: a health care professional has determined that access to the information is likely to endanger the life or safety of you or another person; or the protected health information refers to another person and access to the information is likely to cause harm to that person. If Metamorphosis denies your right of access, you will not be entitled to have that determination reviewed if the reason for the denial was one of the following: the protected health information is excepted from the right of access under applicable law; or the protected health information was obtained from someone other than the health care provider under a promise of confidentiality. Metamorphosis shall have thirty (30) days to act on a written request for access to your medical records. Any written request from you will be responded to in writing from Metamorphosis and we will provide you with the anticipated date by which we will complete action on your request. If access is denied, we will inform you in writing of the basis or bases for the denial. If you believe that information contained in your medical record is incorrect or if important information is missing, you have the right to request that a correction be made to the information in your record. This request must be submitted in writing and must include a reason to support the request. Metamorphosis must act on such a request within 60 days of our receipt of your request. The acceptance or denial of a request to amend or correct your medical record will follow the same process as described above concerning access to your medical record. You have the right to request and receive a written list of certain disclosures of your health information, made after April 14, 2003. You may ask for disclosures we made up to six (6) years before your request. This listing will include the date of the disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed and the purpose of the disclosure. Metamorphosis is not required to include on the list of disclosures those disclosures which were made: for purposes of treatment; for purposes of billing and collection of payment for your treatment; for our health care operations; in response to a prior request from you that was authorized by you or which was made to individuals involved in your care or treatment; or as otherwise allowed pursuant to applicable law. A first request of disclosures will be provided to you free of charge; a subsequent request made within 12 months of a first may result in a reasonable charge to you for such service. You have the right to request that we limit our use and disclosure of your health information for treatment, payment and health care operations. You also have a right to request a limit on the health care information we disclose about you to someone who is involved in your care or the payment of your care, for example, a family member or friend. We are not required to agree to such request however if Metamorphosis agrees to such a request, we must follow the agreed upon restriction. You may cancel the restriction at any time and we, too, may cancel the restriction at any time as long as we notify you of the cancellation. You have the right to complain about any perceived privacy violations or if you disagree with a decision we made about access to your medical records. All complaints, concerns or questions should be submitted in writing to our Privacy Officer. You may contact Metamorphosis’s Privacy Officer as follows: Jessica Heslep 2140 Hollowbrook Rd, Suite 110, Colorado Springs, CO Tel. 719-371-0000, Fax: 888-965-6893We are required to obtain your written acknowledgment that you have read this notice, been given the opportunity to ask questions about this notice, and been given a copy of this notice.
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Document Name: Addiction Therapy Intake
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