New Patient Paperwork
Contemporary Medicine Associates Appointment Policy & Security Deposit

Please Note: As of 5/26/15, all cancellations (and reschedules) made within 48hrs of the scheduled appointment and no-show appointments will be charged a $150.00 Fee.

Contemporary Medicine Associates requires a credit card number to secure an appointment with our practice. This credit card number will only be used for appointments cancelled in less than 48 hours. Appointments not cancelled prior to 48 hours of appointment time will result in a missed appointment fee. By agreeing to the terms and providing your credit card number you are acknowledging that you are aware that your credit card will be charged the missed appointment fee without notice in the event appointments are not cancelled before 48 hours, or if you fail to make it to the appointment. After agreeing to the terms and providing your credit card number, if you contact your bank or credit card company and deny this charge, resulting in a "charge back" any additional fees associated with that charge back will be added to the original missed appointment fee. Thank you for your willingness to co-operate with this necessary policy. This allows our practice to run more efficiently and our doctors to see as many patients as possible while continuing to give each patient the time and care they expect.

Please note that your card will not be charged unless you miss an appointment or fail to cancel / reschedule within 48 hours.

Please provide your payment information below:

 

Name On Card: *
Card Number: *
Expiration Date: : *
Mo: Yr:
Security Code & Billing Zip : *
CV2: Zip Code :
* I give permission to charge based on the appointment policy
Patient Information
Required fields are indicated with red astris *
Last Name:* First Name:* Middle Name:
Email Address :* Social Security Number:* Date Of Birth: *
Sex: Occupation: Employer:
Address:* City:*
State:* Zip:*
Primary Phone:* Alternate Phone: Work Phone:
Insurance & Payment Information
Is Patient Covered By Insurance?:* Insurance Company: Group Number:
Relation of Insured/Responsible Party:* Policy Number: Co-Pay Amount:
Information of Policy Holder or Financially Responsible Party:
First Name: Last Name: Middle Name:
Email: Social Security Number: Date Of Birth
Address: City:
State: Zip:
Primary Phone: Alternate Phone: Work Phone:
Occupation: Employer: Employer Address:
Referral Information
Who Referred You to Our Practice ?: Referring Doctor : Name Of Practice :
Phone: Address : City / State / Zip:
Emergency Contact:
Person to contact in an emergency :* Relationship to Patient :* Primary Phone:* Alternate Phone:
Medical & Psychiatric History
Current Medical Diagnoses
Medical Diagnoses : Details and Additional Comments: Date Of Onset:
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Medical Hospitalizations:
Hospital Name : Reason For Hospitalization: Date:
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Medication Allergies:
Medication Or Allergen : Reaction Last Incident Date:
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Drug and Alcohol Use:
Substance: Amount & Frequency: Last Use:
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In-Patient or Out-Patient Addiction Rehabilitations:
Hospital or Facility: Date: Participation: What was the outcome of the treatment?
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Family Medical History:
Family Member: Nature Of Medical Problems: Details and Additional Comments:
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Family Addiction & Chemical Abuse History:
Family Member: Nature of Dependency: Details and Additional Comments:
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Current Psychiatric Diagnoses:
Diagnoses : Details and Additional Comments: Date Of Onset:
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All Current Medications:
Medication: Dose: Frequency: Prescribing Doctor:
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Previous Psychiatrists and Medications:
Physician Name or Medication : What was the outcome of the treatment?: Date:
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Psychiatric Hospitalizations:
Hospital or Facility: Date: Participation: What was the outcome of the treatment?
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Family Psychiatric History:
Family Member: Diagnoses: Details and Additional Comments:
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Areas Of Concern:
Fatigue / Lack of energy
Eye pain
Difficulty swallowing
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Weakness
Sinus Pain or Congestion
Nausea
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Lack of sleep
Increase / Decrease in tearing
Bruising easily
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Sleeping too much
Increased sensitivity to sounds
Diarrhea / Constipation
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Increase / Decrease in appetite
Ear infections
Indigestion / Heartburn
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Increase / Decrease in weight
Joint Pain or Stiffness
Vomiting
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Fainting / Feeling faint
Backache
Rectal bleeding
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Tremors
Muscle tension
Black or Tarry Stool
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Trembling or Shakiness
Muscle Pain / Soreness
Food Intolerance
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Seizures / Convulsions
Swelling of Hands / Feet / Ankles
Inability to control bowels
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Skin rash
Leg cramps
Inability to control urine
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Memory problems
Numbness / Tingling of Fingers or Limbs
Allergies / Hay Fever
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Sweating
Foot Problems
Coughing blood
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Dizziness / Light headedness
Trouble Walking
Frequent / Painful urination
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Double vision
Balance problems
Penile / Vaginal discharge
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Difficulty in focusing vision
Cold / Clammy Hands
Penile / Vaginal sores
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Dry Mouth
Chest Pain / Discomfort
Painful Breasts / Breast discharge
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Unusual taste sensations
Wheezing
Increase / Decrease in sex drive
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Eye discomfort in bright light
Shortness of breath
Difficulty in sexual function
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In this area you can list other areas of concern in the boxes provided:
Other:
Other:
Other:
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Other:
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Other:
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Other:
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Social History
Education:
Education Type: Graduation Year: Completion Type: School & Area Of Study
1. High School
2. College
3. Trade School or Special Training
4. Trade School or Special Training
Employment / Income History:
Employment Status: Time At Job: Monthly Income : Occupation:
Years Months
Legal & Criminal History:
Offense: Details: Date:
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Current Legal Situation: Date To Complete: Probation Officers Name: Contact Number:
Are you on probation?
Are you on parole?
Would you like to give our office permission to speak to anyone listed above?
Living Situation & Support Resources:
Housing Status: Time At Residence: Who lives with you?:
Years Months
Please list any support systems you have below: (Some examples are Family, Friends, Religious Groups, 12 Step Meetings, and Therapy)
             
