"Bessie Mae Women Application all in one"
Bessie Mae Women’s Health Center Patient Registration HOW DID YOU HEAR ABOUT US? Circle One (Newspaper) (Health Fair) (Web Site) (Outreach Worker) (Flyer) (Walk-in) (Radio) (TV) (Referral):____________ Initial of Interviewer: Patient Chart Number: Date of Application: Date of Birth: Patient Name: Address: Apt. or Floor: City/State/Zip Code: Telephone: Mobile Number: Gender: Male_____________ Female____________ Social Security Number: Race/Ethnicity: Marital Status: Are you a student? Yes____ or No____ Language Spoken: English______ Spanish______ French______ Other: _____ Name of Legal Guardian or Parent/Guarantor: Address: Apt. or Floor City/State/Zip Code: Telephone: Public Housing: Yes_____ or No_____ Relationship to Patient: Social Security Number: Total Dependents: (Family Size): Total Family Gross Income: Occupation: Employer: Employer Address: Employer Telephone: Does your Employer provide Health Insurance? Yes_______ No_______ If Yes, What type of Coverage? Single________ Family______ Insurance Information: Medicaid Number: Medicare Number: Primary Insurance: Member Name: Insurance ID Number: Insurance Group Number: Secondary Insurance: Member Name: Insurance ID Number: Insurance Group Number: In Case of Emergency: Name: Relationship to Patient: Address: City/State/Zip Code: Home Telephone: Work Number: Mobile Number: Other: Patient Certification: I understand that the information which I submit it subject to verification by the Health Center and is subject to review by federal and/or State agencies and others as required. I certify that the above information is true and correct. Applicant Signature: _____________________________________________ Date:_________________________ Internal Use Only Medical Assistance Screening: Does the patient or guardian have a pending AFDC, SSI, Medicare/Medicaid Application? YES_____ No_____ Patient Identification/Proof of Address: (Choose one for Patient Identification and one Proof of Address) Identification Proof of Address Driver’s License: Current Gas/Electric: Social Security Card: Current Telephone Bill: Alien Registration Card: Current Lease: State Voter’s ID: Motor Vehicle ID: Other Legal Form of ID: Income Verification For Uninsured Individuals Only Use Last 3 Current stubs Employment Checks: Current Award Letter: Disability Checks: Income Tax for Current year: Notarized Letter w/ Guarantor’s Income & 3 check stubs: Child Support Stubs: Other Legal form of Income: Bessie Mae Women’s Health Center Service Consent 1. CONSENT TO TREATMENT: The undersigned hereby requests and consents to treatment and/or laboratory procedures, including an HIV test as part of routine testing rendered under general and/or special instructions of his/her medical provider(s). No warranty or guarantees has been as to the results. I understand that I may be seen for medical care by any of the following providers: Physician, Nurse Practitioner, Midwife, and/or a Physician’s Assistant. If you wish to decline HIV testing please indicate by checking the box. Applies only to HIV testing. 2. HEALTH CARE EDUCATION: BMWHC conducts and participates in programs for the education and training of health care professionals. It is understood and agreed that some health services may be provided to the patient by professional-in-training, under the supervision and pursuant to the instructions of your medical providers or authorized BMWHC personnel and that health care personnel-in-training may also observe care rendered to you by BMWHC employees and/or medical providers. 3. RELEASE OF INFORMATION: BMWHC is required by various governmental agencies to review and release patient information as part of a program of medical evaluation. BMWHC also collaborates with various agencies by providing statistical information pertaining to its services. BMWHC may release patient information necessary for patient care to collaborating hospitals or consultants. The undersigned agrees that BMWHC is authorized to review and release such information. 4. RELEASE OF INFORMATION FOR PAYMENT: I authorize BMWHC to release medical information to third party insurance carriers for the purpose of filing insurance claims related to my medical care. 5. CONSENT: Your signature below indicates that you have read and understood the information in document and that you consent to evaluation and treatment under the provisions stated. If you do not understand or consent to anything stated in this document, it is your responsibility to request and receive clarification before signing. _______________________________ _________________________________ Patient Signature Witness Signature Date: Time: If the patient is a minor or is unable to consent, please complete the following: A. Patient is a minor and is______years of age. Name of Father: ____________________________ Name of Mother: __________________________________ B. Patient is unable to consent because ________________________________________________________________________________________________ ________________________________________________________________________________________________ Signature of Closest Relative ____________________________________________________________________________ Relationship_______________________________________ Witness to Signature_________________________________ PATIENT RIGHTS Rights of Each Patient of Bessie Mae Women’s Health Center (BMWHC) Each patient receiving service at Bessie Mae Women’s Health Center shall have the following rights. 