Patient Registration Form

Patient InformationM.I.:

Mailing Address: Apt #

Home Phone: Cell Phone: Work Phone:

If Voice, Please Select Preferred Number:

Sex:

qMale q Female

Social Security #: Emergency Contact Name:

Emergency Contact Phone #: Relationship to Patient:

Phone:

Address of Person Responsible:

City/State/Zip: Relationship to Patient:

How did you hear about us?

Race (please select): Ethnicity (please select one):

o White o American Indian or Alaska Native o Asian o Hispanic or Latino

o Hispanic o Black or African American o Native Hawaiian or Pacific Islander o Not Hispanic or Latino

o OtheroDecline o Other

Preferred Language (please select one): o English o Chinese o Indian (including Hindi & Tamil)

o Filipino/Tagalog o Spanish o Russian o Other

Preferred Pharmacy Name & Location:

Ins. Co. Name Ins. Co. Name

Policy Holder Name: Policy Holder Name:

Policy Holder's Date of Birth: Policy Holder's Date of Birth:

Policy Holder's Social Security #: Policy Holder's Social Security #:

Patient Relationship to Policy Holder: Patient Relationship to Policy Holder:

Home Cell Work

First Name:

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Our office uses our online Patient Portal extensively to communicate with our patients. Patients can view lab results, book appointments, request refills, update key information, pay balances, and many other functions via Patient Portal. Be sure you sign up for it.

Previous Name (if applicable)

Date of Birth:

Responsible Party- If the patient is a minor (under the age of 18), the parent or guardian bringing the patient in will be listed as the guarantor

Date of Birth:

Last Name:

Secondary Medical Insurance

Marital Status:

First Name:

City/State/Zip:

(Please Select Only One Option) Voice Text

Preferred Method of Contact for Reminder Calls and Other Electronically Generated Messages:

Primary Medical Insurance

Insu

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Last Name:

Social Security #:

Friends Family Co-worker Insurance Website

ER/Urgent Care Internet: ____________________ Specialist Newspaper Magazine Other _____________________________________________________________

When you are unavailable to answer the phone, may we leave detailedvoicemails about your medical treatments, care plan, test results, referrals, and prescriptions?o Yes o No If yes, on which phone numbers? Home Cell Work

Email Address:

Patient Portal

Please go to next page Page 1 of 3

Name Date of Birth

Comprehensive New Patient Health History Questionnaire

Main reason for today’s visit:

Please list all healthcare providers you see regularly:

PERSONAL MEDICAL HISTORY: Have you ever had any of the following conditions?

□ Check box if you have no history of significant medical illnesses.

Condition Now Past Condition Now Past

Alcohol / Drug abuse Gynecological Conditions (Endometriosis)

Allergy (Hay Fever) ( ) Gynecological Conditions (Fibroids)

Anemia Gynecological Conditions (Other)

Anxiety Hepatitis – Type A | B | C

Arthritis (Rheumatoid) Herpes (cold sore or genital)

Arthritis (Osteoarthritis) High Blood Pressure

Asthma High Cholesterol

Bladder / Kidney Problems Inflammatory Bowel Disease

Blood Clot ( ) Irritable Bowel Syndrome

Cancer ( ) Kidney Disease / Failure

Cataracts Kidney Stones

Chronic Pain ( ) Liver Disease

Colon Polyp Migraine Headaches

Coronary Artery Disease Osteoporosis

Depression Prostate (enlargement)

Diabetes (adult onset) Seizure / Epilepsy

Diabetes (childhood onset) Sleep Apnea

Diverticulosis Stomach Ulcer

Emphysema (COPD) Stroke

Fractures (broken bones) Thyroid (Nodule)

Gallbladder Disease Thyroid High (Overactive) / Hyperthyroidism

Gastroesophageal Reflux (Heartburn/GERD) Thyroid Low (Underactive) / Hypothyroidism

Glaucoma Other ( )

Gout Other ( )

SURGICAL & PROCEDURE HISTORY – Please enter the year of any procedures or surgeries below.

□ Check box if you have never had any medical procedures or surgeries.

