UPC8192 (06/15)
Patient Information
Legal Name
Last First Middle
Nickname
Social Security Number Birth Date
Male
Female
Marital Status
Street Address Zip City State
Primary Phone
Able to receive text messages
Home
Mobile Other
Preferred Contact Method
Text Phone Email Other
Email *Required Occupation Employer
Primary Care Provider Referring Provider
As part of the American Recovery and Reinvestment Act, healthcare providers are required to obtain the following information.
Please check the boxes in section 1-3 that most apply to you.
1. Race (Choose One)
American Indian or Alaska Native Asian Black or African American
Native Hawaiian or Other Pacific Islander White / Caucasian Other
More than one race Unknown / Not Reported
2. Ethnicity (Choose One)
Hispanic / Latino Non-Hispanic / Latino
Unknown / Not Reported
3. Preferred Language (Choose One)
Arabic French Hindi Khmer Russian Thai
Bulgarian German Hmong Korean Spanish Urdu
Chinese Haitian Italian Polish Somali Vietnamese
English Hebrew Japanese Portuguese Swahili Other
Responsible Party (Policy Holder) / Legal Guardian if minor, please have parent or legal guardian complete the following.
Self
Legal Name
Last First Middle
Relationship to Patient Birth Date
Social Security Number Address
Check here if same
address as above
Primary Phone
Able to receive text messages
Home
Mobile Other
Employer
Emergency Contact
Name
Last First Middle
Relationship to Patient
Address
Primary Phone
Able to receive text messages
Home
Mobile Other
Employer
UPC8192 (06/15)
Patient _____________________ DOB
Medications include over-the-counter medications and supplements. check box if NO medications.
Drug Name Dosage Strength (i.e., mg/mcg) How many times a day?
1
2
3
4
5
Attach additional list if there are more medications
Allergies check box if there are NO medication allergies.
Drug Name / Drug Class / Food Reaction
1
2
3
4
Preferred Local Pharmacy
Name Location
Phone Fax
Insurance
Primary Insurance Name Policy Holder's Name Relationship to Patient Policy Holder's Birth Date
Secondary Insurance Name Policy Holder's Name Relationship to Patient Policy Holder's Birth Date
Medical History check all that apply. Describe details of medical conditions in spaces below.
allergies
anemia
angina (heart pain)
anxiety
arthritis
asthma
atrial fibrillation
blood clots
cancer: type
COPD (Emphysema)
Crohn’s Disease
depression
diabetes type 1 type 2
GERD (acid reflux)
heart disease: type
Hepatitis A B C
high blood pressure
high cholesterol
HIV / AIDS
irritable bowel syndrome
kidney disease: type
liver disease: type
MI (heart attack)
migraines
osteoporosis
prostate enlarged
seizures
stroke
thyroid disease: type
ulcer
Other:
UPC8192 (06/15)
Patient _____________________ DOB
Surgeries check all that apply. Describe details of surgery in spaces below.
angioplasty
appendectomy
arthroscopy knee: left right
back surgery: type
breast biopsy: left right
breast implants
breast reduction
CABG (heart vessel bypass)
cardiac pacemaker
carpal tunnel: left right
cataract: left right
colon surgery: type
c-section
D&C
gallbladder
gastric bypass
groin hernia repair: left right
hip fracture repair: left right
hip replacement: left right
hysterectomy
*items in gray are for females only
knee replacement: left right
LASIK
liver biopsy
mastectomy: left right
ovary removed: left right
prostate surgery: type
thyroid surgery
tonsillectomy
tubes tied
vasectomy
Other:
Family History
Mother ADD/ADHD alcoholism allergies Alzheimer's asthma bleeding disorder
cancer: type: _________________ depression diabetes type 1 type 2 heart attack
heart disease high blood pressure high cholesterol mental illness migraines
osteoporosis seizure stroke thyroid disease tuberculosis
ulcerative colitis other:
Father
ADD/ADHD alcoholism allergies Alzheimer's asthma bleeding disorder
cancer: type: _________________ depression diabetes type 1 type 2 heart attack
heart disease high blood pressure high cholesterol mental illness migraines
osteoporosis seizure stroke thyroid disease tuberculosis
ulcerative colitis other:
Brother(s)
ADD/ADHD alcoholism allergies Alzheimer's asthma bleeding disorder
cancer: type: _________________ depression diabetes type 1 type 2 heart attack
heart disease high blood pressure high cholesterol mental illness migraines
osteoporosis seizure stroke thyroid disease tuberculosis
ulcerative colitis other:
Sister(s)
ADD/ADHD alcoholism allergies Alzheimer's asthma bleeding disorder
cancer: type: _________________ depression diabetes type 1 type 2 heart attack
heart disease high blood pressure high cholesterol mental illness migraines
osteoporosis seizure stroke thyroid disease tuberculosis
ulcerative colitis other:
Social History your answers help determine your risk for certain diseases. Responses are confidential.
