Step 1 of 4 25% Patient InformationName(Required) First Middle Last Preferred Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Cell NumberHome NumberEmail Sex(Required) Male Female Date of Birth(Required) MM slash DD slash YYYY SSN(Required) Driver's License(Required) Language(Required) Race(Required) Employer(Required) Occupation(Required) Payment InformationPerson Responsible for Payment(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Relationship to Patient(Required) SSN(Required) Date of Birth MM slash DD slash YYYY Insurance InformationInsurance Company Policy Number Policy Holder's Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Relationship to Patient 2nd Insurance Policy Number Policyholder's Name First Last Patient's ContactPharmacy(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Legal Guardian First Last Relationship Emergency Contact(Required) First Last Phone(Required)Relationship(Required) May we release medical info to your Emergency Contact? Yes No Do you have a living will? Yes No Date MM slash DD slash YYYY Consent(Required) I hereby voluntarily give consent to all providers at Sanson Family Medicine for the necessary medical treatment for the above-named patient:All professional services rendered are the financial responsibility of the patient. Payment is expected upon the provision of services. For insured patients, we are please to assist in the filing of your claims. *By signing the below, I hereby consent to my insurance carrier releasing all necessary information to Sanson Family Medicine regarding the status of my claims. Further, I hereby authorize Sanson Family Medicine to furnish information to my insurance carrier concerning my medical history, illness and treatments. Further, I authorize my insurance carrier to pay directly to Sanson Family Medicine all benefits to which I and/or my dependents may be eligible for the provision of healthcare services. I have read, understand and agree to the provisions above.Signature(Required) History & PhysicalPatient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Allergies(Required)List any food or drug allergiesPast Medical History(Required) Aids Alcoholism Anemia Anorexia Appendicitis Arthritis Asthma Bleeding Disorder Breast Mass Bronchitis Cancer (list details below) Cataract Chicken Pox Diabetes Emphysema Epilepsy Glaucoma Goiter Gout Heart Disease Hepatitis Hernia Herpes High Cholesterol HIV Positive Hypertension Kidney Disease Liver Disease Measles Migraines Miscarriages Mononucleosis Multiple Sclerosis Mumps Pacemaker Pneumonia Polio Prostate Problems Psychiatric Problems Rheumatic Fever Scarlet Fever Stroke Suicide Attempt Thyroid Problems Tonsilitis Tuberculosis Ulcer Stomach Ulcer Skin Venerial Disease Other (list below) Please check all or any conditions you have had in the past.Medical History Details(Required) Past Surgical HIstoryList all surgeries you have had in the past years and what years they were doneSurgery 1(Required) Date(Required) MM slash DD slash YYYY Surgery 2(Required) Date(Required) MM slash DD slash YYYY Surgery 3(Required) Date(Required) MM slash DD slash YYYY Surgery 4(Required) Date(Required) MM slash DD slash YYYY Surgery 5(Required) Date(Required) MM slash DD slash YYYY Adult Patients Only to Fill This outDo you Smoke?(Required) Yes No If yes, how many packs per day?(Required)Do you Drink?(Required) Yes No If yes, how often?(Required) Past Family HistoryCheck all that apply to any of your blood relativesFamily History(Required) Arthritis Kidney Disease Stroke Tuberculous High Blood Pressure Heart Disease Cancer (list details below) Diabetes Other (list details below) Family History Details(Required) Authorization For Use and Disclosure of Protected Health InformationSanson Family MedicineAUTHORIZATION for Use and Disclosure of Protected Health InformationName(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Date of Birth(Required) MM slash DD slash YYYY I Authorize to disclose protected health information to: Sanson Family Medicine. Phone #: 318-397-7000. Fax #: 318-737-7203. Address: P.O. Box 2257, West Monroe, LA 71294Purpose for disclosure Dates of service to be used / disclosed Please separate dates with a comma.Information to be used / disclosed Entire Medical Records History & Physical Operative / Procedures Reports Pathology Reports Radiology Reports / Films Hospital Records Immunization Records Consultation Reports Lab Reports Other (list details below) Disclosure Details Specific Authorization to Disclose Sensitive RecordsI understand that this authorization is to include use/disclosure of (please initial):Alcohol and/or drug abuse records Psychiatric Records Sexually Transmitted Disease Information HIV / AIDS Info *This information disclosed from records whose confidentiality is protected by federal law. Federal regulations prohibit you from making any further disclosure of this information without specific written consent to whom it pertains, or as otherwise permitted by such regulations. A general authorization is NOT sufficient for this purpose: I understand that I may revoke this authorization, in writing, at any time except to the extent that Sanson Family Medicine has already relied on this authorization I understand that I may revoke this authorization by sending or faxing a written notice to the Office Manager, at Sanson Family Medicine 2309 Arkansas RD., West Monroe, LA 71291 or Fax 318-737-7203 stating my intent to revoke this authorization. Unless otherwise revoked, I understand that the specific date or event upon which this authorization expires is {date_y}. I understand that Sanson Family Medicine may not condition treatment, payment, enrollment, or eligibility for benefits on the completion of this authorization form. I understand that the information being disclosed may be subject to re-disclosure by the recipient and may no longer be protected by the Federal privacy law, if the recipient is not a "covered entity". Signature(Required)Date(Required) MM slash DD slash YYYY Printed Name of Parent or Legal Representative(Required) Please Note: This form must be completed in its entirety. Thank you for your compliance. Consent For Disclosure of Protected Health Information The Standards for Privacy of Individually Identifiable Health Information (Privacy Rule) establishes a set of national standards for the protection of certain health information. The U.S. Department of Health and Human Services issued the Privacy Rule to implement the requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPPA). HIPPA's privacy rules generally give you the right to request a restriction on uses and disclosures of your protected health information (PHI). You are also provided the right to request confidential communication or the request that a communication of PHI be made by alternative means, such as sending corresponding to your office instead of your home. To better serve you, please complete the following: Please contact me in the following manner:Verbal Communication Home Cell Work Preferred PhoneMessage Type Leave message with detailed information Leave message with callback number only Written Communication Mail Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Family Member(s) or Friend(s) with whom we may discuss your medical condition:Name First Last PhoneRelationship Name First Last PhoneRelationship Consent I understand that it is my responsibility to provide this office with written changes concerning the release of my PHIPrinted Name SignatureDate MM slash DD slash YYYY CAPTCHA