Surgical Procedure Year Surgical Procedure Year

Abdominal surgery ( ) Hysterectomy (partial, ovaries left)

Appendectomy (appendix removal) Hysterectomy (total, including ovaries)

Back surgery Joint Arthroscopy ( )

Biopsy ( ) LEEP (Cervix surgery)

Breast Biopsy Neck Surgery

Breast surgery Ovary Removal

Cataract surgery Sinus Surgery

Coronary Bypass Tonsillectomy

Coronary Stent Tubal ligation

C-Section Urological Surgery

Gallbladder Removal Vascular Surgery ( )

Heart Surgery( ) Vasectomy

Hip Surgery ( ) Other ( )

Please go to next page Page 2 of 3

FAMILY HISTORY

Adopted? □ No □ Yes. If adopted, and you do not know your family history, skip the Family History section.

Indicate which relative has had the following diseases (parents, brothers & sisters are the most important). Write in number of siblings in appropriate boxes.* If some siblings are alive and some are deceased use the space to the right to explain further.

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* B

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Mo

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Mo

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Mo

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Dad

D

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Mo

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Dad

’s

Dad

Alive

Deceased

Age currently or at death

Diseases & Conditions Mo

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Bro

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Other blood relatives (list relationship to you)

No significant history known

Hypertension – high blood pressure

Hyperlipidemia – high cholesterol

Heart Attack, Angina (Coronary Artery) Disease)

Diabetes Type I (childhood onset)

Diabetes Type II (adult onset)

Osteoporosis

Depression Alcoholism / Drug abuse

Alzheimers

Asthma Autoimmune Disease

Bleeding or Clotting Disorder

Cancer ( ) Colon Polyp Emphysema (COPD) Genetic Disorder (explain)

Heart Disease (CHF)

Hepatitis B or C

Hypothyroidism / Thyroid Disease

Kidney Disease

Stroke

Sudden Cardiac Death

Other ( )

Other ( )

MEDICATIONS: Please list (or show us your own printed record) all prescription and non-prescription medications. This includes vitamins, herbs, supplements, home remedies, birth control pills, inhalers, over the counter pain pills (Advil, Aleve, Tylenol, etc).

□ Check box if you do not take any prescription or over the counter medications. □ Check box if you brought a list of your medications (give it to my assistant and don’t write in medications below).

ALLERGIES or intolerance to medications? □ No known drug allergies

(If yes, to what & what reaction?)

Medication Dose

(e.g. mg/pill) How often?

Medication

Dose (e.g. mg/pill)

How often?

Thank you for taking the time to complete this form Page 3 of 3

IMMUNIZATIONS: □ Voluntarily declined all vaccines

Vaccine Date Vaccine Date Vaccine Date

Hepatitis A Pneumovax (Pneumonia) Whooping Cough (DTaP)

Hepatitis B Prevnar 13 (Pneumonia) Zostavax (shingles)

HPV Tetanus (Td)

Influenza (flu shot) Varicella (Chicken Pox)

HEALTH MAINTENANCE SCREENING TESTS:

Test Date Result Test Date Result

Screening Labs □ Normal □ Abnormal Sigmoidoscopy □ Normal □ Abnormal

Physical Exam □ Normal □ Abnormal Colonoscopy □ Normal □ Abnormal

Endoscopy □ Normal □ Abnormal Stress Test □ Normal □ Abnormal

Women Only

Mammogram □ Normal □ Abnormal Bone Density Test (DEXA) □ Normal □ Abnormal

Pap Smear □ Normal □ Abnormal

HEALTH ISSUES:

Tobacco Use Alcohol Use

Exposure to second hand smoke? □ Yes □ No Do you drink alcohol? □ No □ Yes

Smoke / smoked □ Cigarettes □ E-Cigarettes □ Pipe □ Cigar □ None # of drinks/week: □ Beer □ Wine □ Liquor

□ Never Smoked

□ Current smoker: Packs/day: # of years:

Are you ready to quit? □ No □ Yes

□ Former smoker: Quit date:

Approximately how many packs/day did you smoke?

How many years did you smoke?

How many times in a year have you had >3 drinks (for women) or >4 drinks (for men) in a day?

Drug Use

Have you ever used recreational drugs? □ No □ Yes

If yes, which ones?

Quit which ones? □ All

Any used currently?

