New Patient Packet New patient history form New patient history form Patient Name * First, Middle, and Last Date of Birth * Allergies to Medicines: * Current Medications Please list all current medication and include month/day/year. Name Start Date Dose Times/Days Taken Add Remove Social History Married Single Widowed Divorced Number of Pregnancies * Live Births Occupation Highest Level of Education Drug Use Y/N, if yes * Alcohol Consumption (avg # drinks/week) * Tobacco Use (packs per week/day) * Medical History Please check off all applicable personal medical diagnoses received by a doctor High blood pressure Heart Attack Diabetes Thyroid disease Kidney problems COPD Acid Reflux Stomach ulcers Asthma Liver Disease (specify) Kidney Disease (specify) Cancer specify (type/year diagnosed) Gastric/Colon disease (specify) Please Specify Autoimmune Disease (Lupus/RA/Sjogrens/Vasculitis) Other Surgical History (please list surgeries and dates) Surgery * Add Remove Family History Rheumatology Auto Immune Diseases As of: (if a provider has treated you or your family, please mark off your diagnosis) Rheumatoid Arthritis Psoriatic Arthritis Lupus Osteoarthritis Gout Spondylarthritis Sjogren’s Syndrome Myositis Vasculitis Osteoporosis Polymyalgia Rheumatica Scleroderma Mother - Alive/Deceased * Father - Alive/Deceased * Siblings - Alive/Deceased * Have you been under the care of another Rheumaologist in the past? Yes No Doctor Name Phone & Fax Last office Visited & Labs was on: I verify that this information is both complete and accuratePatient Signature * Clear Date TELEPHONE COMMUNICATION PREFERENCE Home CAN WE CALL HERE? Yes No CAN WE LEAVE A MESSAGE? Yes No Work CAN WE CALL HERE? Yes No CAN WE LEAVE A MESSAGE? Yes No Mobile Phone CAN WE CALL HERE? Yes No CAN WE LEAVE A MESSAGE? Yes No Other CAN WE CALL HERE? Yes No CAN WE LEAVE A MESSAGE? Yes No Mail or Email So that we may better serve you, please provide the following pharmacy information: If you do not know what Specialty Pharmacy to use, we will send your medication to Kroger Specialty Pharmacy for all Biological and Oral medication. Pharmacy name: Pharmacy Telephone & Fax * Pharmacy Address Pharmacy Address Pharmacy Address Pharmacy Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal New Patient Office Registration First Name * Middle Name * Last Name * Date Of Birth Phone Race Black Hispanic Native American Oriental Asian White Chinese Filipino Native Hawaiian Multiracial Pacific Islander Japanese Language * Employment Status: Full-time Part-time Self-employed Retired Student Child Unemployed OtherOther Responsible Party (Party Responsible for payment): Self Spouse Parent OtherOther Name Last Name First Name Middle Address Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone Work Fax Email Primary Insurance: * Insured Party: * SelfSpouseParentOther Insured Party: Group # * ID * Add Remove Acknowledgment of Financial ResponsibilityThis office does not accept responsibility for collecting your insurance proceeds or negotiating the settlement of a disputed claim. If, for whatever reason, your insurance company does not pay your claim in full, you are responsible for payment of the entire balance, including any finance charges or collection fees that may be included.I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT.Signature * Clear Date MISC requests for (Medical Records, Letters, Disability Placards, FMLA, ETC.)I understand and agree to pay the $25 fee for requesting a hard copy of my medical records and any other added paperwork I would like the doctor to fill out. I understand that I will need to allow 72 hours for my medical records to be processed and 2 weeks for forms to be filled out.Signature * Clear Date Medication Refill Policy I understand that should I need any refills on my medications, they should be requested during my appointment with the doctor. I know that should I make any requests outside of this time, I must allow 3-5 business days for my prescriptions to be filled. I take responsibility for calling the office in the appropriate time frame for my medications to be refilled before I run out.Signature * Clear Date Assignment of Benefits I hereby assign and convey directly to the above named health care provider, as my designated authorized representative, all medical benefits and/or insurance reimbursement, If any, otherwise payable to me for services, treatments, therapies, and/or medications rendered or provided by the above -named health care provider, regardless of its managed care network participation status. