Patient Information

Name: ___________________________________________ I prefer to be called: ___________________

Address: ______________________________________ City: ______________State: _____ Zip: _______

Primary Phone: (_____)__________________________          •Cell   •Work    •Home  •Parent

Secondary Phone: (_____)________________________                •Cell   •Work   •Home   •Spouse

May we leave you a message?   Primary Phone:  •Yes   •No       Secondary Phone:  •Yes   •No

Date of Birth: ______________________ Social Security Number: _______________________________

E-mail Address: _________________________________________

May we discuss your health information with a spouse or relative:   • Yes     • No

If so, who? Name and relationship to the patient: ____________________________________________

       Check appropriate box:   •Minor   •Single    •Married    •Widowed     •Separated    •Divorced

Employer: _______________________________________________ Phone: (____)_________________

Address: ________________________________________ City: ____________________ State: _______

Emergency Contact: ______________________________  Phone: _______________Relation:_________

Whom may we thank for referring you? ____________________________________________________

Insurance Information

We require proof of insurance before each visit.

If you do not have your insurance card with you, full payment at time of service is required.

Who is financially responsible for your visit today? Please check one:  •Self   •Spouse   • Parent   •Other

Primary Insurance

Name of Insured: _______________________________________________ DOB: __________________

Relation to Insured: ____________________________ Social Security Number: ____________________

Insurance Company: ________________________________Group #: __________ ID#: ______________

Insurance Company Customer Service Phone: ___________________________

 Secondary Insurance (leave blank if none)

Name of Insured: _______________________________________________ DOB: __________________

Relation to Insured: ____________________________ Social Security Number: ____________________

Insurance Company: ________________________________Group #: __________ ID#: ______________

Insurance Company Customer Service Phone: ____________________________

*We have the right to call and obtain information over the phone with your insurance carrier for your benefit. However, eligibility and benefit information given by phone does not constitute an authorization, and does not guarantee payment. Actual payment is subject to the patient’s contracted and eligibility at the time of service.

*By signing below, I have read and do fully understand that about benefits and eligibility explained to me by AFMC, Inc. I also understand that in the event my insurance does not cover any of the above benefits or denies any of the above benefits due to medical necessity, I am fully responsible for payment in full. AFMC is in-network with Premera Blue Cross Blue Shield and Aetna.

Cancellation Policy: We require at least 24 hours notice to cancel an appointment. For the initial appointment, cancelling with less than 24 hours notice will result in a $200.00 fee and a no-show will result in a $385.00 fee. For established patients, a no-show will result in a $50.00 fee.

Returned Checks: Any checks that have bounced or have been returned will result in a $50.00 fee.

Patient Signature: _____________________________________________ Date: __________________

Financial Responsibility

• Payment of your deductible, if not already met, and the patient portion of your charges are required at the time of service. Payment can be made by cash, check or credit card.
• Alaska Functional Medicine Clinic bills your insurance as a courtesy. However, there are many insurance plans in the United States and it is impossible for AFMC to know the specific benefits of your plan. It is your responsibility, not your insurance company’s, to make sure your bill is paid.
• If you want AFMC to bill your insurance, you must provide us with:

• A valid state ID or drivers’ license
• A copy of your insurance card

• Your insurance must pay on charges according to their usual and customary fee scale. AFMC’s fees are set independently from the insurance company guidelines. In the event your insurance company determines a service to be “not covered” or “above the usual or customary charges”, you will be responsible for the balance due.
• AFMC does not bill Medicaid or Medicare as a primary or secondary insurance. All charges must be paid at time of service.
• It is the patient’s responsibility to preauthorize with their insurance company prior to any procedures or testing.
• In many instances, your practitioner may order services or testing which are independent from Alaska Functional Medicine Clinic. Such organizations include laboratories, pathologists, x-ray facilities and hospitals. These organizations and physicians will directly bill you and your insurance for their services. Our office may provide them with billing information.