1. To be informed of these rights. As evidenced by the patient’s written acknowledgement or by documentation by BMWHC staff in the medical record that the patient was offered a written copy of these rights and given a written or verbal explanation of these rights, in terms the patient can understand. BMWHC shall notify patients of any rules and regulations it has adopted governing patient conduct in the facility; 2. To be informed of services available at each BMWHC site, of the names and professional status of the personnel providing and/or responsible for the patient’s care, and of fees and related charges. Including the payment, fee, deposit and refund policy of the facility and any charges for the services not covered by sources of third-party payment or not covered by the facility’s basic rate; 3. To receive reasonable continuity of Health Care among providers; 4. To received prompt treatment for problems of acute onset; 5. To be seen as close to their scheduled appointment(s) as possible; 6. To be informed if BMWHC has authorized other health care and educational institutions to participate in the patient’s treatment. The patient also shall have the right to know the identity and function(s) of these institutions, and to refuse to allow their participation in their (patient’s) treatment; 7. To receive from the patient’s physician(s) or clinical practitioner(s), in terms that the patient understands, an explanation of his or her complete medical/health condition or diagnosis, recommended treatment, treatment options, including the option of no treatment, risk(s) of treatment, and expected result(s). If this information would be detrimental to the patient’s health, or if the patient is not capable of understanding the information, the explanation shall be provided to the patient’s next of kin or guardian. This release information to the next kin or guardian, along with the reason for not informing the patient directly, shall be documented in the patient’s medical record; 8. To participate in the planning of the patient’s care and treatment, and to refuse medication and treatment. Such refusal shall be documented in the patient’s medical record; 9. To be included in experimental research only when the patient gives informed, written consent to such participation, or when a guardian gives such consent for an incompetent patient in the accordance with law, rule and regulation. The patent may refuse to participate in experimental research, including the investigation of new drugs and medical devices; 10. To voice grievances or recommend changes in policies and services to facility personnel, the management or Board Of Trustees of BMWHC, and/or outside representatives of the patient’s choice either individually or as a group, and free from restraint, interference, coercion, discrimination, or reprisal; 11. To be free from mental and physical abuse, free from exploitation, and free from use of restraints unless they are authorized by a physician for a limited period of time to protect the patient or others from injury. Drugs and other medications shall not be used for discipline of patients or convenience of facility personnel; 12. To confidentially treat information about the patient. Information in the patient’s medical record shall not be released to anyone outside the facility without patient’s approval, unless another health care facility t which the patient was transferred requires the information, or unless the release of the information is required and permitted by law, a third-party payment contract, or a peer review, or unless the information is needed by the New Jersey State Department of Health for statutorily authorized purposes. The facility may release data about the patient for studies containing aggregated statistics when the patient’s identity is masked; 13. To be treated with courtesy, consideration, respect and recognition of the patient’s dignity, individuality, and rights to privacy shall also be respected when facility personnel are discussing the patient; 14. To not be required to perform work for the facility unless the work is part of the patient’s treatment and is performed voluntarily by the patient. Such as work shall be in accordance with local, state and federal