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the above-named health care provider to release all medical information necessary to process my claims. Further, I hereby authorize my plan administrator fiduciary, insurer, and/or attorney to release to the above named health care provider any and all Plan documents, summary benefit description, insurance policy, and/or settlement information upon written request from the above named health care provider or its attorneys in order to claim such medical benefits. In addition to the assignment of the medical benefits and/or insurance reimbursement above, I also assign and/or convey to the above named health care provider any legal or administrative claim or chose an action arising under any group health plan, employee benefits plan, health insurance or tort Feas or insurance concerning medical expenses incurred as a result of the medical services, treatments, therapies, and/or medications I receive from the above-named health care provider (including any right to pursue those legal or administrative claims or chose an action). This constitutes an express and knowing assignment of ERISA breach or fiduciary duty claims and other legal and/or administrative claims. l intend by this assignment and designation of authorized representative to convey to the above named provider all of my rights to claim (or place a lien on) the medical benefits related to the services, treatments, therapies, and/or mediations provided by the above named health care provider, including rights to any settlement, insurance or applicable legal or administrative remedies (including damages arising from ERISA breach of fiduciary duty claims). The assignee and/or designated representative (above - named provider) is given the right by me to (1) obtain information regarding the claim to the same extent as me; (2) submit evidence; (3) make statements about facts or law; (4) make any request including providing or receiving notice of appeal proceedings; (5) participate in any administrative and judicial actions and pursue claims or chose in action or right against any liable party, insurance company, employee benefit plan, health care benefit plan, or plan administrator. The above named provider as my assignee and my designated authorized representative may bring suit against any such health care benefit plan, employee benefit plan, plan administrator or insurance. company in my name with derivative standing at provider’s expense. This lifetime assignment will remain in effect until revoked by me in writing. It is valid for all administrative and judicial reviews under PPACA (health care reform legislation), ERISA, Medicare and applicable federal and state laws. A photocopy of this assignment is to be considered valid, the same as if it were the original.Signature * Clear Date Please call the office for the Notice of the Privacy Practice 281-766-7886 Ext 1 Acknowledgment and Requested RestrictionsI have reviewed this office’s notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.Signature * Clear Date Relationship (if not patient) Witness (optional) Clear Patient Release Information I _____________________________, hereby authorize the following person/people to complete access to my medical records and allow them to receive medical phone messages from the clinic. I also let the following individual(s) speak with Dr. Brionez regarding all my medical information, testing results, and medical decision-making of the Patient or Personal Representative. * Clear Date Authorize Personal information name, phone, and relationship to the patient Authorization for Disclosure of Confidential Information Patient Name Date of Birth Address Authorizes: Name of Person/Facility: Address or Fax Number To release the following medical information to ARH.Check All That May Be Released: History Physical EKG Report Lab Reports X-ray Therapy Reports Operative Report Psychological Reports Care Plan Progress Notes OtherOther Note: Memorial Hermann patients must initial the following statement: “I acknowledge and at this moment consent to such that the released information may contain alcohol, drug abuse, psychiatric, HIV Testing, HIV results, or AIDS information”INITIAL HERE: This authorization covers patient care rendered from:Start Date: End Date: Purpose of Disclosure: Medical Care Insurance Attorney OtherOther The patient agrees that a photocopy of this authorization may be considered valid. Yes No The authorization shall be valid for ninety (90) days from the date of signature below unless revoked in writing by the patient before that expiration. * Clear Date Informed consent and pain management agreement as required by the texas medical board reference: texas administrative code, title 22, part 9, chapter 170 3rd edition:developedbythetexaspainsociety,april2008(www.Texaspain.Org) NAME OF PATIENT: Date TO THE PATIENT: As a patient, you have the right to be informed about your condition and the recommended medical or diagnostic procedure or drug therapy to be used so that you may make the informed decision whether to take the drug after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you, but rather, it is an effort to make you better informed so that you may give or withhold your consent/permission to use the drug(s) recommended to you by your physician. For this agreement, the word”physician”is defined to include not only my physician but also my physician’s authorized associates, technical assistants, nurses, staff, and other health care providers as might be necessary or advisable to treat my condition. Consent to treatment and drug therapy:: I voluntarily request my physician (name at bottom of agreement) to treat my condition, which has been explained to me as chronic