SOCIAL HISTORY:

Marital status: □ single □ partner □ married □ divorced □ widowed Spouse/partner’s name:

Number of children: Age and sex of your children: # of grandchildren: # of great grandchildren:

Education: □ high school or GED □ trade school □ college □ graduate school □ other

Occupation: Employer:

If you are not working, you are: □ retired □ unemployed □ on a leave of absence □ disabled □ homemaker □ other

Country of birth:

WOMEN’S HEALTH HISTORY:

Total number of pregnancies: Number of births: Number of miscarriages: Number of abortions:

Healthy Living Primary Care

PPO Auto-Pay Policy

Please choose one of the options below: For your convenience, we created two forms of payment to assist with balances until your deductible is met.

I choose to keep my HSA/Credit Card on file for any balance due after billing my insurance. I understand

you will mail a statement and allow 3 weeks for me to contact the office with any concerns. If I have no

concerns, my balance will be paid with the credit card on file. I will receive an email through Patient Portal

once the payment has been processed.

I choose to pay $100 upon check-in that will go toward any patient portion of my office visit until my

deductible is met. If there is a credit remaining on my account it will be used toward future balances. This

amount will only be charged to me if there is no credit already remaining on my account.

Authorization for Credit Card Use

Patients Name: _______________________________________________

Name on Card: _______________________________________________

Billing Address: _______________________________________________

_______________________________________________

Credit Card Type: _____Visa _____MasterCard _____Discover _____AmEx

Credit Card Number: _________________________________________________

Expiration Date: _______________________

Card Identification Number: ____________ (3 digit code on the back of the credit card)

I understand I have up to 3 weeks from the date my billing statement was mailed out, to pay my balance in full. If I have not paid my balance in full after the 3 weeks, I authorize this office to charge up to $150 to the credit card above to settle up to $150 of the balance on my account. I further understand that if there is a balance remaining after charging $150 to the credit card above, that I will make payment in full immediately to avoid any late fees.

Cardholder Signature: ____________________________________________

Date: ____________________________________________

Print Name: ____________________________________________

If there are any questions about your statement please contact our biller, Annie through Patient Portal or call her at (510) 679-7222 upon receipt of the statement.

This agreement will remain in place until the expiration of your credit card on file. If you would like to cancel the authorization, please provide us with a written request would.

Healthy Living Primary Care Dr. Joy Liu, D.O. Dr. Kevin Moynihan, M.D. Dr. Jayferson Golepang, M.D.

Diane Asmuth, P.A.-C Loran Killar, PhD, P.A.-C Noelle Menesini, P.A.-C Nisha Nijjar, F.N.P.-C

2545 E. Bidwell Street, Suite 110, Folsom, CA 95630 • 11634 Fair Oaks Blvd, Fair Oaks, CA 95628 Phone: (916) 983-8868 Fax: (916) 983-8891

Office Policies

WELCOME TO OUR PRACTICE: We are glad you have selected our office for your healthcare needs. Our care

team include three physicians, four mid-levels, and many supporting staffs. We work as a team to provide

quality care to people of all ages. We offer personalized care through the use of the latest in medical

information and diagnostic technology. Developing a strong and long-lasting relationship between the patient

and physician is important to us.

KNOW YOUR INSURANCE PLAN: Under the dynamic changes of the insurance world, it is critical for patients

to understand their own insurance benefits and restrictions. Until your deductible is met, office visits, blood

work and imaging tests are the patient’s responsibility. Preventive lab tests are only limited to cholesterol

panel, complete metabolic panel, complete blood count, thyroid test, and prostate enzyme. Any other tests is

subject to potential out-of-pocket payments, depending on your plan. Preventive visits only cover screening

for high blood pressure, cholesterol, breast exam, Pap smear, vaccinations and physical exam. Discussion of

any medical condition during your preventive visit is subject to an additional charge for a sick visit.

APPOINTMENTS: One of the goals of this office is to respect our patients’ time by having you in the exam

room at the time of the scheduled appointment as opposed to being in the waiting room. In the event that

you are inadvertently delayed in your arrival for your appointment, every effort will be made to fit you into

the existing schedule. However, there may be times that we will request that you re-schedule your

appointment if we cannot accommodate you.

CANCELLATIONS: If you find that you need to cancel your appointment, please provide the office with 24-

hours’ notice to avoid a $25.00 no-show/same-day cancellation fee via Patient Portal, phone call or voicemail.

We will be glad to reschedule you to a more convenient time.

