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Genesis Healthcare, Inc.
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New Patient Application
Annual Patient
GHC New Patient Application
Instructions
Select GHC Office
Please select your GHC office
*
Pee Dee Health Care
Genesis Healthcare Darlington (Behavioral Health)
Olanta Family Care
Lamar Family Care
Walterboro Family Care & Pediatrics
Genesis Healthcare Florence
Lowcountry Pediatrics
Patient Information
Section 1 of 13
Last Name
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First Name
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Middle Initial
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Social Security #
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Numbers only (example 123456789)
Address
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City
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State
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Zip
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Numbers only
Home Telephone
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Cell Phone
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If you do not have a cell phone, please enter: 000-000-0000
Date of Birth
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*
Age
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Email
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*
Yes! Sign me up for Genesis email updates
Yes
No
Consent to Call
Yes
No
Consent to Text
Yes
No
Gender
Male
Female
Female-to-Male/Transgender Male
Male-to-Female/Transgender Female
Gender Non-Conforming/Neither Male nor Female
Other
(Gender) Other
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Sexual Orientation
Bisexual
Lesbian/Gay/Homosexual
Straight/Heterosexual
Unknown
Rather Not Disclose
Other
(Sexual Orientation) Other
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Insured's Language
English
Spanish
Chinese
French
German
Italian
Sign Language
Other
(Insured's Language) Other
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Marital Status
Single
Married
Divorced
Widowed
Separated
Life Partner
Unknown
Race
African American/Black
White
Asian
American Indian/Alaska Native
Korean
Pacific Islander
Asian Indian
Chinese
Filipino
Japanese
Vietnamese
Samoan
Guamanian or Chamorro
Rather Not Answer
Other
(Race) Other
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Ethnicity
Hispanic/Latino
Non-Hispanic/Latino
Mexican
Cuban
Mexican American
Puerto Rican
Rather Not Answer
Other
(Ethnicity) Other
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Veteran Status
Yes
No
Decline
Homeless Status
Yes
No
Decline
Student
Yes, Full Time
Yes, Part Time
No
Public Housing
Yes
No
Decline
If (student) yes, Provide School Name
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Current Primary Care Provider
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Date of last visit with current provider
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Current Primary Care Provider
City
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Do you want to change current provider?
Yes
No
Current Primary Care Provider
State
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Current Primary Care Provider
Phone #
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Currently Treated by Home Health/SC House Calls/Hospice
Yes
No
Current Pharmacy
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Current Pharmacy
City
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Current Pharmacy
Phone
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Do you have a provider preference?
Yes
No
Requested Provider
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Emergency Contact (ages 19 and above):
Emergency Contact Name
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Emergency Contact Phone
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Emergency Contact Relationship
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GHC Reference and Board Section
How did you hear about Genesis Healthcare? Please select one:
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Referral
Current Patient
Social Media Advertisement
Newspaper Article
Community Event
Referral Source
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If you selected 'Referral' for how you heard about Genesis Healthcare, please specify the referral source:
Are you interested in serving on the Board of Directors for Genesis Healthcare?
Yes
No
Insurance
Section 2 of 13
Primary Insurance
Insured’s Name (If other than patient):
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Primary Insurance
Insurance Company
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Primary Insurance
Address
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Primary Insurance
ID Number
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Primary Insurance
DOB
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Primary Insurance
Employer
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Secondary Insurance
Secondary Insurance
Insured’s Name (If other than patient):
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Secondary Insurance
Insurance Company
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Secondary Insurance
Address
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Secondary Insurance
ID Number
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Secondary Insurance
DOB
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Secondary Insurance
Employer
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MEDICARE PATIENTS – LIFETIME AUTHORIZATION TO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDER, PHYSICIANS, AND PATIENT
Section 3 of 13
I certify that the information given to me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Health Care Financing Administration or its intermediaries or carriers any information needed for this or related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for covered Medicare services to the physician. As my healthcare provider, I appoint Genesis Healthcare, Inc1 to act as my representative in connection with any claim or asserted right under Title XVIII of the Social Security Act and related provisions of Title XI of the Act and authorize Genesis Healthcare, Inc make any claims, present or elicit evidence, obtain appeals information, and receive notice in connection with my claim, appeal, grievance. I further authorize Genesis Healthcare, Inc to release any and all medical and billing information to any health care provider involved in my treatment and to any health care facility directly or indirectly involved in my treatment for purposes including, but not limited to, billing, collection, quality assurance or risk management activities, or defense of litigation or anticipated litigation and to any insurance company, health maintenance organization or other entity which is directly or indirectly responsible for payment or review of services provided by Genesis Healthcare, Inc.
