Basin Clinic &

Basin Clinic Urgent Care Center

Patient Name:
Chief Complaint/Reason For Visit:
Date of Birth: S.S.#:
Email Address:
Ethnicity:
Marital Status:
Responsible Party S.S.#:
Address:
City: State:
Zip:
Home Phone: Work Phone:
Guardian (if patient is under 18):
Emergency Contact: Phone:
Primary Insurance:

Do you have a regular physician you would like a copy of this visit sent to?

Dr. Name: Patient Signature:__________________________________

In accordance with the Federal Truth-In-Lending Act, all doctors are required to give their patients complete information in connection with the extension of credit.

Basin Clinic Policy: The patient is responsible for all medical bills. Our staff will help with completion of insurance forms. It is the patient’s responsibility to know their contract benefits, assure collection of insurance payments to us and negotiate with your insurance company over disputed claims.

If You Don’t Have Insurance: Our policy requires payment in full at the time of service. We offer a 25% cash discount when paid in full at the time of service. If you cannot make complete payment we require that you make payment arrangements with the receptionist prior to service and make a $100 partial payment on the day service is rendered.

If You Have Insurance: We will be glad to bill your insurance for you as long as we have correct insurance information. We require a one time $50 deposit for new patients with insurance in case the visit is applied to your yearly deductible. We require you as a patient to be responsible for any balance your insurance does not pay. Any balance over 30 days is your responsibility. If we are a provider for your insurance, be aware that if the patient needs to be referred to another doctor or hospital, that provider may not be a preferred provider for your insurance and the patient/policy holder will be responsible for any amount not paid by their insurance to that non-preferred provider.

Forms of Payment: We accept payment in cash, check, money order, Visa, MasterCard, American Express or Discover. There will be a $30.00 charge on all returned checks.

Delinquent Accounts: Those accounts not paid within 90 days will be turned over to collections or taken to small claims court. We reserve the right to add late charges for delinquent accounts. Should collection be necessary, the responsible party agrees to pay and additional 33% collection fee charged by the collection service and all legal fees of collection, with or without suit, including attorney fees and court costs. We will no longer provide medical care once an account has gone to collection.

Monthly Statements: You will receive an itemized monthly statement until your bill is paid in full whether you have insurance or not. Interest of 1.5% per month will be applied to any amount over 30 days if a payment has been received.

To the extent necessary to determine liability for payment and to obtain reimbursement for this account, I authorize disclosure of portions of the patients record. I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled including Medicare, private insurance, and other health plans to Rodney S. Anderson, M.D.; Karl L. Breitenbach, M.D.; Laura B. Arnold, M.D.; Kirk J. Woodward, M.D.; Mike Olsen, M.D.; Amy Olsen, FNP; Aaron Fausett, PA-C; Scott Frisby, PA-C; Michael Wilson, PA-C and Carolyn Henry, LCSW. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered valid as the original. I understand that I am financially responsible for all charges incurred.

I certify that the above information is accurate to the best of my knowledge. I have read and agree to the Financial Policy of this office.

Signature___________________________________Date___________________

DATE_____________________

NAME____________________________________________________
PATIENT SSN#_____________________________________________



FATHER OF BABY
NEWBORN’S PHYSICIAN
REFERRED BY

BIRTHDATE:          AGE:  
RACE:     MARITAL STATUS:

MAILING ADDRESS:

OCCUPATION: (Homemaker, student, etc..)
EDUCATION: (Last grade completed)

PHONE: (Daytime)                 (Evening)

INSURANCE CARRIER/MEDICADE #

EMERGENCY CONTACT:       RELATIONSHIP:       PHONE:

TOTAL PREG

FULL TERM

PREMATURE

ABORTIONS:
INDUCED       
SPON.

ECTOPICS

MULTIPLE BIRTHS

LIVING

MENSTRUAL HISTORY

LMP:
NORMAL AMOUND/DURATION

MENSES MONTHLY: YES NO       FREQUENCY: DAYS
MENARCHE: (AGE ONSET)
ON BCPS AT CONCEPT. YES NO Hcg +

PAST PREGNANCIES (LAST SIX)

DATE MO/YR

SEX M/F

GA WEEKS

LENGTH OF LABOR

BIRTH WEIGHT

TYPE DELIVERY

ANES.