Married Domestic Partnership
Single Divorced Widowed
Do you drink alcohol? Yes No
If yes, what type?
If yes, how much?
If yes, how often?
Daily
Weekly
Monthly
Occasionally Rarely
Do you use illegal drugs? Yes No
If yes, what type?
If yes, how much?
If yes, how often?
Daily
Weekly
Monthly
Occasionally Rarely
Sexual Orientation:
Bisexual Heterosexual Homosexual
Transgender Identity
Female to Male Male to Female Unknown
Do you have any religious or spiritual preferences that would
affect your healthcare?
Tobacco Use
Do you...
smoke a pipe
chew tobacco
smoke cigarettes
How many... packs per day?
years?
If you quit, what year?
UPC8192 (06/15)
Patient _____________________ DOB
Preventive Screenings list dates of the most recent preventive services you've received.
Test
Test Never
Performed
Where
Performed?
Last
Exam Date
Findings/Results
Bone density
Blood sugar
Cholesterol
Colonoscopy
Glaucoma
Hearing
HIV
Lung cancer scan (CT of chest)
Lung scan
Mammogram
Medicare wellness visit
Prostate exam (males only)
Ultrasound aorta
Vision
Vision examination
Immunizations list dates of most recent immunizations or attach record.
Vaccination Date Date Date
Chicken Pox
Hepatitis A
Hepatitis B
HPV
Influenza
Meningococcal
MMR
Pneumonia PCV13 (Prevnar 13)
Pneumonia PPSV23 (Pneumovax)
Shingles
Tetanus and Diphtheria (Td)
Tetanus, Diphtheria, Pertussis (Tdap)
Pregnancy History list the number of each type in the box below.
Full Term Premature C-Section Vaginal Live Birth Ectopic Miscarriage Abortion
Women’s Health History
Age of first menstrual period? ______ Are you currently pregnant? Yes No Possibly
Age of first birth? ______ Date of last mammogram? _________ Result?
Beginning date of last menstrual period? ______ Date of last pap smear? _________ Result?
If you have achieved menopause, what age? ______ What Year? _________
Natural Surgical
(choose one)
03 21 DD
AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
PATIENT NAME:
DATE OF BIRTH: Medical record # ___ _
I hereby authorize the use or disclosure of the Protected Health Information described below to be provided to or obtained by
the following:
Name and Address of Individual/Facility/Company to Receive PHI Name and Address of Individual/Facility to Disclose PHI
Information authorized for use or disclosure, or to be obtained:
Immunization Records TB Skin Test Results Lab reports X-ray Reports Progress Notes History & Physical
Discharge Summary Operative Report ER Record Consultation Addendum Denial Other
Medical information between to
The information will be obtained, used, or disclosed for the following purpose only:
Insurance Continued treatment Legal At the request of the patient or patient’s representative
Other (specify)
I understand:
x I may revoke this authorization at any time, in writing, except revocation will not apply to information already retained, used
or disclosed in response to this authorization. I may revoke this document by presenting my written revocation as provided
in the Notice of Privacy Rights. Unless revoked, the automatic expiration date will be six (6) months from date of signature
or upon occurrence of the following event: .
