New Patient Adult Packet - Internal Medicine And Pediatrics In Lockport, NY

CHRISTOPHER BENEY, MD., PC77 Elizabeth Drive Lockport, NY 716-433-2674335 High Street Drive Wilson, NY 716-433-2674Chad Shepherd, DNP, FNP Karey M. Schmelz. RPA-C Shannon McCrory, DHED, CPNP-PCAmberlee M. Peace, RPA-C Lindsey C. Brown, RPA-CAdult RegistrationPATIENT NAME DATE OF BIRTHADDRESS CITY ZIPHOME PHONE CELL PHONEEMAILPREFERRED METHOD OF CONTACT: HOME PHONECELL PHONEEMAILPREFERRED PHARMACYPREFERRED PRIMARY PROVIDER FROM LIST ABOVERACE: WHITEBLACK/AFRICAN AMERICAN HISPANIC/LATINOASIANAMERICAN INDIAN/ALASKAN NATIVEOTHERDECLINE TO ANSWERETHNICITY: HISPANIC OR LATINONON HISPANIC OR LATINODECLINE TO ANSWERPRIMARY LANGUAGEEMPLOYERMARITAL STATUS:SINGLEMARRIEDOCCUPATIONDIVORCED WIDOWEDSPOUSE NAMEDOBSPOUSE PHONE NUMBEREMERGENCY CONTACT OTHER THAN SPOUSENAME RELATIONSHIP PHONENAME RELATIONSHIP PHONENAME RELATIONSHIP PHONEPLEASE BE PREPARED TO PRESENT YOUR INSURANCE CARE AT CHECK IN AT EVERY VISIT.NAME OF INSURANCE COMPANYPOLICY # GROUP#

Annual Comprehensive Health QuestionnaireCHRISTOPHER BENEY, MC., PC77 Elizabeth Drive Lockport, NY 716-433-2674335 High Street Drive Wilson, NY 716-433-2674Chad Shepherd, DNP, FNP Karey M. Schmelz. RPA-C Shannon McCrory, DHED, CPNP-PCAmberlee M. Peace, RPA-C Lindsey C. Brown, RPA-CThe following questionnaire will assist your physician in formulating a comprehensive medicalassessment for you at your annual wellness exam. It is essential that you provide intervalchanges in your medical and family situation as well as details of any current health concerns toallow your physician to be more effective in assessing your present and future health concerns.Of course, if there have been no changes since your last visit, you may simply write “no change.”Your responses will be reviewed with you by your physician during your evaluation.Section 1: Present Health Status1. How do you assess your overall health status? Excellent Good Fair Poor2. What would you say your overall health status is over the past few years?Stable Improving Declining3. How content are you with your general health?Very Content Somewhat content Disappointed in present health4. Do you see a dentist routinely? Yes No. When was your last visit? .Are there any concerns regarding your teeth? Yes NoIf yes, please explain .5. When was your last eye exam? .6. Do you wear glasses? Yes No7. Do you have hearing aids? Yes No8. Do you have an advanced care plan or directive?Yes No (If yes please bring copy to office)Would you like to discuss one today? Yes NoSection 2: Past Medical History1. Have you had any significant medical illnesses since your last physical? Yes NoIf yes, pleaseexplain:2. Have you been in the hospital or emergency room since last physical? Yes NoIf yes, please list withdates:

3. Have you had any surgical procedures or diagnostic testing since your last physical?Yes NoIf yes, please list with dates:4. Please list your current medications, including any over the counter supplements and howyou take them specifically. (Please attach an itemized list if not enough space)5. Please list your food and drug allergies:6. Have you received any vaccinations since your last physical? Yes NoPlease list withdates:7. Do you see any other doctors (specialists)? Yes No If yes pleaselist:8. Please list any past surgeries you havehad:Section 3: Family History:1. Any new medical illnesses or hospitalizations with your immediate family since your lastphysical? Yes No If Yes please list who:2. Is there any behavioral health issues in your immediate family (i.e. depression, stress,alcoholism, illegal drug use, prescription drug abuse)? Yes NoMother:Father:Siblings:Section 4: Social History:1. What is your marital status?2. Are you sexually active? Yes No Self-described gender orientationAny contraceptives used and what kind?3. Number of Children? Boys GirlsBesides spouse and children, any one else living in your home?Explain:4. What is your current occupation?5. Do you smoke tobacco? Yes No How much a day? For how manyyears? Are you ready to quit?