PLACE OF DELIVERY

PERINATAL MORTALITY YES/NO

TREATMENT PRETERM LABOR YES/NO

COMMENTS / COMPLICATIONS

PAST MEDICAL HISTORY


0 NEG
+ POS

DETAIL POSITIVE REMARKS

INCLUDE DATE & TREATMENT


0 NEG
+ POS

DETAIL POSITIVE REMARKS

INCLUDE DATE & TREATMENT

1. DIABETES


16. Rh SENSITIZED


2. HYPERTENSION

17. TUBERCULOSIS

3. HEART DISEASE

18. ASTHMA

4. RHEUMATIC FEVER

19. ALLERGIES (DRUGS)

5. MITRAL VALVE PROLAPSE

20. GYN SURGERY

6. KIDNEY DISEASE/UTI

7. NEUROLOGIC/EPILEPSY

21. OPERATIONS / HOSPITALIZATIONS (YEAR & REASONS)

8. PHYCHIATRIC


9. HEPATITIS/LIVER DISEASE


10. VARICOSEITIES/PHLEBITIS

22. ANESTHETIC COMPLICATIONS

11. THYROID DISFUNCTION

23. HISTORY OF ABNORMAL PAP

12. MAJOR ACCIDENTS

24. UTERINE ANOMALY

13. HISTORY OF BLOOD TRANSFUS.

25. INFERTILITY


AMT/DAY PREPREG

AMT/DAY PREG

# YRS USE



14. TOBACCO




26. STREET DRUGS

15. ALCOHOL




27. OTHER

COMMENTS:

GENETICS SCREENING

INCLUDES PATIENT, BABY’S FATHER, OR ANYONE IN EITHER FAMILY WITH:


YES / NO


YES / NO

1 PATIENT’S AGE > 35 YEARS

10 HUNTINGTON CHOREA

2 THALASSEMIA

11 MENTAL RETARDATION

3 NEURAL TUBE DEFECT (MENINGOMYELOCELE, OPEN SPINE, OR ANENCEPHALY)

IF YES, WAS PERSON TESTED FOR FRAGILE X?

4 DOWN SYNDROME

12 OTHER INHERITED GENETIC OR CHROMOSOMAL DISORDER

5 TAY-SACHS {EG. JEWISH BACKGROUND}

13. PATIENT OR BABY’S FATHER HAD A CHILD WITH BIRTH DEFECTS NOT LISTED ABOVE

6 SICKLE CELL DISEASE OR TRAIT

14. > FIRST-TRIMESTER SPONTANEOUS ABORTIONS OR A STILLBIRTH

7 HEMOPHILIA

15 MEDICATIONS OR STREET DRUGS SINCE LAST MENSTRUAL PERIOD

8 MUSCULAR DYSTROPHY

IF YES, AGENT(S)

9 CYSTIC FIBROSIS

16 OTHER SIGNIFICANT FAMILY HISTORY (SEE COMMENTS)

COMMENTS:

INFECTION HISTORY

YES / NO

4 PATIENT OR PARTNER HAVE HISTORY OR GENITAL HERPES

1 HIGH RISK AIDS

5 RASH OR VIRAL ILLNESS SINCE LAST MENSTRUAL PERIOD

2 HIGH RISK HEPATITIS B

6 HISTORY OF STD, GC, CHLAMYDIA, HPV, SYPHILIS

3 LIVE WITH SOMEONE WITH TB OR EXPOSED TO TB

7 OTHER (SEE COMMENTS)

COMMENTS:
INTERVIEWER’S SIGNATURE________________________________________

INITIAL PHYSICAL EXAMINATION

DATE     PREPREGNANCY WEIGHT    HEIGHT     BP

1. HEENT                       NORMAL        ABNORMAL

12. VULVA        NORMAL        CONDYLOMA        LESIONS

2. FUNDI                         NORMAL        ABNORMAL

13. VAGINA          NORMAL        INFLAMMATION        DISCHARGE

3. TEETH                       NORMAL        ABNORMAL

14. CERVIX        NORMAL        INFLAMMATION        LESIONS

4. THYROID                   NORMAL        ABNORMAL

15. UTERUS         NORMAL        ABNORMAL        FIBROIDS

5. BREASTS                  NORMAL        ABNORMAL

16. ADNEXA         NORMAL        MASS

6. LUNGS                       NORMAL        ABNORMAL

17. RECTUM        NOMRAL        ABNORMAL

7. HEART           NORMAL        ABNORMAL

18. DIAGONAL CONJUGATE        REACHED        NO        CM

8. ABDOMEN                 NORMAL        ABNORMAL

19. SPINES          AVERAGE        PROMINENT        BLUNT

9. EXTREMITIES           NORMAL        ABNORMAL

20. SACRUM        CONCAVE        STRAIGHT        ANTERIOR

10. SKIN           NORMAL        ABNORMAL

21. ARCH             NORMAL         WIDE        NARROW

11. LYMPH NODES           NORMAL        ABNORMAL

22. GYNECOID PELVIC TYPE            YES        NO

COMMENTS: (Number and explain abnormals):
Exam by________________________________