patient consent to treat and acknowledgement of

patient consent to treat and acknowledgement of

PATIENT CONSENT TO TREAT
AND ACKNOWLEDGEMENT OF PRIVACY
PRACTICES
CONSENT FOR EVALUATION AND TREATMENT
I consent to medical treatment from U.S. HealthWorks Medical Group (USHW), its affiliates, physicians, and
employees. Treatment may include any necessary examination, test, or medical procedures ordered by the
physician(s) to be performed by USHW staff. I understand I may refuse treatment at any time. If I am seeking nonregulated substance abuse testing, I authorize USHW to obtain a specimen of my urine, blood, saliva, breath, hair,
or other specimen to determine the presence of drugs or alcohol. I understand that some physical exams (like
fitness for duty, school, or sports) and other services are not intended to diagnose medical conditions or replace
the medical care of my personal physician.
ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES
I have reviewed or have been given an opportunity to review the USHW Notice of Privacy Practices (NPP). I have
had an opportunity to ask questions about it and received satisfactory answers. I may ask for a copy of the NPP
or can view it electronically at http://www.ushealthworks.com
ASSIGNMENT OF BENEFITS / FINANCIAL RESPONSIBILITY AGREEMENT
 If I am being treated as an urgent care patient for a non-work-related injury and I have health insurance, I
assign to USHW all payments under the terms of my applicable insurance policies.
 If I am being treated as an urgent care patient for a non-work-related injury and I do not have health insurance,
I understand I am responsible for payment. I have a right to ask for the charge amounts before electing
treatment.
 If I am treated for a workers’ compensation injury or illness, USHW will seek payment from the responsible
payer, which is typically the employer or the employer’s workers’ compensation insurance carrier. I may be
responsible for a co-payment where allowed by law.
 If I am receiving employer-directed services (e.g. drug testing, physicals, medical surveillance) USHW will seek
payment from the employer. I may be responsible for payment if allowed by State or Federal law.
 If I am responsible for payment and my account is referred to collections, I understand that I may have to pay
collection expenses incurred by USHW.
SIGNATURE
Patient Signature:
Patient Name:
© US HealthWorks (12/31/2014)
Date:
Date of Birth:
AUTHORIZATION TO DISCLOSE PROTECTED
HEALTH INFORMATION TO EMPLOYER
My employer or potential employer has sent me to U.S. HealthWorks Medical Group (“USHW”) for
testing, evaluation, or treatment. By signing below, I authorize USHW to disclose my protected health
information in accordance with the following terms and conditions:
1. REQUIRED: Name of current or prospective employer :
2. If I have been sent to USHW for only a drug screen, my protected health information only includes
the results of that drug screen. Otherwise, my protected health information can include the results of
tests or evaluations, including diagnoses and medical history relevant to the tests and evaluations
performed that my employer or prospective employer has ordered or requires.
3. USHW may disclose my protected health information to my employer, prospective employer, or to an
entity designated to evaluate my suitability for (1) initial or continued employment or (2) other activity
required by my employer, or any other disclosure required by law.
4. I understand that my health information may not be protected from further disclosure by some entities
receiving my information under this authorization, and that USHW has no control over subsequent
disclosures by other entities.
MY RIGHTS IN CONNECTION WITH THIS AUTHORIZATION
 This authorization will expire one year from the date of when I am no longer employed by the above named
employer or one year from the date below, whichever is later.
 I can ask for a copy of the protected health information that will be disclosed. A processing and/or copying
charge may apply as permitted by law.
 My treatment may not be conditioned on my signing of this authorization unless the sole purpose of my
visit to USHW is for my employer or prospective employer to obtain health information about me.
 I have a right to not sign this authorization or to limit the information I authorize to be disclosed. However,
refusal to sign this authorization may violate a condition of employment or prospective employment.
Contact your employer for details.
 I may revoke this authorization at any time, but I must do so in writing to the clinic where I received services.
My revocation will not apply to disclosures that have already occurred under this authorization. Revocation
of this authorization may carry consequences related to my employment or prospective employment.
Contact your employer for details.
 I have a right to receive a copy of this authorization.