CHRONIC DISEASE MANAGEMENT PROGRAM (if you qualify): If you have at least two chronic diseases, you

qualify for our Chronic Disease Management Program at no charge to you. This program’s goal is to make sure

that your health is well managed. Our designated CCM specialist will review your chart monthly for such

things as preventative care, medication reconciliation, RX refills, and medical management by other

specialists. Patient understands that only the primary care physician can administer this program and that

patient can opt out of the program anytime.

I understand and agree to all the above policies.

Patient’s Name: ____________________________________ Parent’s/Conservator’s Name: _____________________________

Patient’s/Parent’s/Conservator’s Signature: _________________________________________________ Date:_____________

Healthy Living Primary Care

Office Procedures LABS:

Lab orders are sent to Quest electronically for your convenience. You can go to any Quest without a printed order. If you would like to go to LabCorp, we will print you the lab order.

If you are given a paper slip at check out, it is important to bring that lab slip with you to the lab.

You can make appointments online at www.QuestDiagnostics.com to cut down wait time.

If you have a PPO, most lab tests count toward your deductible. For most insurances, preventive lab tests are limited to cholesterol panel, comprehensive metabolic panel, complete blood count, thyroid test, and prostate enzyme. Please call your insurance if you have questions about cost and coverage.

IMAGING TESTS:

Call Sutter Imaging to schedule the test and bring in the printed order.

However, any patient with Covered California and Connected Care needs to go to Mercy Imaging

If prior authorization is required by your insurance, we will obtain the authorization and you will be contacted through our Patient Portal once this is complete. Depending on the urgency of your exam, prior authorization can take up to 7-10 business days to process.

REFERRALS:

Please allow up to 7-10 business days to process your referral unless it is medically urgent. You will be notified through our Patient Portal when your referral is done.

Please make an appointment with the specialist within 30 days because many offices will disregard the referral after 30 days. There is a $25 fee for any repeat referrals.

All pertinent medical information will be sent with the referral to the specialist. You also have access to your medical record through our Patient Portal if anything additional is needed by the specialist.

We will do our best to refer you to a specialist within your insurance network. However, it is your responsibility to confirm that the specialist is in your network before receiving services with that office.

TEST RESULT:

We will always notify you of all test result. If you do not hear from us after 2 weeks, contact us via Patient Portal.

For routine or preventative lab/test, our providers will send you the interpretation of the test results through our Patient Portal. Afterward, you will also be able to view your results on Patient Portal.

If the test result is abnormal and requires an in-depth discussion, we will contact you via Patient Portal to schedule a follow-up appointment.

For follow-up tests, our provider will discuss the test results with you in detail at your next follow-up appointment.

If any test result is urgent, you will be contacted by phone.

KNOW YOUR INSURANCE PLAN:

Under the dynamic changes of the insurance world, it is critical for patients to understand their own insurance benefits and restrictions. Until your deductible is met, office visits and tests are the patient’s responsibility.

URGENT CARE/AFTERHOUR CARE:

We have multiple providers here daily to take care of your urgent medical needs. You should be able to get an appointment with someone on our care team on the same day if you call early in the day. If you need care after office hours, on-call doctors are available for consultation 24/7. Directions to local urgent care centers are outlined in our voicemail message. Keep in mind that for life threatening emergencies you should call 911.

RX REFILLS:

Please check for any refills you might need prior to each visit. If you need a prescription refill between visits, please contact your pharmacy and they will send an electronic request to our office. You can also request for medication refill on Patient Portal. Please allow 24 to 48 hours for your prescription to be approved by the physician and processed by our office. However, we are not able to refill narcotic medication without a visit.

I understand and agree to all the above office procedures.

Patient’s Name: ___________________________ Parent’s/Conservator’s Name: _____________________________

Patient’s/Parent’s/Conservator’s Signature: ___________________________________________ Date:_____________

Healthy Living Primary Care NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED

AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.

We are required by applicable federal and state law, including the Health Insurance Portability & Accountability Act of 1996

(HIPAA), to maintain the privacy of your medical information. We are also required to give you this notice about our privacy

practices, our legal duties, and your rights concerning your medical information.

You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this

notice, please contact us using the information listed at the end of this notice.

We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by

applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all

medical information that we maintain, including medical information we created or received before we made the changes.