I authorize Alaska Functional Medicine Clinic to bill my insurance and release medical or other information necessary to process my medical claims.                                                        ________Initial

                                                        or                                

I have decided to opt-out of having AFMC bill my insurance and will not personally seek reimbursement or submit claims to my insurance for services rendered at AFMC. I understand I will be given a 20% discount on office visits and 50% off lab work. All other services will be charged in full.                ________Initial

I understand that AFMC has opted out of Medicaid and Medicare, and that it is illegal to seek reimbursement for services rendered at AFMC.  I understand I will be given a 20% discount on office visits and 50% off lab work. All other services will be charged in full.                                                ________Initial

I acknowledge and agree to all financial responsibilities outlined in this agreement.        ________Initial

Patient Name: ____________________________________________________ Date: ______________

Patient Signature: ______________________________________________________________________                                                

RECEIPT OF NOTICE OF PRIVACY POLICIES AND CONSENT

Date: ________________________

Patient Name: ___________________________________________ DOB: _________________

In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services and to conduct health care operations involving our office.

The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. You are free to refer to this notice at any time before you sign this form. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and services provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes (1) our submission of your health information to a billing agent or vendor for processing claims or obtaining payment; (2) our submission of claims to third-party payers or insurers for claims review, determination of benefits and payment; (3) our submission of your health information to auditors hired by third-party payers and insurers; and (4) other aspects of payment described in our Notice of Privacy Practices.

Our Notice of Privacy Practices will be updated whenever our privacy practices change. When you sign this document, you signify that you agree that we can and will use and disclose your health information to treat you, to obtain payment for our services and to perform health care operations. You also signify that you have received a copy of our Notice of Privacy Practices.

You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment or healthcare operations, but as described on our Notice of Privacy Practices, we are not obligated to agree to these restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.

I have read this document and understand it. I consent to the use and disclosure of my health information for purposes of treatment, payment and healthcare operations. I acknowledge that I have received the Notice of Privacy Practices from Alaska Functional Medicine Clinic.

Patient Signature:                                                         Date:

____________________________________________________                 __________________

If signing as a personal representative of the patient, describe the relationship to the patient and the source of authority to sign this form:

Name and Source of Authority:  

________________________________________________________________

Relationship to Patient:                                                         Date:

__________________________________________________                 _________________

Photography Consent

I,                                                                                         , authorize my physician, aesthetician, and staff representatives to take photographs of my face and/or body for medical purposes to be used for my patient care, marketing, literature and/or case presentations.

I understand that:

» Photographs are taken to capture treatment outcomes.

» They may be used for print, visual, or electronic media including but not limited to: scientific presentations, websites, social media and for purposes of informing the medical profession or general public about the procedure. These uses may also include marketing on behalf of the physician’s practice.

» I will not be identified by name in any of the published materials.

» I certify that I have read this release carefully and fully understand its terms.

(If under 18, guardian or parent must sign)

 Print Name:                                                             Signature:                                                             Date:                            

Medical Information

Surgical History

List Procedure(s) and Date(s): ___________________________________________________________________

Allergies

Medications: ________________________________________________ Severity:__________________________

Foods: ______________________________________________________ Severity:__________________________

Medical History – check all that apply

__ADHD 
__AIDS/HIV 
__Abuse/Domestic Violence 
__Allergies 
__Anemia 
__Anesthesia Complications 
__Anxiety Disorder 
__Arthritis 
__Asthma 
__Autism Spectrum Disorder ASD 
__Bedwetting 
__Birth Defects
      or Inherited Disease 
__Bladder or Kidney Problems 
__Blood Diseases 
__Blood Transfusion 
__Breast Cancer 
__Breast Problem 
__COPD 
__Cancer 
__Chicken Pox 
__Chronic ear infections 
__Congestive Heart Failure (CHF) 
__Constipation 
__Coronary Artery Disease 

__Depression 
__Developmental or
     Behavioral Disorders 
__Diabetes 
__Difficulty swallowing 
__Diverticulitis 
__Ear or Hearing Problems 
__Eating Disorder 
__Eczema 
__Endometriosis 
__Fibromyalgia 
__GI Problems 
__Gout 
__Headaches 
__Heart Disease 
__Heart Problems 
__Hepatitis 
__High Cholesterol 
__Hospitalizations 
__Hypertension 
__Hyperthyroidism 
__Hypothyroidism 
__Infertility 
__Kidney Disease 
__Kidney Stones 

__Liver Disease 
__Lung Disease 
__Meniere's disease 
__Mental Disorder 
__Mental Illness 
__MRSA exposure
__Muscle, Joint,
      or Bone Problems 
__Nasal polyps 
__Obesity 
__Osteoporosis 
__Other 
__Ovarian Cancer 
__Polyps 
__Pre-Eclampsia 
__Pulmonary Embolism 
__Reflux/GERD 
__Seizures/Epilepsy 
__Skin Problems 
__Stroke 
__Thrombophilias 
__Thyroid Problems 
__Tuberculosis 
__Varicosities 
__Vision or Eye Problems 
 