 
Notice Of Privacy Practices & The Use Of Electronic Medical Records:
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULY

Purpose: Contemporary Medicine Associates (CMA) and its professional staff and employees follow the privacy practices described in this Notice. Contemporary Medicine Associates maintains your medical information in records that will be maintained in a confidential manner, as required by law. However, Contemporary Medicine Associates must use and disclose your medical information to the extent necessary to provide you with quality health care. To do this, we must share your medical information as necessary for treatment, payment and health care operations.

1. What are Treatment, Payment and Health Care Operations? Treatment includes sharing among health care providers involved in your care. For example, your physician may share information about your condition with the pharmacist to discuss appropriate medications, or with radiologists or other consultants in order to make a diagnosis. CMA may use your medical information as required by our insurer, managed care or other personal health plan to obtain payment for your treatment. We also may use and disclose your medical information to improve the quality of care, e.g., for review and training purposes.

2. How will the Clinic Use My Medical Information? Your medical information may be used, unless you ask for restrictions on a specific use or disclosure, for the following purpose:
Family members or close friends involved in your care or payment for your treatment.
To inform you of treatment alternatives or benefits or services related to your health. ( You will always have an opportunity to refuse to receive this information)
As required by law
Public health activities, including disease prevention, injury or disability, reporting births and deaths; reporting child abuse or neglect; of suspected abuse, neglect or domestic violence (if you agree or as required by law).
Health oversight activities, (e.g. audits, inspection, investigations, and licensure).
Lawsuits and disputes.
Law enforcement (e.g., in response to a court order or other legal process; to identify or locate an individual being sought by authorities; about the victim of a crime under restricted circumstances, about a death that may be the result of criminal conduct; about criminal conduct that occurred on CMA’s premises; and in emergency circumstances relating to reporting information about a crime.)
 Coroners, medical examiners, and funeral directors.
 Organ and tissue donation.
 Certain research projects.
 To prevent a serious threat to health or safety.
 To military command authorities if you are a member of the armed forces or a member of a foreign military authority.
 National security and intelligence activities.
 Protection of the President or other authorized persons or foreign heads of state, or to conduct special investigations
 Inmates. (Medical information about inmates of correctional institutions may be released to the institution.)
 Worker’s Compensation. (Your medical information regarding benefits for work-related illnesses may be released as appropriate.)
 To carry out health care treatment, payment, and operations functions through business associates, (e.g., to install a new computer system).
 Your authorization is required for other disclosures. Except as described above, we will not use or disclose your medical information unless you authorize (permit) CMA in writing to disclose your information. You may revoke your permission, which will be effective only after the date of your written revocation. Alcohol and drug abuse information has special privacy protections.
 CMA will not disclose any information identifying an individual as being a patient or provide any medical information relating to the patient’s substance abuse treatment unless: (i) the patient
 consents in writing; (ii) a court order requires disclosure of the information; (iii) medical personnel need the information to meet a medical emergency; (iv) qualified personnel use the information for the purpose of conducting scientific research, management audits, financial audits, or program evaluations; or (v) it is necessary to report a crime or a threat to commit a crime, or to report abuse or neglect as required by law.