We may use and disclose medical information about you for the following purposes: Treatment, Payment and Health Care

Operations:

Treatment: We may use your medical information to treat you or disclose your medical information to a physician or other

health care provider providing treatment to you.

Payment: We may use and disclose your medical information to obtain payment for services we provide you.

Health Care Operations: We may use and disclose your medical information in connection with the normal course of

operating our practice. Health care operations may also include quality assessment activities, performance evaluations,

conducting training programs, accreditation, and certification, licensing or credentialing activities.

We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and

services that may be of interest to you.

Any other uses and disclosures of your medical information will only be made with your written authorization or in response to legal

requirements such as disaster relief, court orders, suspected abuse, neglect, or domestic violence, or in certain instances affecting

national security.

You have the following rights with respect to your protected health information which you may exercise by written request using the

contact information at the end of this notice:

The right to request additional restrictions on the use or disclosure of your medical information. We are not required to agree

to these additional restrictions, but if we do, we will abide by our agreement which must be in writing.

The right to inspect and copy your protected health information.

The right to request amendments to your protected health information.

The right to receive an accounting of disclosures of your personal health information for other than treatment, payment,

health care operations or pursuant to other authorized disclosures as stated above.

The right to obtain a copy of this notice

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we have made to amend or restrict

the use or disclosure of your medical information or to have us communicate with you by alternative means or at alternative locations,

you may contact us using the contact information listed at the end of this notice. You also may submit a written complaint to the U.S.

Department of Health and Human Services. We will provide you with the address to file your complaint upon request.

We support your right to the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint

with us or with the U. S. Department of Health and Human Services.

Contact Office: Healthy Living Primary Care Patient’s Name ____________________________

Phone: 916-983-8868 Fax: 916-983-8891

Address: 2545 E. Bidwell St, Suite 110, Folsom, CA 95630 Patient’s Signature _________________________

Date ____________________________________

Healthy Living Primary Care Dr. Joy Liu, D.O. Dr. Kevin Moynihan, M.D. Dr. Jayferson Golepang, M.D.

Diane Asmuth, P.A.-C Loran Killar, PhD, P.A.-C Noelle Menesini, P.A.-C Nisha Nijjar, F.N.P.-C

2545 E. Bidwell Street, Suite 110, Folsom, CA 95630 11634 Fair Oaks Blvd, Fair Oaks, CA 95628

Phone: (916) 983-8868 Fax: (916) 983-8891

Consent for Text Message Reminder

I hereby give my consent to Healthy Living Primary Care to use SMS Text Messaging at mobile

phone number _______________________ for appointment reminders ONLY. I

understand that I will be provided with the option to confirm or cancel your appointment via text

messaging. However, if you would like to reschedule I will need to contact Healthy Living Primary

Care at 916-983-8868. I also understand that my mobile service provider may charge a SMS text

message fee for any messages sent and/or received from my phone number.

Patient Name: Please print

Signature: Date:

In the event of a Parent/Guardian signing for a minor, please state your relationship:

All patients have the right to change their minds. If you wish to change your reminder option, please

notify reception. If you change your phone number please inform us so that we can update our

records.

Healthy Living Primary Care Dr. Joy Liu, D.O. Dr. Kevin Moynihan, M.D. Dr. Jayferson Golepang, M.D.

Diane Asmuth, P.A.-C Loran Killar, PhD, P.A.-C Noelle Menesini, P.A.-C Nisha Nijjar, F.N.P.-C

2545 E. Bidwell Street, Suite 110, Folsom, CA 95630 11634 Fair Oaks Blvd, Fair Oaks, CA 95628

Phone: (916) 983-8868 Fax: (916) 983-8891

Medication History Consent

By signing below I give permission for this medical office to access my pharmacy benefits data electronically through RxHub. This consent will enable this medical office to:

Determine the pharmacy benefits and drug co pays for a patient’s health plan.

Check whether a prescribed medication is covered (in formulary) under a patient’s plan.

Display therapeutic alternatives with preference rank (if available) within a drug class for medications.

Determine if a patient’s health plan allows electronic prescribing to Mail Order pharmacies, and if so, e-prescribe to these pharmacies.

Download a historic list of all medications prescribed for a patient by any provider. In summary, we ask your permission to obtain formulary information, and information about other prescriptions prescribed by other providers using RxHub. _________________________________ Patient Name _________________________________ _________________ Patient Signature Date