pain. I hereby authorize and give my voluntary consent for my physician to administer or write a prescription(s) for dangerous and controlled drugs (medications) to treat my chronic pain. It has been explained that these medication(s) include opioid/narcotic drug(s), which can be harmful if taken without medical supervision. I further understand that these medication(s) may lead to physical dependence and addiction and may produce adverse side effects or results like other drugs used in medicine . The alternative methods of treatment, the possible risks involved, and the possibilities of complications have been explained to me as listed below. I understand that this listing is incomplete, only describes the most common side effects or reactions, and that death is possible due to taking these medications. The specific medication(s) that my physician plans to prescribe will be described and documented separately from this agreement. This includes the use of medications for purposes different than what has been approved by the drug company and the government (this is sometimes referred to as “off-label” prescribing). My doctor will explain his treatment plan(s) for me and document it in my medical chart. I HAVE BEEN INFORMED AND understand that I will undergo medical tests and examinations before and during my treatment. Those tests include random unannounced checks for drugs and psychological evaluations if and when necessary. I hereby permit to perform the tests, or my refusal may lead to the termination of treatment. The presence of unauthorized substances may result in my discharge from your care. For female patients only: To the best of my knowledge, I am NOT pregnant. If I am not pregnant, I will use appropriate contraception/birth control during my course of treatment. Accept that my responsibility is to inform my physician immediately if I become pregnant. If I am pregnant or am uncertain, I WILL NOTIFY MY PHYSICIAN IMMEDIATELY. All of the above possible effects of medication(s) have been fully explained to me, and I understand that, at present, there have not been enough studies conducted on the long-term use of any medication(s), i.e., opioids/narcotics to assure complete safety to my unborn child(ren). With full knowledge of this, I consent to its use and hold my physician harmless for injuries to the embryo/fetus/baby. I UNDERSTAND THAT THE MOST COMMON SIDE EFFECTS THAT COULD OCCUR IN THE USE OF THE DRUGS USED IN MY TREATMENT INCLUDE BUT ARE NOT LIMITED TO THE FOLLOWING: constipation, nausea, vomiting, excessive drowsiness, itching, urinary retention (inability to urinate), orthostatic hypotension(low blood pressure), arrhythmias(irregular heartbeat), insomnia, depression, impairment of reasoning and judgment, respiratory depression (slow or no breathing), impotence, tolerance to medication(s), physical and emotional dependence or even addiction, and death. Operating an automobile or other machinery while using these medications may be dangerous, and I may be impaired during all activities, including work. The alternative treatment methods, the possible risks involved, and the possibilities of complications have been explained to me. I still desire to receive medication(s) for treating my chronic pain. The goal of this treatment is to help me gain control of my chronic pain to live a more productive and active life. I realize I may have a chronic illness, and there is a limited chance of a cure. Still, taking medication(s) regularly reduces (but probably not eliminates) my pain to enjoy an improved quality of life. I realize that the treatment for some will require prolonged or continuous use of medication(s). Still, an appropriate treatment goal may also mean the eventual withdrawal from using all medication(s). My treatment plan will be tailored specifically for me. I understand that I may withdraw from this treatment plan and discontinue using the medication(s) at any time and that I will notify my physician of any discontinued use. I further understand that I will be provided medical supervision if needed when discontinuing medication use. I understand that no warranty or guarantee has been made to me regarding the results of any drug therapy or cure of any condition. The long-term use of medications to treat chronic pain is controversial because of the uncertainty about the extent to which they provide long-term benefits—allowed to ask questions about my condition and treatment, risks of non-treatment, and the drug therapy, medical treatment, or diagnostic procedure(s) to be used to treat my condition, and the risks and hazards of such drug therapy, treatment and procedure(s) . I have sufficient information to give this informed consent. PAIN MANAGEMENT AGREEMENT I UNDERSTAND AND AGREE TO THE FOLLOWING: This pain management agreement relates to my use of any medication(s) (i.e., opioids, also called ’narcotics, painkillers, and other prescription medications, etc.) for chronic pain prescribed by my physician. I understand that there are federal and state laws, regulations, and policies regarding the use and prescribing of controlled substance(s). Therefore, medication(s) will