x I release the entities listed above, their agents and employees from any liability in connection with the use or disclosure of
the protected health information. The entity authorized to disclose the information will not be compensated by the recipient
for such disclosure. Normal applicable fees, such as copy fees, may apply.
x Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer
protected by federal law. However, the recipient may be prohibited from disclosing substance abuse information under the
Federal Substance Abuse Confidentiality Requirements.
x Unless the purpose of this authorization is to determine payment of a claim for benefits, the requesting entity will not
condition the provision of treatment, payment, enrollment in a health plan, or eligibility for benefits on obtaining this
authorization.
I understand that the information authorized for use or disclosure may include information which may indicate the
presence of a communicable or non-communicable disease and may include, but is not limited to, diseases such as
hepatitis, syphilis, gonorrhea, and human immunodeficiency viruses also known as Acquired Immune Deficiency
Syndrome (AIDS). I further understand that my medical information may indicate that I have or have been treated for
psychological or psychiatric conditions or substance abuse.
______________________________________ ________________
SIGNATURE OF PATIENT DATE
________________________________________________________________________
SIGNATURE OF PERSONAL REPRESENTATIVE DATE
DESCRIPTION OF REPRESENTATIVES AUTHORITY TO ACT FOR THE PATIENT
NOTICE OF RIGHTS: Information in your medical records that you have or may have a communicable or venereal disease is
made confidential by law and cannot be disclosed without your permission except in limited circumstances including disclosure
to persons who have had risk exposures, disclosure pursuant to an order of the court or the Department of Health, disclosure
among healthcare providers or for statistical or epidemiological purposes. When such information is disclosed, it cannot contain
information from which you could be identified unless disclosure of that identifying information is authorized by you, by an order
of the court or the Department of Health or by law
Processed by (Print Name & Dept):
Original: Releasing entity Copy: Patient or representative (Required) UPC8196 Revised 06/2015
PRINT
SAVE AS
RESET
MEDICAL AND FINANCIAL
CONSENT
Patient Name:
Date of Birth:
Medical Record #:
MEDICAL TREATMENT AUTHORIZATION
I agree to procedures that are requested by me and/or ordered by my physician(s) in connection with my inpatient, outpatient and/or
emergency treatment, and medications. If I am a pregnant patient, I consent to hospital care of my infant(s) and consent for release of my
private health information needed to care for my infant. You have the right to accept or refuse any care, treatment or service your physician
or staff recommends to you. You should ask for information about anything you do not understand or if you need more information.
I acknowledge that I have received written notice of my patient rights, including my right to execute an Advance Directive in accordance
with Oklahoma State Law.
Yes No I have a legal representative
Yes No I want to appoint a patient representative to make decisions for me should I become unable to make healthcare decisions.
If yes, the following person should make decisions for me: __________________________________________ and their
contact information is: .
Yes No Do you wish the clinic to notify your patient representative or legal representative of your appointment?
I understand I have a right to receive information in a manner or language I, and/or my representative, can understand. I understand
interpreter services are available 24 hours a day at no cost.
If my treatment includes treatment groups, I understand that my participation in these groups or classes may involve discussions of my
condition in the presence of other patients and I consent to the discussion.
I understand that the practice of health care delivery may involve “telemedicine” which is the transfer of my medical data, or exchange of
medical information by means of audio, video or data communication to a medical care provider with expertise in a particular area of care.
A healthcare provider may be able to assist in the examination and provide additional information about a diagnosis. The physician and
staff who have access to your medical information will keep it confidential in accordance with laws and confidentiality policies.
NOTICE OF PRIVACY PRACTICES
Protected health information may be used and disclosed ot carry out treatment, payment or healthcare operations. Please refer to the
Notice of Privacy Practices for complete description of uses and disclosures. I acknowledge that I have received a written Notice of
Privacy Practices.