3. You Have Rights Regarding Your Medical Information. You have the following rights regarding your medical information, provided that you make a written request to invoke the right on the form provided by CMA.
 Right to request restriction. You may request limitations on your medical information we use or disclose for health care treatment, payment, or operations (e.g., you may ask us not to disclose that you have had a particular treatment), but we are not required to agree to your request. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
 Right to confidential communications. You may request communications in a certain way or at a certain location, but you must specify how or where you wish to be contacted.
 Right to inspect and copy. You have the right to inspect and copy your medical information regarding decisions about your care; however, psychotherapy notes may not be inspected and copied. We may charge a fee for copying, mailing and supplies. Under limited circumstances, your request may be denied; you may request review of the denial by another licensed health care professional chosen by CMA. CMA will comply with the outcome of the review.
 Right to request amendment. If you believe that the medical information we have about you is incorrect or incomplete, you may request an amendment on the form provided by CMA, which requires specific information. CMA is not required to accept the amendment.
 Right to accounting of disclosures. You may request a list of the disclosures of your medical information that have been made to persons or entities other than for health care treatment, payment or operations in the past six (6) years, but not prior to April 14, 2003. After the first request, there may be a charge.
 Right to a copy of this Notice. You may request a paper copy of this Notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

4. Requirements Regarding This Notice. CMA is required by law to provide you with this Notice. We will be governed by this Notice for as long as it is in effect. CMA may change this Notice and these changes will be effective for medical information we have about you as well as any information we receive in the future. Each time you register at CMA for health care services, you may receive a copy of the Notice in effect at the time.

5. Complaints. If you believe your privacy rights have been violated, you may file a complaint, in writing, with CMA or with the Secretary of the United States Department of Health and Human Services. You will not be penalized or retaliated against in any way for making a complaint to CMA or the Department of Health and Human Services.


Contact our Privacy Officer at Contemporary Medicine Associates, (713) 661-7888 if:
 You have a complaint;
 You have any questions about this Notice;
 You wish to request restrictions on uses and disclosures for health care treatment, payment, or operation; or
 You wish to obtain a form to exercise your individual rights described in paragraph 5.

Notification on the use of Electronic Medical Records:
As part of our commitment to provide our patients with integrated, high quality health care services, the physicians and staff of Contemporary Medicine Associates utilize Practice Fusion & Patient Fusion, a web based electronic health record (EHR) system to comply with a recent Federal Mandate. The EHR system allows our physicians and staff to consolidate, store, retrieve and share medical information about a patient’s medical history. The EHR is endorsed by the Department of Health and Human Services of the US government as a way to increase accuracy, improve efficiency, and reduce medical errors. Medical records are created when you receive treatment from a health professional, as you do from our office. Records may include your medical history, details about your lifestyle (such as smoking or involvement in high‐risk sports), and family medical history. In addition, your medical records contain chart notes, consultation notes, laboratory test results, medications prescribed, and reports that indicate the results of operations and other medical procedures. Information will be entered directly or scanned into a web based medical record system in the computer. This chart is connected to a network of physicians, insurance companies, and public health agencies, and required federal and state organizations. The EHR has levels of security to protect against inappropriate access or disclosure, and all users adhere to strict HIPAA criteria. Should you have any questions, please address them with our office manager or your personal physicians.
Nurse Practitioner Consent:

This facility has Nurse Practitioners to assist in the delivery of medical care. A Nurse Practitioner (N.P.) is not a doctor. A Nurse Practitioner is a graduate of a Master’s Program of Nursing and they are certified by National Licensing Agencies, and licensed by the State Board of Nursing. Under the supervision of a physician, they can diagnose, treat, and monitor common acute and chronic diseases, as well as provide health maintenance care. “Supervision” does not require the constant physical presence of the supervising physician, but rather overseeing the activities of and accepting responsibility for the medical services provided.

A Nurse Practitioner may provide such medical services that are within his/her education, training, and experience. These services may include:

• Obtaining histories and performing physical exams
• Ordering and/or performing diagnostic and therapeutic procedures
• Formulating a working diagnosis
• Developing and implementing a treatment plan
• Monitoring the effectiveness of therapeutic interventions
• Offering counseling and education
• Supplying sample medications and writing prescriptions
• Making appropriate referrals

PLEASE ACKNOLEDGE THESE STATEMENTS
I have read, understand, and acknowledge the Contemporary Medicine Associates Cancellation Policy, Privacy Policy, Nurse Practitioner Consent & the notifications regarding Electronic Health Records and agree to participate by signing this document and receiving services at Contemporary Medicine Associates PLLC.
Select your acceptance of our missed appointment policy here: *
Select your acknowledgement of our privacy policy here: *
Select your acknowledgement of Electronic Medical Record use here: *
Select your Nurse Practitioner Consent here: *