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


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 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



You may feel embarrased to talk to your doctor about urinary problems. But, like gray and thinning hair, such problems are a part of aging. One of the causes of urinary symptoms in men over 50 is a treataoic condition called benign prostatic hyperplasia (BPH). In fact, It has been estimated that by the age of 80, 1 in every 4 males in the US will require treatment of their urinary symptoms caused by BPH.

Take this quiz to help you and your doctor decide whether you could benefit from a BPH treatment.

TAKING THE QUIZ (Please circle the answer that best represents your response to each of the following questions. The questions are designed to gauge the severity of any symptoms you may be experiencing.)

Not at all Less than 1 time in 5 Less than half the time About half the time More than half the time Almost always Patient Score

1. INCOMPLETE EMPTYING (Over the past month, how often have you had a sensation of not emptying your bladder completely after you have finished urinating?)

2. FREQUENCY (Over the past month, how often have you had to urinate again less than 2 hours after you have finished urinating?)

3. INTERMITTENCY (Over the past month, how often have you found you stopped and started again several times when you urinated?)

4. URGENCY (Over the past month, how often have you found it difficult to postpone urination?)

5. WEAK STREAM (Over the past month, how often have you had a weak urinary stream?)

6. STRAINING (Over the past month, how often have you had to push or strain to begin urination?)

7. NOCTURIA (Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?)

Your Total Score

7. QUALITY OF LIFE DUE TO URINARY SYMPTOMS (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?)

Delighted Pleased Mostly satisfied Mixed Mostly dissatisfied Unhappy Terrible

Adapted from Barry MJ. et al. The American Urological Association symptom index for benign prostatic hyperplasia. J Urol. 1992:148:1549-1557.

SCORING THE QUIZ: Add the numbers from your answers to questions 1 through 7. The maximum possible score is 35. The final question will help you judge how you feel about your symptoms.

PLEASE NOTE: This test is used to measure the severily of your symptoms. It is not a diagnostic test. In other words, it will not tell you whether or not you have BPH. Talk to your doctor to determine whether your symptoms are due to BPH.
Remember: This information is not intended as a substitute for medical treatment.


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