By signing below, I acknowledge that I have received a copy of the Utica Park Clinic Notice of Privacy Practices and that I agree to
uses and disclosures described in the Notice of Privacy Practices listed under the section: How We May Use and Disclose
Your Health
Information.
Patient Signature Patient Personal Representative Date/Time
TELEPHONE CONSUMER PROTECTION ACT CONSENT DISCLOSURE
I expressly consent to allow Utica Park Clinic (UPC), to contact me by use of an automated telephone dialing device and to leave
automated or pre-recorded voice messages, send me text messages, short message services messages (SMS), or send me email
messages regarding my treatment, notification of appointments, notification that certain medications or other products or services being
provided are ready for pick-up, communicate to me about my account, or communicate with me regarding the collection of any money
that I may owe to UPC related to treatment provided to me, my child, or person to whom I am guardian. I agree that this prior express
written consent shall also extend to any third party that is servicing my account on behalf of UPC or attempting to collect any money due
regarding my account on behalf of UPC. This consent does not extend to telemarketing of future goods and services to me. My express
consent includes contact to the following telephone numbers and email addresses.
Residential Land Line Telephone Number: Cellular or Wireless Telephone Number:
Other Telephone Number: Email Address:
FINANCIAL RESPONSIBILITY
I hereby assign to Utica Park Clinic (UPC) and any health care provider designated by UPC to receive such monies, and all rights and
interest in insurance benefits and/or entitlements and I direct
that all such payments be made directly to UPC or its designee. Charges for
services shall be at the provider’s regular rates unless otherwise agreed in writing by UPC or as required by law.
I understand I am financially responsible for deductibles, coinsurance, and all services not covered by insurance benefits and/or
entitlements. A safe is available for safekeeping of valuables. UPC and its affiliates are released from responsibility for all valuables or
personal items, including eyeglasses, dentures, and hearing aid(s) and jewelry that I retain in my possession during my clinic visit.
Patient Guardian Parent of Minor Witness Date/Time
If not signed, complete the following to explain the reason why:
Emergency situation Individual refused to sign Unable to sign Reason
UPC8198 (07/15)
MEDICAL AND FINANCIAL
CONSENT
INFORMATION ABOUT YOUR SPECIFIC RIGHTS ABOUT ADVANCE DIRECTIVES
The Patient Self Determination Act directs Utica Park Clinic to inform you that you have rights under Oklahoma State Laws to make
decisions about your care. You have the right to accept or refuse any procedure or care that your physician or staff recommends to you.
Your physician will prescribe a treatment plan for you and talk with you about those recommendations including the risks, benefits and
alternatives. You should ask for information about anything you do not understand or if you need more information. If at any time you feel
your rights are not being respected, your nurse will help you contact the hospital representative.
The Oklahoma Rights of the Terminally Ill and Persistently Unconscious Act (Living Will/Appointment of a Healthcare Proxy Law) is a way
for a person with decision making capacity to specify future circumstances and conditions in which life sustaining treatment should be
withheld. You can appoint another person (aka: surrogate decision maker) to make those decisions for you should you become unable to
make decisions for yourself. You can do both. A Living Will does not address your wishes or belongings after death. It is only for certain
types of healthcare decisions. A Living Will may apply only to future events or circumstances when
the person becomes terminally ill, not
necessarily the present. The Oklahoma Do Not Resuscitate Act provides a specific written form called a DNR form that you should sign
only if you are certain that under no circumstances is cardiopulmonary resuscitation to be provided. A copy of each of these types of
Advance Directives can be made available to you and our staff may assist you if you elect to complete an advance directive. If you are
scheduled for surgery you will want to talk with your surgeon and your anesthesiologist about your advance directive prior to surgery. We
will not recognize DNR during anesthesia. If considering such documents raises difficult issues for you, our Pastoral Care Department is
available for more intensive help. You may also have a Durable Power of Attorney for Healthcare. Utica Park Clinic recommends that all
individuals appoint a healthcare proxy to assure that someone the individual knows/trusts is authorized to make decisions for them if they
become incapacitated.