Patient/Patient Authorized Representative Signature (Sign below with your mouse or finger):
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Patient Name (Print):
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Relationship to Patient if Unable to Sign:
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FINANCIAL STATEMENT
Section 4 of 13
I understand and agree that regardless of my insurance coverage, I am ultimately responsible for payment of any charges for professional services rendered. I understand that I will be ultimately responsible for collection fees and any attorney fees should my account be placed with a collection agency due to nonpayment of my account. I certify that the information I have given is true and correct to the best of my knowledge. If I have health insurance, Genesis Healthcare, Inc. will file on my behalf, but it is my responsibility to see that my health insurance policy pays the benefits provided under said policy. If there is a change in family member status, it is my responsibility to give the information, in writing, to Genesis Healthcare, Inc. as I am responsible for all charges incurred for my family members. I request that payment for professional service rendered be made directly to Genesis Healthcare, Inc. I permit a copy to be used in place of the original.
Patient/Patient Authorized Representative Signature (Sign below with your mouse or finger):
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Patient’s Name (Print):
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Relationship to Patient if Unable to Sign:
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MINOR PATIENTS ONLY (0-18 years)
Section 5 of 13
If the patient is a minor, please complete the Minor Patient section. If the patient is NOT a minor, please proceed to the next section "History Intake".
Is the patient a minor (0-18 years)?
Yes
No
Mother
Mother (if the address and phone numbers are the same as the patient, please indicate same.)
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Mother Full Name
Mother
Phone
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Mother
Address
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Mother
City
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Mother
State
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Mother
Zip
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Mother
Employer
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Mother
Employer Phone
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Father
Father (if the address and phone numbers are the same as the patient, please indicate same.)
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Father Full Name
Father
Phone
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Father
Address
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Father
City
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Father
State
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Father
Zip
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Father
Employer
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Father
Employer Phone
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Alternate Caregiver
Please list any caregivers that you authorize to obtain medical care for your child in your absence:
1st Alternate Caregiver Name
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1st Alternate Caregiver Relationship to Minor
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1st Alternate Caregiver Phone Number
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2nd Alternate Caregiver Name
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2nd Alternate Caregiver Relationship to Minor
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2nd Alternate Caregiver Phone Number
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3rd Alternate Caregiver Name
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3rd Alternate Caregiver Relationship to Minor
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3rd Alternate Caregiver Phone Number
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4th Alternate Caregiver Name
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4th Alternate Caregiver Relationship to Minor
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4th Alternate Caregiver Phone Number
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Parent Signature
With my permission, I hereby authorize the above individuals to consent to all medical care and attention which is deemed necessary and appropriate by a health care provider at Genesis Healthcare, Inc for this minor. This includes, but is not limited to emergency services, lab tests, procedures, and immunizations. The listed individuals are given authority to discuss and change appointments, financial or insurance details, and clinical information including labs/tests.