only be provided if I follow the rules specified in this Agreement. My physician may, at any time, choose to discontinue the medication(s). Failure to comply with the following guidelines and conditions may cause discontinuation of medication(s) and my discharge from care and treatment. Discharge may be immediate for any criminal behavior: * My progress will be periodically reviewed, and if the medication(s) are not improving my quality of life, the medication(s) may be discontinued. * I will disclose to my physician all medication(s) I take at any time, prescribed by any physician. * I will use the medication(s) exactly as directed by my physician. * I agree not to share, sell, or otherwise permit others, including my family and friends, access to these medications. * I will not allow or assist in the misuse/diversion of my medication, nor will I give or sell them to anyone else. * All medication(s) must be obtained at one pharmacy, where possible. Should the need arise to change pharmacies, my physician must be informed. I will use only one pharmacy and provide my pharmacist with a copy of this agreement. I authorize my physician to release my medical records to my pharmacist. * I understand that my medication(s) will be refilled regularly. I know my prescription(s) and medication(s) are like money. If either are lost or stolen, they may NOT BE REPLACED. * Refill(s)will not be ordered before the scheduled refill date. However, early refill(s) are allowed when traveling, and I make arrangements before the planned departure date. Otherwise, I will not expect to receive additional medication(s) before the time of my next scheduled refill, even if my prescription(s) runs out. * I will receive medication(s) only from ONE physician unless it is for an emergency or the medication(s) that another physician prescribes is approved by my physician. Information that I have been receiving medication(s) specified by other doctors that my physician has not approved may lead to a discontinuation of medication(s) and treatment. * If it appears to my physician that there are no demonstrable benefits to my daily function or quality of life from the medication(s), then my physician may try alternative medication(s) or may taper me off all medication(s). I will not hold my physician liable for problems caused by discontinuing medication(s). * I agree to submit to urine and blood screens to detect the use of non-prescribed and prescribed medication(s) at any time and without prior warning. If I test positive for an illegal substance(s), such as marijuana, speed, cocaine, etc., treatment for chronic pain may be terminated. Also, a consult with, or referral to, an expert may be necessary, such as submitting to a psychiatric or psychological evaluation by a qualified physician such as an addictionologist or a physician specializing in detoxification and rehabilitation and cognitive behavioral therapy/psychotherapy. * I recognize that my chronic pain represents a complex problem that may benefit from physical therapy, psychotherapy, alternative medical care, etc. I also acknowledge that my active participation in managing my pain is essential. I agree to actively participate in all aspects of the pain management program recommended by my physician to achieve increased function and improved quality of life. * I agree to inform any doctor who may treat me for any other medical problem(s) that I am enrolled in a pain management program since using other medication(s) may cause harm. * I, at this moment, give my physician permission to discuss all diagnostic and treatment details with my other physician(s) and pharmacist(s) regarding my use of medications prescribed by my other physician(s). * I must take the medication(s) as instructed by my physician. Any unauthorized increase in the dose of medication(s) may be viewed as a cause for discontinuation of the treatment. * I must keep all follow-up appointments as my physician recommends, or my treatment may be discontinued. I certify and agree to the following: 1) Not currently using illegal drugs or abusing prescription medication(s), and I am not undergoing treatment for substance dependence (addiction) or abuse. Reading and making this agreement while fully possessing my faculties and not under the influence of any substance that might impair my judgment. 2) Never involved in the sale, illegal possession, misuse/diversion, or transport of controlled substance(s) (narcotics, sleeping pills, nerve pills, or painkillers) or illicit substances (marijuana, cocaine, heroin, etc.) 3) No guarantee or assurance has been made regarding the results that may be obtained from chronic pain treatment. With full knowledge of the potential benefits and possible risks involved, I consent to regular pain treatment since I realize that it provides me an opportunity to lead a more productive and active life. 4) I have reviewed the side effects of the medication(s) that may be used to treat my chronic pain. I fully understand the explanations regarding the benefits and the risks of these medication(s) , and I agree to the use of these medication(s) in the treatment of