A psychiatric advance directive is akin to a traditional advance directive for healthcare. An individual who is concerned that at some point
he/she may be subject to involuntary psychiatric commitment or treatment has the right to execute a psychiatric advance directive. The
psychiatric advance directive names another person who is authorized to make decisions for the
individual if he/she is determined to be
legally incompetent to make his/her own choices. It may include instructions about hospitalization, alternatives to hospitalization, the use
of medications, types of therapies and the patient’s wishes concerning restraint or seclusion. It includes information as to who to notify
upon appointment, as well as who should not be permitted to visit.
You should keep your advance directive at home with you in a safe place. You should provide a copy to your primary care physician for
your medical record in their office. Tell your family where your advance directive is. We recommend that you talk with them about it. Do
not put your advance directive in a safe deposit box with other important papers. Your family and healthcare providers need access
to it readily when you are unable to make decisions for yourself. We will put a copy in your medical record for this hospitalization.
If you have an advance directive and did not bring it with you, it is urgent that you make arrangements to bring it. In the meantime, our best
advice is to complete a document approved by the State of Oklahoma today. Our staff can help you update your current advance directive,
or complete a new one. Please tell your doctor and/or nurse about the substance of your advance directive so we can document what you
tell us in your medical record. We want to honor your values and wishes about healthcare that you believe is right for you.
COMPLAINTS AND GRIEVANCES
You and/or your representative have the right to express complaints or grievances related to the quality of care received, to have those
complaints heard and when possible, resolved. Complaints/grievances should be directed initially to and reviewed by the department and
clinical manager and/or director providing the patient care which is the subject of the complaint. If the problem cannot be resolved quickly,
it may become a formal grievance handled through the process defined for the clinic.
Patients have the right to address their concerns to Utica Park Clinic Risk Management, 1145 S Utica Ave, Suite 110, Tulsa, OK 74104.
918-579-1073.
Oklahoma State Dept of Health KEPRO BFCC QIO (Area 3)
1000 NE 10th Street Rock Run Center
Oklahoma City, OK 73117-1299 5700 Lombardo Center Drive, Suite 100 Seven
www.ok.gov/health Hills, OH 44131
405-271-6576 Phone: 216-447-9604
Fax: 844-878-7921
www.keproqio.com
Effective as of April 1
st
, 2015
UPC8191 (04/15) Page 1 of 3
UTICA PARK CLINIC
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.
If you have any questions about this notice, please contact the Utica Park Clinic (UPC) Privacy Officer
at 918-579-1073.
This Notice Describes Our Practices And Those Of:
Any medical staff member and any health care professional who participates in your care;
Any volunteer we allow to help you while you are here; and
All employees of any hospital, clinic, laboratory, or other facility affiliated with Utica Park Clinic.
All of these people follow the terms of this notice. They may also share health information that identifies
you (also known as “protected health information”) with each other for treatment, payment or health care
operations as described in this notice.
Our Pledge Regarding Health Information:
We understand that health information about you and your health is personal. We are committed to
protecting health information about you. This notice will tell you about the ways that we may use and
disclose health information about you. This notice also describes your rights and certain obligations we
have regarding the use and disclosure of protected health information. We are required to comply with any
state laws that offer a patient/plan member additional privacy protections.
We Are Required By Law To:
Maintain the privacy of health information that identifies you;
Give you and other individuals this notice of our legal duties and privacy practices with respect to
protected health information;
Follow the terms of the notice that is currently in effect; and
Required By Law. We may use and disclose information about you as required by law. For example,
we may disclose information to report gunshot wounds, suspected abuse or neglect, or similar injuries
and events.
Public Health. Your health information may be used or disclosed for public health activities such
as assisting public health authorities or other legal authorities (e.g., state health department, Center
for Disease Control, etc.) to prevent or control disease, injury, or disability, or for other public health
activities.
Staple
Effective as of April 1
st
, 2015
UPC8191 (04/15) Page 2 of 3
.sesopruP tnemecrofnE waL Subject to certain restrictions, we may disclose information needed or
requested by law enforcement officials.