laws and rules; 15. To exercise civil and religious liberties, including the rights to independent personal decisions. No religious beliefs or practices, or any constitutional, civil, and/or legal rights solely because of receiving services from the facility; Complaints may be lodged with the following regulatory bodies: Div. of Health Facilities Eval. & Lic. State of New Jersey New Jersey State Department of Health Office of the Ombudsman for the CN367 Institutionalized Elderly Trenton, New Jersey 08625-0367 CN 808- Trenton, New Jersey 08625 Telephone: (800)792-9770 Telephone: (877)582-6995 ______________________________________ _____________________________________ PROVIDER PATIENT ______________________________________ _______________________________________ DATE DATE Bessie Mae Women’s Health Center Administration NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW PERSONAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CARFULLY. We respect patient confidentiality and only release personal health information about you in accordance with the State and federal law. This notice describes our policies related to the use of the records of your care generated by Bessie Mae Women’s Health Center. Privacy Contact If you have any questions about this policy or your rights you any contact our Compliance Officer, 973-766-1303 USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION In order to effectively provide you care, there are times when we will need to share your personal health information with others beyond Bessie Mae Women’s Health Center, This includes for: Treatment With your permission we may use or disclose personal health information about you to provide, coordinate Health Center that we are consulting with or referring you to. Payment Information will be used to obtain payment for the treatment and services provided. This will include contacting your health insurance company for prior approval of planned treatment or for billing purposes. Healthcare Operations We may use information about you to coordinate our organization’s activities. This may include setting up your appointments, reviewing your care, training staff. Information Disclosed Without Your Consent Under state and federal law, information about you may be disclosed without your consent in the following circumstances: Emergencies Sufficient information may be shared to address the immediate emergency you are facing. Follow Up Appointments/Care We will be contacting you to remind you of future appointments or information about treatment alternatives or other health-related benefits and services that may be of interest to you. As Required by Law This would include situations where we have a subpoena, court order, or are mandated to provide public health information, such as communicable diseases or suspected abuse and neglect such as child abuse, elder abuse, or institutional abuse. Coroners Funeral Directors We may disclose personal health information to a coroner or personal health examiner and funeral directors for the purposes of carrying out their duties. Governmental Requirements We may disclose personal health information to a health oversight agency for activities authorized by law, such as adults, investigations inspections and licensure. There also might be a need to share information with the Food and Drug Administrations related to adverse events or product defects. We are also required to share information, if requested with the Department of Health and Human Services to determine our compliance with federal laws related to health care. Criminal Activity or Danger to Others If a crime is committed on our premises or against our personnel we may share information with law enforcement to apprehend the criminal. We also have the right to involve law enforcement and to warn any potential victims when we believe an immediate danger may exist to someone, or if we believe you present a danger to yourself. PATIENT RIGHTS You have the following rights under State and federal law: Copy of Record You are entitled to inspect the personal health record Bessie Mae Women’s Health Center has generated about you. We may charge you a reasonable fee for copying and mailing your record. Release of Record You may ask us no to use or disclose part of the personal health information. This request must be in writing. Bessie Mae Women’s Health Center is not required to agree to your request if we believe it is in your nest interest to permit use and disclosure of the information. The request should be given to the Program Director who will consult with the staff involved in your case to determine if the request can be granted. Contacting You You may request that we send information to another address or by alternative means. We will honor such request as long as it is reasonable and we are assured it is correct. We have a right to verify that the