Parent/Legal Guardian Signature (Sign below with your mouse or finger):
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Parent/Legal Guardian Name (Print):
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List all siblings at this practice:
1. Full Name
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1. DOB
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1. Age
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2. Full Name
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2. DOB
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2. Age
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3. Full Name
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3. DOB
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3. Age
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4. Full Name
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4. DOB
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4. Age
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5. Full Name
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5. DOB
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5. Age
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HISTORY INTAKE
Medication Allergies
Medication Allergies | Reaction
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For all medication allergies list the Medication Allergy and Reaction:
Past Medical History
Diabetes
Yes
No
High Blood Pressure
Yes
No
Low Blood Pressure
Yes
No
Heart Disease
Yes
No
Heart Pacemaker
Yes
No
Irregular Heartbeat
Yes
No
Lung Disease/Asthma
Yes
No
Cholesterol
Yes
No
Stroke
Yes
No
Seizure Disorder
Yes
No
Cancer
Yes
No
Anemia
Yes
No
Blood Clots
Yes
No
Excessive Bleeding
Yes
No
Arthritis
Yes
No
Osteoporosis
Yes
No
Liver Disease
Yes
No
Kidney Disease
Yes
No
Anxiety
Yes
No
Depression
Yes
No
HIV/Aids
Yes
No
Sickle Cell Disease
Yes
No
Other Past Medical History
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Current Medications | Dosage/Frequency
1. Current Medication
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1. Dosage/Frequency
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2. Current Medication
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2. Dosage/Frequency
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3. Current Medication
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3. Dosage/Frequency
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4. Current Medication
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4. Dosage/Frequency
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5. Current Medication
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5. Dosage/Frequency
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6. Current Medication
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6. Dosage/Frequency
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7. Current Medication
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7. Dosage/Frequency
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8. Current Medication
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8. Dosage/Frequency
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9. Current Medication
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9. Dosage/Frequency
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10. Current Medication
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10. Dosage/Frequency
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11. Current Medication
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11. Dosage/Frequency
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12. Current Medication
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12. Dosage/Frequency
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13. Current Medication
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13. Dosage/Frequency
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14. Current Medication
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14. Dosage/Frequency
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15. Current Medication
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15. Dosage/Frequency
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16. Current Medication
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16. Dosage/Frequency
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17. Current Medication
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17. Dosage/Frequency
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18. Current Medication
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18. Dosage/Frequency
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19. Current Medication
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19. Dosage/Frequency
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20. Current Medication
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20. Dosage/Frequency
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21. Current Medication
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21. Dosage/Frequency
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22. Current Medication
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22. Dosage/Frequency
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Surgical History
Tonsils Surgery
Yes
No
Tonsils Surgery Date
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Appendix Surgery
Yes
No
Appendix Surgery Date
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Gall Bladder Surgery
Yes
No
Gall Bladder Surgery Date
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Hernia Surgery
Yes
No
Hernia Surgery Date
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Hysterectomy Surgery
Yes
No
Hysterectomy Surgery Date
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Breast/Mastectomy Surgery
Yes
No
Breast/Mastectomy Surgery Date
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Heart Surgery
Yes
No
Heart Surgery Date
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Back/Neck Surgery
Yes
No
Back/Neck Surgery Date
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Hip/Knee/Shoulder Surgery
Yes
No
Hip/Knee/Shoulder Surgery Date
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Other Surgical History
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List of Current Providers/Specialists
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NARCOTIC ACKNOWLEDGMENT
Section 7 of 13
I (Print Name) acknowledge that it has been explained to me that Genesis Healthcare, Inc. does not provide chronic narcotic pain management. This includes the use of narcotic medication as well as other supplemental controlled substances. I understand and agree that I will be referred to another clinic for pain management by that facility’s physician.
Patient Signature/Patient Authorized Representative (Sign below with your mouse or finger):
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Patient Name (Print):
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Relationship to Patient if patient unable to sign:
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ANSWERING MACHINE/VOICE MAIL MESSAGES
Section 8 of 13
There may be times when our office is not able to reach you by telephone. With your permission, we would like to be able to leave messages on your home answering machine/cell phone voice mail. To comply with strict legal standards, a written release will allow us to leave a message on your answering machine. By signing below, you are authorizing us to leave messages on your answering machine at the telephone number you have given us in your record.
Patient/Patient Authorized Representative Signature (Sign below with your mouse or finger):
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Patient Name (Print):
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Relationship to patient if Unable to Sign:
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HIPAA AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Section 9 of 13
Some patients prefer other individuals, especially family members, be allowed access to their medical information. To comply with strict legal standards, a written release is required to allow another person access to your medical records. This release grants permission to individual(s) listed below to: Make or confirm appointments, have access to x-ray and laboratory findings, pick up sample medications, be made aware of your diagnosis, prognosis, and treatment plans, and serve as your emergency contact. This permission applies to telephone and answering machine messages as well as other means of communication.