Judicial And Administrative Proceedings. We may disclose information in response to an appropriate
subpoena, discovery request or court order.
Health Oversight Activities. We may disclose your health information to a health oversight agency for
activities authorized by law, such as audits, investigations, and inspections to monitor the health care
system.
Decedents. Health information may be disclosed to funeral directors, medical examiners or coroners to
enable them to carry out their lawful duties.
Organ/Tissue Donation. Your health information may be used or disclosed for cadaveric organ, eye or
tissue donation purposes.
Research. We may use or disclose your health information for research purposes after a receipt of
authorization from you or when an institutional review board (IRB) or privacy board has waived the
authorization requirement by its review of the research proposal and has established protocols to ensure
the privacy of your health information. We may also review your health information to assist in the
preparation of a research study.
Health And Safety. Your health information may be disclosed to avert a serious threat to the health or
safety of you or any other person pursuant to applicable law.
Government Functions. Your health information may be disclosed for specialized government
functions such as protection of public officials or reporting to various branches of the armed services.
Workers’ Compensation. Your health information may be used or disclosed in order to comply with
laws and regulations related to Workers’ Compensation.
Business Associates. We may disclose your health information to business associates (individuals or
entities that perform functions on our behalf) provided they agree to safeguard the information.
Other Uses And Disclosures. We may contact you to provide appointment reminders or for billing or
collections and may leave messages on your answering machine, voice mail or through other methods.
Except for uses and disclosures described above, we will only use and disclose your health information
with your written authorization. Subject to compliance with limited exceptions, we will not use or disclose
psychotherapy notes, use or disclose your health information for marketing purposes or sell your health
information, unless you have signed an authorization. You may revoke an authorization by notifying us in
writing, except to the extent we have taken action in reliance on the authorization.
Effective as of April 1
st
, 2015
UPC8191 (04/15) Page 3 of 3
Your Health Information Rights:
You have the right to:
ylsuoiverp evah uoy fi neve ,tseuqer nopu secitcarp noitamrofni fo eciton siht fo ypoc repap a niatbO
agreed to receive this notice electronically;
Inspect and obtain a copy of your health information that we maintained;
Request an amendment to your health information under certain circumstances;
evitanretla ta ro snaem evitanretla yb noitamrofni htlaeh ruoy fo noitacinummoc laitnedifnoc a tseuqeR
locations. Please be advised that this request for alternative means or locations of communications
applies only to this provider or location;
Receive an accounting of certain disclosures made of your health information; and
eerga ot deriuqer ton era eW .noitamrofni ruoy fo serusolcsid dna sesu niatrec no noitcirtser a tseuqeR
to a requested restriction, except for requests to limit disclosures to your health plan for purposes of
payment or health care operations when you have paid for the item or service covered by the request
out-of-pocket and in full and when the uses or disclosures are not required by law.
To exercise any of these rights, please contact our Privacy Officer at the address at the end of this notice.
Changes To This Notice:
We reserve the right to change the terms of this notice and make the new terms effective for all protected
health information kept by UPC. We will post a copy of the current notice in our facility and on our website,
http://www.uticaparkclinic.com. You may also get a current copy by contacting our Privacy Officer at the
address at end of this notice. The effective date of the notice is in the top right-hand corner of each page.
Complaints:
If you believe your privacy rights have been violated, you may file a complaint with UPC or with the
Secretary of the U.S. Department of Health and Human Services. To file a complaint with UPC, submit your
written complaint to our Privacy Officer at the address at end of this notice. You will not be penalized for
filing a complaint.
Contact Information For Questions Or To File A Complaint:
If you have any questions about this notice, want to exercise one of your rights that are described in this
notice, or want to file a complaint, please contact the UPC Privacy Officer at:
Utica Park Clinic
1145 S. Utica Avenue, Suite 110
Tulsa, OK 74104
Attn: Privacy Officer
Phone: 918-579-1073