6. Are you exposed to secondhand smoke? Yes No7. Do you drink Alcohol? Yes NoIf yes, how often? How much in one sitting?8. Do you use illegal drugs or abuse prescription medications? Yes NoPlease explain if yes9. Have you felt the need to cut down on drinking alcohol or drug use? Yes NoHave you felt annoyed by others criticizing your drinking or drug use? Yes NoHave you ever felt guilty about drinking or drug use? Yes NoHave you ever felt you needed a drink first thing in the morning? Yes No10. Do you follow a healthy diet? Yes No Specific diet?11. Do you exercise? Yes No How often?12. Do you consume caffeinated beverages? Yes NoHow much?13. Do you feel you have an adequate social life? Yes No14. Do you feel you have the resources necessary (i.e. food, housing, transportation etc.) tomeet your daily needs? Yes No15. Do you have difficulty sleeping at night? Yes No Average hours of sleep16. In the last few weeks have you felt nervous, anxious or on edge? Yes No17. In the last few weeks have you been unable to stop or control worrying about things?Yes No18. In the last few weeks have you had little interest or pleasure in doing things?Yes No19. In the last few weeks have you felt down, depressed or hopeless? Yes No20. Lastly is there anything you feel you want to discuss at your visit specifically?If so, pleaseexplain:

Current MedicationsPlease provide us with a list of your current medications.Please be aware, it is our office policy that we DO NOT prescribe controlled medications. If you are oncontrolled medications you must be currently established with pain management.Please sign to acknowledge the above: Date:Name of 2.)13.)14.)15.)16.)17.)18.)19.)20.)

Christopher Beney, MD.,PC.FINANCIAL POLICYINSURANCE: We participate in most managed care plans and will bill your insurance plan as may be necessary. If we do not participatewith your managed care plan, payment in full is required at the time of service, unless other arrangements have been made in advance. Wemay be able to bill your plan as a courtesy to you and credit your account if we receive any additional payment. Knowing your insurancebenefits – including eligibility, covered benefits, and medically necessary procedures is your responsibility; please contact customerservices at your insurance company for questions you may have regarding your coverage. You are responsible for any charges notcovered by your plan. We do not accept Worker's Compensation Proof of Insurance. All patients must complete and/or update our Patient Information Form at each office visit. You must furnish validand up-to-date proof of insurance coverage and a copy of your driver’s license. If you provide false or expired insurance information youwill be responsible for the balance of the claim. Please notify us of any changes in insurance coverage prior to time of service. Insurancedenials for termination of coverage will be automatically billed to you. Co-payments and deductibles. All co-payments and unsatisfied deductibles must be paid at the time of service. By contractual law yourinsurance company requires us to charge for, and you to pay for, all required co-payments, coinsurances, deductible and non-coveredservices. Claim submission. We will submit your insurance claims and assist you in any way reasonable to help get your claim paid. Yourinsurance company may need you to supply information directly to them. It is your responsibility to comply with their request in a timelymanner. New York insurance law requires your insurance company to provide timely payment. Please be aware that the balance of yourclaim is your responsibility to pay whether or not your insurance company has paid. We are not a party to your insurance contract. Referrals. If your managed care plan requires approval or authorization for referrals to a specialist, radiological imaging, medical facilitycare, etc., it is your responsibility to inform the office of this requirement prior to referral.We require 72 hours notice to facilitate a referral request and cannot issue retroactive referrals.OUT-OF-NETWORK CARE / SELF PAY: Please be aware that you have an option to seek care from Physicians eventhough they are not participating in your network. In this situation, your out-of-pocket expense will be greater. As acourtesy to our out-of-network patients, we will file your insurance claim if desired, and offer a 10% reduction from our usual fees. Thisbenefit also applies to individuals without insurance.I certify that I, and/or my dependent(s) have insurance and assign directly to Dr. Christopher Beney all insurance benefits, if any,otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid or notpaid by Insurance. I authorize the use of my signature on all Insurance submissions. I also acknowlege the use of my health careinformation by the above physician may be disclosed to insurance company and their agents for the purpose of obtaining payment forservices and determining benefits payable to related services.Patient Name DOBSignatureDateNO SHOW POLICYChristopher E. Beney M.D., P.C would appreciate a 24 hour notice in the event a scheduled appointment needscancellation. In the event the office is not notified this would be deemed as a “No Show”A “no show” is the term we use when a patient misses an appointment without cancelling it within one (1) businessday in advance. Unfortunately, “No-Shows” inconvenience those patients who need access to medical care in atimely manner.A failure to present at the time of a scheduled appointment will be recorded in your medical chart as a “no show”.You will be sent a letter alerting you to the fact that you failed to show for a scheduled appointment and did notcancel the appointment within one (1) business day in advance. This is a warning letter. A copy of the letter will beplaced in your medical record. Three (3) “no-shows” will result in a dismissal from the practice.By signing below I have acknowledged and read Christopher E. Beney M.D., P.C’s No Show PolicyName (please print)SignatureDate

CHRISTOPHER BENEY, MD, PCPermission to release Medical Information for personal relationshipsPlease read and list anyone in your personal life that you would like to allow them to have information aboutyour medical care, including them to be able to make and cancel appointments. Please note if someone is notlisted and they call to speak about you or your appointments we will not be able to speak with them.I understand that: this authorization may include disclosure of information relating to my medicalrecords, I have the right to revoke this authorization at any time by writing to the provider listed. Iunderstand that I may revoke this authorization except to the extent that action has already been taken based onthis authorization.Signing this authorization is voluntary. I understand that generally my treatment, payment, andenrollment in a health plan, or eligibility for benefits will not be conditional upon my authorization ofthis disclosure.I authorize information regarding my care and treatment to be released as set forth on this form to the hipphonePatient NameDOBSignatureDate