payment information you are providing is correct. Due to agency policy, we are not able to provide information by email. Amending Record If you believe that something in your record is incorrect or incomplete, you may request we amend it. To do this contact the Program Director and ask for the Request to Amend Heath Information form. In certain cases, we may deny your request. If we deny your request for an amendment you have a right to file a statement you disagree with us. We will then file our response and your statement and our response and your statement and our response will be added to your record. Accounting for Disclosures You may request an listing of any disclosures we have made related to your personal health information, except for information we used for treatment, payment, or health care operations purposes or that we shared with you or your family, or information that gave us specific consent to release. It also excludes information we were required to release. To receive information regarding disclosure made for a specific time period no longer than six years, please submit your request in writing to our Compliance Officer. We will notify you of the cost involved in preparing this list. Questions and Complaints If you have any questions, or wish a copy of this Policy or have any complaints you may contact our Complaints Officer in writing at our office for further information. You also may complain to the Secretary of Health and Human Services if you believe Bessie Mae Women’s Health Center, has violated your Compliance rights. We will not retaliate against you for filing a complaint. Changes in Policy Bessie Mae Women’s Health Center, reserves the right to change it Compliance Policy based on the needs of Bessie Mae Women’s Health Center and changes in state and federal law. ACKNOWLEDMENT I have read this Notice or have had it explained to me. I understand this Notice and have had the chance to ask questions about any matter I don’t understand. ______________________________ ______________________________ Signature Date For Staff Use Only The following good faith efforts were made to obtain acknowledgement: However, acknowledgement was not obtained because:______________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _______________________________ Signature Date Bessie Mae Women’s Health Center RISK ASSESSMENT QUESTIONNAIRE Obtain information listed below from patient’s first visit. Date: _____________________________________ Chart: ____________________________________ S.S Number: ______________________ 1. What is your age? 15 yrs. to 25 yrs._____ 26 yrs. to 35 yrs._____ 36 yrs. to 45 yrs._____ 46 yrs. to 55 yrs.______ 56 yrs. and up ______ 2. What is your sex? Male_______ Female_______ 3. What racial group do you belong to? White_______ Black_______ Hispanic_______ Other_______ Asia or pacific Islander_______ American Indian or Alaskan Native_______ 3a. If Hispanic, Please check one: Mexican/Mexican American_____ Puerto Rican______ Cuban_______ Other______ 4. Have you ever “main lined” or injected drugs? Yes______ No_______ Sometimes_______ 4a. Heroin_____ Cocaine_____ Speedballing_____ Other_____ 5. Have you ever smoked or snorted drugs? Yes______ No______ Sometimes______ 5a. If yes have you ever used drugs which you did not inject such as: Heroin_____ Cocaine_____ Crack_____ Speed_____ Marijuana_____ Other (specify) _____ 6. Have you ever given sex for drugs or money? Yes______ No______ Sometimes______ 7. Have you ever had sex with anyone who: (Check all that apply) Has the AIDS virus or AIDS_________ Has received blood (between 1978-1985) _______ Has Hemophilia_____ Has shot up (injected) drugs_______ Is a man who has had sex with other men_______ Is a sex partner of a Homosexual/Bisexual_______ Has had many sexual partners________ Unsure_______ 8. Do you think you have been exposed to the AIDS virus? Yes______ No______ Unsure______ 9. Have you ever been tested for the AIDS virus? Yes______ No______ Unsure______ 10. What were the results of your HIV test? Positive_____ Negative_____ Inconclusive_____ 11. Have you ever had: Yes No Hepatitis B (Inflammation of the liver) _____ _____ Hepatitis C _____ _____ Syphilis _____ _____ Herpes _____ _____ Gonorrhea _____ _____ Scabies _____ _____ Chlamydia _____ _____ Others (specify) _____ _____ 12. Last Grade complete while in school____________ 13. Income Source: (Check One) Salary_______ S.S.I_______ Social Security_______ Pension_______ City Welfare_______ County Welfare_______ Other________ Who live with you? (Check all that apply) Husband____ Partner____ Children____ Sister _____ Brother_____ Mother ____ Father ____ Aunt _____ Uncle _____ Niece_____ Nephew____ Grandmother ____ Grandfather ____ Grandchild____ Foster Parent ____ Foster Child____ Other (specify) ____ Provider Name__________________________ Signature__________________________ Date________