Prescription History Download Consent


I hereby authorize Mesa Urologists, A Division of Ironwood Physicians, P.C. to download my prescription history from my pharmacy. I understand I have the right to revoke this authorization at any time by submitting a request in writing.

I hereby do NOT authorize Mesa Urologists, A Division of Ironwood Physicians, P.C. to download my prescription history from my pharmacy. I understand I have the right to revoke this authorization at any time by submitting a request in writing.







Patient Demographic
Information


Patient Information


Contact

Preferred Method of Contact

Responsible Party

Other than Patient

Responsible Party Other than Patient


Insurance Information





Financial Policy/Assignment of Benefits For Patients


  • I understand that I have medical insurance which when billed on my behalf should pay for their portion of my office visits and treatment charges. initials
  • I will inform Ironwood Physicians, PC or Ironwood Cancer and Research Centers of a change in my insurance coverage. initials
  • I understand the billing process may take 4-6 weeks at which time may insurance company will determine and pay for services per my contract. initials
  • I understand that it is my responsibility to pay all co-pay, deductible and estimated co-insurance amounts at the time of service rendered and remaining balance as determined by my insurance company. initials
  • I understand that I will leave my credit card information to be kept on file and that if I do not pay within 60 days after my insurance has paid, I acknowledge that Ironwood Physicians, PC and Ironwood Cancer and Research Centers will charge the balance to the credit card on file. initials
  • I understand that if for any reason my insurance company does not pay for the covered services within 90 days of the services provided, I shall assume responsibility for the total amount owed, which may be charged to the credit card on file. initials
  • I thereby assign all medical benefits directly to Ironwood Physicians, PC and Ironwood Cancer and Research Centers for services rendered at the facilities. initials
  • I understand if a CT or PET/CT scan is completed it will be necessary for a licenced Radiologist to interpret or read your scan results. You will be receiving two statements for your CT or PET/CT scan for their professional interpretation of the CT or PET/CT scan separate of Ironwood. intials
  • We may request proof of insurance premium payment. initials
  • I have read and received a copy, if desired, of this document. initials





Consent to Release Protected Health Information
Contact List


Initials I authorize Ironwood Physicians, PC to use/disclose my personal health information to the individuals listed on his form
Initials I understand that Ironwood Physicians, PC staff may leave detailed messages on my voicemail.
Relationship:    (Describe)         (Describe)
Relationship:    (Describe)         (Describe)
Relationship:    (Describe)         (Describe)

I hereby authorize Ironwood Physicins, PC.to use and disclose my personal health information to the Individuals Identified on this form.

I understand this authorization does not expire unless written notice is malled to P.O. Box 6423 Chandler AZ, 85246.

I understand this may include information relating to communicable diseases, such as HIV/AIDS, sexually transmitted diseases, behavioral or mental health, alcohol and/or drug abuse treatment, and genetic testing information, if any records exist.

I understand that the individual identified on this form will be treated by Ironwood Physicians PC as individuals involved directly in my care and as such, Ironwood Physicians, PC will be allowed to release my personal health information to these individuals for the purposes of treatment, payment and healthcare operations.

I understand that I have a right to request and receive a Notice of privacy Practices from Ironwood Physicians, PC.

I have read and received a copy of the above statements and accept the terms. A duplicate of the statement is considered the same as the original. I voluntarily sign this authorizaion, and I understand that my ability to obtain health care from Ironwood Physicians PC will not be affected if I refuse to sign this authorization.



Mesa Urologists Medical History Questionnaire



CHRONIC HEALTH PROBLEMS Since SURGERIES Date
HOSPITALIZATIONS Date INJURIES Date
List all drugs you presently use regularly or take occasionally
MEDICATION Strength Dose
NEW ALLERGIES

Are you allergic to
   

   
Please provide approximate date of the most recent events of the following if applicable:

List other allergies

SOCIAL HISTORY
Martial Staus




Tobacco Use

years ago


Alcohol Use

years ago

  
  
Drug Use

years ago



FAMILY HISTORY
Relatives Alive     Health Died     Cause Age Is there family history of Residence-travel-activity
Father
Mother
Brothers
Sisters
Sons
Daughters























How long in AZ
Permanent resident
Home town/area
Foreign travel
Activities
Hobbiees


Mesa Urologists
Medical History Questionnaire


Who referred you here? (Print name)          
Have you ever had following?




In the last year have you had incontinence of urine?



In the last year did you have any voiding problems?

times to urinate at night








Do you have problems in your sexual life?



Male Only



Female only



Have you had any of the following problems in the last year?
GENERAL




EYES

or




EARS, NOSE AND THROAT






DIGESTIVE TRACT











MUSCLE, BONES & JOINTS





NEUROLOGICAL








PSYCHIATRIC





CARDIOVASCULAR SYSTEM








RESPIRATORY SYSTEM




SKIN







LYMPHATIC & HEMATOLOGICAL






ENDOCRINE SYSTEM






OBSTETRICAL HISTORY






MESA UROLOGISTS

If you are a women

Note at all Occasionally About once a day About three times a day About half the time Almost Always Score
Urgency- How often do you have a strong sudden urge to urinate that makes you fea you will leak urine if you can't get to a bathroom immediately?
Urgency Incontinence- How often do you leak urine after feeling an urge to go?
None Drops 1 Teaspoon 1 Tablespoon 1/4 Cup Entire Bladder Score
Incontinence- How much urine do you think usually leaks?
1-6 times 7-8 times 9-10 times 11-12 times 13-14 times 15 or more times Score
Frequency- How many times do you urinate during the day?
None 1 times 2 times 3 times 4 times 5 times or more Score
Wake to urinate- How many times do you usually get up each night to urinate?
Your Total
Score
Quality of life due to urinary symptoms Delighted Mostly Satisfied Mixed Mostly Dissatisfied Unhappy Terrilbe
If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?


PATIENT HEALTH QUESTIONNAIRE (PHQ-9)



Over the last 2 weeks, how often have you been bothered by any of the following problems?
(use "" to indicate your answer)
Not at all Several days More than half the days Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so figety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself
add columns
+
+

(Healthcare professional: For interpretation of TOTAL,
please refer to accompanying scoring card).

10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Copyright @1999 Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD@ is a trademark of Pfizer Inc. A2663B 10-04-2005