SIGNATURE
Patient Signature:
Patient Name:
© US HealthWorks (12/31/14)
Date:
Date of Birth:
2-Hole 1/4 2 3/4 c-to-c
EMPLOYER SERVICES
INTAKE INFORMATION
CLOCK IN
ARRIVAL
CLOCK IN
COMPLETION FORMS
PATIENT NAME (Nombre del Paciente):
AGE (Edad):
ADDRESS (Dirección):
CITY (Ciudad):
STATE (Estado):
SOCIAL SECURITY (SS#):
TEL. CELL (Celular): (
ZIP:
DATE OF BIRTH (Fecha de Nacimiento):
)
SEX(o):
TEL. HOME (Casa): (
M
F
)
EMAIL ADDRESS ( Dirección de Correo Electrónico):
EMPLOYER NAME (Empleador):
VISIT FOR (Visita para):
JOB POSITION (Posición) :
Pre-Placement Exam (Exámen de Trabajo)
DRUG TEST (Exámen de Drogas) OTHER (Otro):
FOR OFFICE USEFOR
ONLY
/ SOLO
OFFICE
USEPARA
ONLY USO DEL MEDICO
SERVICES:
PHYSICAL EXAM
DRUG SCREEN:
MEDICAL SURVEILLANCE EXAM
VISION:
Snellen
URINALYSIS:
Titmus
Dipstick
AUDIOGRAM
BACK EVALUATION
PFT
DOT
ALCOHOL TEST: Breath:
Non-DOT
DOT
Instant: Panel:
Non-DOT
Saliva
REPORTING INSTRUCTIONS:
Lab
Return paperwork w/ employee
EKG
FCE/ PAT
Return paperwork by mail
Fax report to:
LAB TESTS:
X-RAYS:
Attention:
Secure Number:
Other:
OTHER SERVICES:
ADDITIONAL COMMENTS/ INSTRUCTIONS:
CLOCK OUT
DISCHARGE
CLOCK IN
FOR MA
ST2004 (Rev 3-11)
© US HealthWorks
A Dignity Health Member
*ES1*
EMPLOYMENT EXAM / EXÁMEN DE EMPLEO
HEALTH HISTORY / HISTORIA MÉDICA
ES1
In accordance with current law, limit yourself to answering the questions below. Do not disclose any genetic information about you or your relatives.
De acuerdo con ley vigente, limítese a contestar las preguntas; no ofrezca información genética suya o de sus padres.
PAST MEDICAL / SOCIAL HISTORY
ANTECEDENTES MÉDICOS PERSONALES Y SOCIALES
No Yes/Si Have you ever had any medical allergies?
No Yes/Si Do you have any permanent disabilities?
1
¿Alguna vez ha sufrido de alergias médicas? 7
¿Sufre usted de alguna incapacidad permanente?
2
No Yes/Si Have you ever had recurrent illnesses or major injuries?
No Yes/Si Do you use tobacco in any way? If ‘Yes’ state type and quantity per day.
¿Ha sufrido de enfermedades o lesiones importantes? 8
¿Usa usted algún tipo de tabaco? ¿Si lo hace, indique tipo y cantidad diaria?
3
No Yes/Si Currently on any medications? If YES, list names and dosage below.
No Yes/Si Do you consume alcohol? If YES, state type and quantity.
¿Toma alguna medicina? Liste los nombres y las dosis abajo. 9
¿Consume bebidas alcohólicas? Si responde SI, indique tipo y cantidad.
No Yes/Si Do you currently have a chronic illness such as:
 High blood pressure, heart disease, stroke
 Diabetes, thyroid disease, liver disease, kidney disease
No Yes/Si Have you worked in hazardous environments? Is so, describe.
5
 Mental illness, seizures or movement disorders?
¿Ha trabajado en ambientes peligrosos? Por favor, describa. 10
¿Sufre usted de alguna enfermedad crónica como:
No Yes/Si Have you suffered any work-related injuries/illnesses?
 Presión alta, enfermedades del corazón, trombosis,
¿Ha sufrido alguna vez una lesión o enfermedad en el trabajo?
6
 Diabetes, enfermedades de la tiroides, hígado o riñones,
 Enfermedades mentales, convulsiones o movimientos involuntarios?
REVIEW OF SYSTEMS / REVISION DE SISTEMAS
4
No Yes/Si Have you ever had hospitalizations or surgeries?
¿Alguna vez ha tenido hospitalizaciones u operaciones?
HAVE YOU HAD, OR COMMONLY HAVE ANY OF THE FOLLOWING? ¿HA PRESENTADO USTED, O COMUNMENTE PRESENTA ALGUNA DE LAS SIGUIENTES CONDICIONES?
No Yes/Si CONSTITUTIONAL
No Yes/Si SKIN
CONSTITUCIONAL
PIEL
10
Fever, chills, fatigue, body aches or weight gain or loss?