my chronic pain. * Clear Date Name and contact information for pharmacy ARH Patient Consent for Use of Email Communications Letter To better serve our patients, this office has established an email address for some forms of communication. For routine matters that do not require immediate response, please get in touch with us at info@advancedrheum.com. Please remember, however, that this form of communication is inappropriate for use in an emergency. The turnaround time for routine patient communications is 24-48 hours. The service provider may delay message delivery. Should you require urgent or immediate attention, this medium is not appropriate. When sending an email, please put the subject of your message in the subject line so we can process it more efficiently. Also, be sure to put your name, date of birth, and return telephone number in the body of the message. We also ask that you acknowledge receipt of emails from this office using the auto-reply feature. Communications relating to diagnosis and treatment will be filed in your medical record. This office is dedicated to keeping your medical record information confidential. Despite our best efforts, third parties may have access to messages due to the nature of email. When communicating from work, you should know that some companies consider email corporate property, and your messages may be monitored. Even when emailing from home, you may feel that access to your email is not well controlled, so you should consider that. In addition, you should be aware that, although addressed to me, my staff and colleagues would have access to this information. I understand that this office will not be responsible for information loss, delay, or breaches in confidentiality due to technical factors beyond this office’s control. I understand and agree to the above email policy. By signing below, you agree that we may send medical-related correspondence to you via email and that we may respond to your emails to us via email. * Clear Witness (optional) Clear Date Cancellation and No-Show Policy We schedule our appointments so that each patient receives the right amount of time to be seen by our physicians and staff. That is why you must keep your scheduled appointment with us and arrive on time. As a courtesy and to help patients remember their scheduled appointments, ARH sends text messages and email reminders 5 days, 2 days, and 3 hours before the appointment. If your schedule changes and you cannot keep your appointment, please get in touch with us so we may reschedule you and accommodate those waiting for an appointment. As a courtesy to our office and those patients waiting to schedule with the physician, please give us at least 24 hours’ notice. If you do not cancel or reschedule your appointment with at least 24 hours notice, we may assess a $50.00 “no-show” service charge to your account. This “no-show charge” is not reimbursable by your insurance company. You will be billed directly for it. After three consecutive no-shows to your appointment, our practice may decide to terminate its relationship with you. I understand the “no-show” policy of ARH and agree to provide a credit card number, which may be charged $50.00 for any no-show of a scheduled appointment. I understand that I must cancel or reschedule any appointment at least 24 hours in advance to avoid a potential no-show charge to the credit card provided. We thank you and appreciate your cooperation and understanding. * Clear Date ARH Artificial Intelligence (AI) Disclosure Form At ARH, we are committed to providing the highest quality of care for our patients. As part of this commitment, we may use Artificial Intelligence (AI) tools and technology to support certain aspects of clinical care, administrative processes, and patient education. How AI May Be Used Clinical Support: Al tools may assist providers by reviewing medical information, supporting decision-making, and identifying potential treatment options. Final medical decisions are always made by your healthcare provider. Administrative Support: Al may be used to streamline scheduling, documentation, and communication to improve efficiency and patient experience. Patient Education: AI-generated materials may be provided to help explain medical conditions, treatments, or processes in a clear and understandable way. Important Information for Patients AI is a supportive tool, not a replacement for medical judgment. All diagnoses, treatment plans, and medical decisions are determined by your healthcare provider. Your privacy is protected. Any use of Al systems complies with HIPAA and all applicable privacy and security standards. If you have questions about AI use in your care, please ask your provider. Acknowledgment I have read and understand the information above regarding the use of Artificial Intelligence (AI) tools at ARH. I understand that Al may be used in supportive roles, but my medical care and treatment decisions will always be directed by my healthcare provider. Patient Name (Print): Patient Signature: Date: NAME OF PATIENT: Date Patient Signature: * Clear Captcha Submit If you are human, leave this field blank.