Social History

Able to Care for Self?   Yes   No

Alcohol intake, drinks per week: _________

Caffeine intake, drinks per week: _________

Nicotine intake (circle):
Smoking /  E-cigs / Chewing tobacco  

How much? __________  Since Age: ________

Secondhand smoke exposure?  Yes  No

Illicit drugs: __________________________

Animal exposure?   Yes   No

Are you currently employed?   Yes   No  

Occupation: _________________________

Blind or serious difficulty seeing:   Yes  No

Deaf or serious difficulty hearing:   Yes  No

Changes in family/social situation: Yes  No

Diet Description (ie. Gluten free, vegan, diabetic, etc) ________________________

Difficulty concentrating, remembering or making decisions Yes  No

Social History - continued

Difficulty doing errands alone Yes  No

Difficulty dressing or bathing Yes  No

Difficulty walking or climbing stairs Yes  No

Education Completed ______________________

Home water fluoridated (circle) Yes  / No

General stress level (circle):
Low  /  Medium  /  High

Guns present in home Yes  No

Exercise level (circle): None  /  Occasional  /  Moderate  /  Heavy

Live alone or with others? (ie. Roommates, Both parents, one parent, relatives, adoptive, siblings):
________________________________________________________________________________________________

Legally blind in one or both eyes? Yes  No

Marital status _______________________

Number of children _____________________

School name: _____________________________

Seat belt/car seat used routinely? Yes  No

Sexual orientation _________________________

Sexually active? Yes  No  

Number of sexual partners _______  

Protected sex? Yes   No   Sometimes

Smoke/CO detectors in home? Yes  No

Sporting activities: _________________________

Sunscreen used routinely? Yes  No

Women’s Health History

1. Abnormal Pap (circle)  Yes    No
2. Age at First Child __________
3. Age at Menarche __________
4. Current Birth Control Method __________
5. Date of Last Menstrual Period  __________  
6. Last Pap Smear __________
7. Last Colposcopy __________  
8. Last Mammogram __________  
9. Last Bone Density __________
10. Desired Birth Control Method __________
11. Duration of Flow (days) __________
12. Flow (circle)  Heavy  Moderate  Light
13. Frequency of Cycle (Q days) __________
14. Menses Monthly (circle) Yes  No
15. HPV Vaccine (circle) Yes    No
16. Age at Menopause __________
17. Post Menopausal Bleeding?   Yes    No   NA
18. Performs Monthly Breast Exams?   Yes    No
19. STIs/STDs (circle)   Yes    No
20. Sexual Problems?  Yes    No
21. Sexually Active?  Yes    No

22. Number of Pregnancies ___________ Miscarries __________ Children ____________
23. Currently on Hormone Replacement Therapy (circle)  Yes   No

Family History 

__Alcohol abuse 
__Alzheimer's disease 
__Anemia 
__Anxiety disorder 
__Arthritis 
__Asthma 
__ADHD 
__Blood coagulation disorder 
__Cerebrovascular accident 
__COPD 
__Coronary arteriosclerosis 
__Dementia 
__Depressive disorder 
__Diabetes mellitus 
__Disease of liver 
__Disorder of nervous system 
__Disorder of thyroid gland 
__Endometrial carcinoma 
__Epilepsy 
__Headache 
__Heart disease 
__Hypercholesterolemia 
__Hypertensive disorder 
__Kidney disease 
__Liver problem 
__Malignant neoplasm of uterus 
__Malignant tumor of breast 
__Malignant tumor of cervix 
__Malignant tumor of colon 
__Malignant tumor of lung 
__Malignant tumor of ovary 
__Mental disorder 
__Migraine 
__Multiple sclerosis 
__Myocardial infarction 
__Obesity 
__Osteoporosis 
__Seizure disorder 
__Sleep disorder 
__Substance abuse

If you have one or more of these symptoms, there is a 95% probability you’ll benefit from a food toxicity test.  Please review the following list and check any symptoms you may have and any symptoms that you have “learned to live with”. Be sure to discuss these symptoms with your provider.

Medications

Please list all the dose and frequency of all prescriptions, over-the-counter, and/or supplements you are currently taking:

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