Patient’s Signature (Sign below with your mouse or finger):
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Patient Print:
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1. Designated Party:
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Telephone:
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Relationship:
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CONSENT FOR TREATMENT AND AUTHORIZATION
Section 10 of 13
I, the undersigned, do hereby authorize and consent to medical examinations, x-rays, blood tests, laboratory procedures, immunizations, therapeutic injections, invasive or surgical procedures and other medically appropriate services under the general or specific supervision of any member of the medical staff of Genesis Healthcare, Inc for the patient named on this form. It is understood that this authorization is given in advance of any specified diagnosis, treatment or care being required but it is given to provide authority and power to render care by providers of Genesis Healthcare, Inc. in the exercise of her/his best judgment that they may deem advisable. I understand that state law requires physicians to report certain communicable diseases to the Health Department. SC Code Ann. Sec 44-29-10. Regulation 61-20. I agree that if I leave a physician’s office against the advice of my physician(s) of Genesis Healthcare, Inc and its personnel, they are released from responsibility or liability for any injuries or damages which may result from leaving against medical advice. I authorize a physician of Genesis Healthcare, Inc to test me for HIV antibodies or tuberculosis when the doctor or any employees are exposed to body fluids in a manner which may transmit human immunodeficiency virus (HIV), or infection of tuberculosis. In the event of such an exposure, you will be deemed to have consented to such testing, and to have consented to the release of the test results to the person(s) who may have been exposed.
Patient/Patient Authorized Representative Signature (Sign below with your mouse or finger):
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Patient Name (Print):
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Relationship to Patient if Unable to Sign:
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Important Patient Information
Please read the provided information
NOTICE OF PRIVACY PRACTICE
Section 12 of 13
I have received GHC’s Notice of Privacy Practices and agree to the terms regarding the use and disclosure of medical information.
Patient/Patient Authorized Representative Signature (Sign below with your mouse or finger):
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*
Patient Name (Print):
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Relationship to Patient if Unable to Sign:
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AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
Section 13 of 13
Please Fax Records to Attention:
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I authorize the use and disclosure of my individual health information as described below. I understand that the information I authorize a person or entity to receive may be re-disclosed and no longer protected by federal privacy regulations. (Note: S.C. Law prohibits the re-disclosure of mental health records).
Patient’s Name:
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DOB
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Social Security #
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*
Numbers only (example 123456789)
MR#
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Person/Organization disclosing the information:
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Person/Organization receiving the information (Select 'Yes' for all that apply):
Pee Dee Health Care
201 Cashua St Darlington, SC 29532 Phone: (843) 393-7452 Fax: (843) 393-6210
Yes
Genesis Healthcare Darlington (Behavioral Health)
115 Exchange St Darlington, SC 29532 Phone: (843) 393-9421 Fax: (843) 968-3473
Yes
Olanta Family Care
211 S Jones Rd Olanta, SC 29114 Phone: (843) 396-9730 Fax: (843) 396-9735
Yes
Lamar Family Care
301 W Main St Lamar, SC 29069 Phone: (843) 395-8400 Fax: (843) 395-8401
Yes
Walterboro Family Care & Pediatrics
830 Robertson Boulevard Walterboro, SC 29488 Phone: (843) 781-7428 Fax: (843) 781-7429
Yes
Genesis Healthcare Florence
1523 Heritage Ln Florence SC, 29505 Phone: (843) 673-9992 Fax: (843) 673-9996
Yes
Lowcountry Pediatrics
99 Bridgetown Rd, Goose Creek, SC 29445 Phone: (843) 572-3300 Fax: (833) 771-2207
Yes
Information for treatment period:
Information for treatment period:
From (Date):
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Information for treatment period:
To (Date):
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Type(s):
Office Note
Yes
Hospital Notes
Yes
Laboratory Test
Yes
Consults
Yes
Radiology Reports
Yes
Ancillary Testing Reports
Yes
If Type(s) Other Please Specify
*
Purpose(s):
Insurance
Yes
Legal Investigation
Yes
Disability Evaluation
Yes
Continued Care
Yes
If Purpose(s) Other Please Specify
*
OR
OR
I may request my information be released to me to exercise my right to access and obtain a copy of my PHI.
Yes
No
I have read and understand this Authorization. I certify that I am the Patient listed above or a person authorized to permit release of records on the Patient's behalf. I hereby release Genesis Healthcare, Inc from any liability or damages arising in connection with or related to the use and/or disclosure of my protected health information pursuant to this Authorization.
Patient Signature (Sign below with your mouse or finger):
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*
Patient Name – Print
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Authorized Representative
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Relationship to Patient
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Telephone Number
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