17
Skin diseases or problems like color changes, cancer, tumors, cysts or other?
Fiebre, escalofrios, fatiga dolor en el cuerpo o cambios significativos de peso?
¿Enfermedades de piel como manchas cáncer, tumores, quistes u otros?
No Yes/Si HEAD
No Yes/Si EYES
CABEZA
OJOS
11
Trauma, injuries, or frequent or severe headaches?
18
Trauma, injuries, infections, pain, burning, itching or light sensitivity?
¿Trauma, lesiones, infeccion, dolor, picazón, quemazón o sensibilidad a la luz?
¿Golpes, lesiones o dolores de cabeza severos o seguidos?
No Yes/Si CARDIOVASCULAR
No Yes/Si GENITOURINARY
CARDIOVASCULAR
GENITOURINARIO
Palpitations, shortness of breath, chest pain/pressure, swelling in legs/feet?
Blood in urine, painful/frequent urination, kidney stones, venereal diseases?
12
19
¿Palpitaciones, dificultad para respirar, dolor en el pecho, hinchazón en
¿Orina con sangre o dolor, orina frecuente, cálculos de riñón,
piernas o pies?
enfermedades venéreas?
No Yes/Si EARS,NOSE,THROAT
No Yes/Si MUSCULOSKELETAL
OIDOS,NARIZ,GARGANTA
MUSCULOSQUELÉTICO
Ear, nose or throat problems such as decreased hearing, pain, hoarseness,
20
Joint pain, neck or back pain, broken bones?
sinus problems, etc.?
¿Dolor en las articulaciones, dolor en la espalda o el cuello, fracturas?
13
¿Problemas de oido, nariz o garganta como sordera, dolor,
No Yes/Si ENDOCRINE
ENDOCRINO
ronquera, sinusitis, etc.? 21
Increased appetite or thirst, increased urination, hair loss, osteoporosis?
¿Aumento de la sed, apetito u orina, perdida del cabello, osteoporosis?
No Yes/Si RESPIRATORY
No Yes/Si NEUROLOGICAL
RESPIRATORIO
NEUROLÓGICO
14
Asthma, frequent coughing, bronchitis, tuberculosis or coughing of blood?
22
Dizziness, muscle weakness, numbness?
¿Asma, tos frecuente, bronquitis, tuberculosis, tos con sangre?
¿Mareos o vértigo, debilidad muscular, falta de sensación?
No Yes/Si GASTROINTESTINAL
No Yes/Si FOR WOMEN ONLY
GASTROINTESTINAL
PARA MUJERES SOLAMENTE
Abdominal problems such as pain, reflux, nausea, vomiting, ulcers, black
Painful or irregular menstruation, vaginal discharge or pain?
15
23
stools, diarrhea, constipation, hemorrhoids, diverticulitis, liver disease?
Are you pregnant? Last menstrual period?
¿Dolor abdominal, indigestión o reflujo, nausea o vómitos, vómitos
¿Menstruación o períodos dolorosos o irregulares, secreciones o dolor
o heces con sangre, constipación, diarrea, úlceras digestivas, diverticulitis?
vaginal? ¿Esta embarazada? Último periodo menstrual:
No Yes/Si BLOOD DISORDERS, CANCER
ENFERMEDADES DE LA SANGRE
No Yes/Si FOR MEN ONLY
PARA HOMBRES SOLAMENTE
16
Anemia, spontaneous or easy bleeding, bruising, cancer?
24
Penile discharge, prostate problems, genital pain or masses?
¿Anemia, moretones, sangramiento espontáneo, cáncer?
¿Secresiones en el pene, problemas de próstata, dolor o masas genitales?
PLEASE WRITE THE NUMBER OF ANY “YES” ANSWERS ABOVE AND EXPLAIN EACH ONE OF THEM HERE.
Por favor, escriba aquí el número de las preguntas en las cuáles haya contestado que SÍ y explíquelas a continuación.
PROVIDER COMMENTS
I certify that the information provided above is correct. (Certifico que la información suministrada es correcta.)
 Relevant history was discussed with patient.
 Advised to follow up with personal physician.
Patient Signature (Firma del Paciente):
Provider Signature:
Date (Fecha):
IF ID LABELS ARE USED, AFFIX HERE AND DO NOT COVER ANY OF THE TEXT ABOVE.
Name:
ST2001 (Rev 9/13)
Incident #:
EMPLOYMENT EXAM
HEALTH HISTORY
Date:
© US HealthWorks